Small Intestinal Bacterial Overgrowth, aka SIBO, is a common cause of digestive symptoms; gas, bloating, constipation/diarrhea, reflux and abdominal pain. It is also a common cause of IBS. This case reviews how you can become symptom free after treating SIBO. Also, and possibly more important, is that we do not always need to reach a “true negative” on the breath test to be symptom free and feeling great.
Dr. Michael Ruscio, DC: Hey, guys. Just wanted to give you the fast facts for this episode, which is essentially me walking through my SIBO treatment protocol for a recent patient who had some very nice results with SIBO. You can see the transcript for the specifics on my protocol. It’s a little bit long, actually, for the fast facts, but you can see that along with her lab tests.
In short, we used herbal antimicrobials with biofilm agents and then the elemental diet and then a combination of the two. The more important aspect of successful treatment is monitoring by and working with your doctor in order to personalize the available treatments.
[Continue reading below]
Dr. R’s Fast Facts Summary
- See transcript below for my specific protocol for recent patient “Christine” with her lab tests:
- We tried herbal antimicrobials with biofilm agents, then the elemental diet, and then a combination of the two
- The more important aspect of successful treatment is monitoring by and working with your doctor to personalize treatment
- Principles are more important than protocols in successful treatment
- We introduce the concept of ‘prebiotic responders in SIBO.’
- Get help with the diagnosis and treatment of SIBO.
- Get your personalized plan for optimizing your gut health with my new book.
- Healthcare providers looking to sharpen their clinical skills, check out the Future of Functional Medicine Review Clinical Newsletter.
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Principles are more important than protocols in successful treatment, and we really elaborate on that concept, and I think especially for the practitioners listening, that’s an important thing to hear, and hopefully it will be helpful for you.
And then we also introduce the concept “prebiotic responders in SIBO,” which is something I’m starting to notice in the clinic.
All right. Hope you enjoy it, and I hope it helps. Thanks. Bye.
DR: Hey, folks. Welcome to Dr. Ruscio Radio. This is Dr. Ruscio. I am with here with Susan McCauley. Hey, Susan. How are you?
Susan McCauley: I’m good. And for everybody not in California, it’s raining here!
DR: I know! It’s a rare, rare event to rain, but you know, the funny thing is it was raining this morning, and then for lunch I was able to sit outside in the sun and it was nice enough to sunbathe. We’re truly blessed here. Even if it rains, it’s still sunny.
SM: I know. But it was so funny. My cats were crazy! They usually are used to going outside in the backyard, and they ran outside and ran right back in! They forgot what rain was!
DR: Yeah, well, I’m sure there will be a whole news piece about the rain. I think we talked about this one previous episode, but being from Massachusetts and living through snowstorms—
SM: Oh, I’m sure you laugh at us!
DR: It rains here and people are like, “Oh, my God! There were rolling blackouts, and we stocked up on water and amenities.” It rained for a day!
SM: Well, they had on the news this morning how many outages. I was like, why are there power outages?! It rained a half an inch!
DR: It’s crazy, I know.
SM: I’m excited because this is one of my all-time favorite topics that we talk about, so what do we have in store for today?
DR: Yeah, we end up talking about this a lot and, I guess, for good reason because it is a common condition. We’re going to talk about SIBO today, but I wanted to address some questions about a recent case review that went out in the newsletter a few weeks ago—or by the time this podcast goes out, it’ll probably be a month or so ago. I just recorded a case review with a patient, and we essentially talked about how well she’s doing and how she has overcome her symptoms, and we also introduced a concept of someone being able to have a positive lab value on SIBO but be free of symptoms. I introduced that concept, and then people lost their minds, wanting the protocol. So I want to just start off by saying there is no magic protocol. I will run through what we did, but I again want to just off by making sure to say that what we did with this patient we could do with someone else and get a terrible result. We shouldn’t think “protocols.” We should think “process.” We should think “fundamentals.”
And while I’m on my soapbox here, let me just go a little longer! I think one of the most challenging things for someone who is trying to become skilled in functional medicine or natural medicine or what have you is learning how to think for themselves. Unfortunately, much of the education is expert driven, meaning we go to X expert’s seminar or we go to see X guru, and it’s more about following the leader in a lemming-like approach, using their protocol rather than thinking about what are the fundamental principles that we need to tackle. So I’d like to start off with a quote from Emerson. I used to think it was Ralph Waldo Emerson, but it’s actually Harrington Emerson, and it reads, “As to methods, there may be a million and then some, but principles are few. The man who grasps principles can successfully select his own methods. The man who tries methods, ignoring principles, is sure to have trouble.”
SM: That is a really good one, and I think it speaks to what we’re talking about, that we need to understand what SIBO is and how it works and what the underlying mechanisms are instead of rotely following some supplement protocol.
DR: Exactly, and along those same lines, to think for yourself.
DR: There may be a treatment that is well documented to work well which may work terribly for a patient. In fact, one of the concepts that I’ll introduce at the end here is something I’m starting to term “prebiotic responders in SIBO,” and this completely flies in the face of everything that we think regarding SIBO treatment, yet some patients have done very well with this. This is something I’ve stumbled across as I’ve thought through these things critically, as I’ve listened to what my patients have reported back to me, and I’ve thought for myself through these things. So, yes, thinking for yourself and not following protocols is hugely important because that will enable you to evolve. We can give you the best protocol in the world today, but in three or four years, things may change, right? And so if you’re just dependent on that protocol, if you don’t evolve, if you don’t grow, you will die. And the same thing happens with how you practice. You have to be constantly growing and evolving, which requires you to think.
Anyway, let’s get into the meat of the matter here before too many people just tune out and send me hatemail.
SM: Turn us off!
DR: Yeah! So this patient—and we’ll put the link if you want to view the video conversation between this patient and me. I think it’s really nice just to hear her discuss the changes and the improvements that she noticed and everything. I think that will be helpful for people, so we’ll put the link in here.
And I should also mention, while we’re on the podcast here, if you’re subscribed to the podcast but you’re not subscribed to the newsletter, I would definitely subscribe to the newsletter because, of course, this lady’s case review didn’t go out via the podcast, and we have quite a few articles that are going to be coming down the pike, too, that won’t be released via the podcast either. And then all the research highlights that go out through the newsletter, so definitely if you’re on the podcast subscription list and you’re not on the newsletter, I think it would behoove you to plug in there.
SM: So where do they go sign up? Is it just at DrRuscio.com?
DR: Yeah, it’s just the homepage for DrRuscio.com in the upper right-hand corner. On the right side there there’s a newsletter box, and you just plug in your email, and then you’ll start getting all the updates.
DR: So this lady presented as a 39-year-old female with a fairly long history of gastrointestinal complaints and some other complaints. Some of her chief complaints were food reactivity, overweight, insomnia, bowel irregularity tending toward constipation, fatigue, problems with mental clarity, headaches, constipation, and chemical sensitivity. Sorry, I said constipation twice, but these are not uncommon presentations. A very common presentation. And she had actually done Steven Wright and Jordan Reasoner, their leaky gut cure protocol or course, and she had improved from that, but then she had regressed. And so she spoke with them and they said, Well, if the protocol is helping you, but you’re not able to sustain it, then maybe you need to see Dr. Ruscio and he can help figure out what’s going on.
I think that’s also a common scenario, where people jump from one self-help course to the next, to the next, to the next, and the same thing keeps being repeated. They get a little bit better and they regress, they get a little bit better and they regress, and the real travesty about what happens there is there’s not a clinician observing you, testing you, listening to how you respond, and taking notes to learn from that. That’s the one bad thing about jumping from one self-help course to another. Those are such prime chances for a clinician to observe and listen and learn about that particular case. I just want to throw that note out there for people. It really is well worth investing time to work with a clinician because that can really provide the clinician with a lot of valuable insight and information.
When we initially worked up this patient—we’ll call her Christine. That’s her first name, and she’s in the video, so I feel OK saying that since it’s already on the video and she’s fine with that! When we first worked up Christine, we performed a SIBO breath test, the lactulose-provoked hydrogen/methane breath test, and her initial values—and I’ll put the pictures of her labs in the show notes—but we did her SIBO lab and we also did a comprehensive pathogen screen through Quest. Now, everything through Quest came back clear, but SIBO came back positive, and she had a peak value of hydrogen of 29, a peak value of methane of 84, and a combo peak of 113.
SM: For people that don’t know what those numbers mean, how high are they out of the norm?
DR: Well, the way I like to grade these for patients is on a scale of mild, moderate, and severe.
DR: I would consider this a severe case of SIBO with methane being the main gas positive.
DR: Specifically, we don’t want to see hydrogen above 20, we don’t want to see methane usually above 3, so of course, 3 to 84 being her level—
SM: Wow, that’s huge!
DR: That’s why I would call this severe. And we don’t want to see the combo gas above usually 15 to 20 also, and so that’s why we see that positive there.
Again, her hydrogen 29 peak; methane 84 peak, very high; and her combo 113; so this is definitely a severe case of SIBO, and this can actually be one of the most challenging presentations, being the methane predominant, because methane is one of the harder to clear. I think pretty much every doctor that treats SIBO has noticed the same correlation or the same finding, which is methane is harder to see a response in compared to hydrogen. Does that mean that you can’t see a response in methane? Absolutely not, but it’s just the harder of the two gases.
SIBO treatment protocol
DR: So what did we do for treatment? We put her on a probiotic-prebiotic combination known as Primal Defense, which has a moderate amount of prebiotic, and it also has some lactobacillus bacteria, some saccharomyces bacteria, and some spore-forming bacteria. And we also had her on some enzymes. We had her on Digestzymes from Designs for Health, which is a blend of hydrochloric acid and pancreatic enzymes and bile. And then finally, we also had her on a straight hydrochloric acid supplement, and that was only because she had previously noted she did better on hydrochloric acid. I typically will not put someone on a straight dose of hydrochloric acid unless I think they really need it. In her case, it seemed like she needed it, so we started off with that.
And then the specific SIBO treatment, we used two different antimicrobials in the first month, and in this case—and there are a few different herbal protocols I use for SIBO, so I hate to not give people something to blindly follow, and to tell you the truth, guys, does it really matter, in my opinion, if you’re using one herbal blend versus another? I don’t really think so. This comes down to principles rather than methods. The herbal protocol we used in this case the first month was GI Microb-X from Designs for Health dosed at six a day along with oregano oil from Designs for Health dosed at six a day. The second month, we used OrthoFlora Yeast six capsules a day, and we used ParaBotanic Select, which is by Moss, at six capsules a day also.
Then, in addition with that, I added in allicillin, and I forget which allicillin. I believe it was Allimax Pro, which is the highest-dose, best-priced allicillin I’ve been able to find. And I added in with that samento and InterFase Plus.
Samento, also known as cat’s claw, and InterFase Plus are both biofilm agents, and this was back when I was randomly allocating patients to either receive antibiofilm treatment along with SIBO treatment or not receive antibiofilm treatment. I’m no longer doing this because we’ve collected enough data and I’m now happy to say that we’re working to crunch the numbers with a biostatistician, and we’ll hopefully be submitting this for peer review and then publication in the near future. And as soon as I have the numbers back from the biostatistician, we’ll probably do a follow-up podcast and I’ll give you the straight talk on what effect we saw or did not see. My initial inkling is that the biofilms don’t really make a huge difference in the treatment of SIBO. I could be wrong in that, but that’s just from my quick purview of the data and the numbers in Excel. I don’t think that the biofilms make a huge difference.
SM: Do you think the mechanism for that is that the overgrowth isn’t one of those sneaky ones that tries to protect itself like H. pylori does with the biofilms to protect itself to live, that they’re just there and the biofilm doesn’t need to be disrupted?
DR: Yeah, it may be that the bacteria that participate in SIBO are not as prone to forming biofilms, or it may be that because the small intestine is a much more volatile environment that biofilms never have a chance to fully establish.
DR: It could be because of the acidity difference in the small intestine compared to the large intestine compared to the stomach, as you mentioned with H. pylori, that being where H. pylori is going to predominantly reside, of course.
Yeah, we could certainly speculate as to the mechanisms. I’m not really sure what exactly would be happening there, but what I’m chiefly concerned about is, does it seem to make a difference in the clinical outcomes, because even though this is only two additional compounds to add, this may add another $200 or so to treatment, and if someone has to be treated two or three or four times… right now these things really start to multiply, and coming back to the quote I opened with, if my principle is to try to find the minimum amount of treatment needed to realize the maximum effect, I’m going to apply this same principle to things like adrenal support, to things like nutritional support, to things like hormone support, and that will manifest itself in thousands of dollars more or less of treatment for a patient over the course of their treatment.
SM: And I think with InterFase Plus, just with my personal experience because I’ve taken it in the past, is that the compliance… it’s not an easy supplement to take with that second dose being usually in the afternoon, and it has to be on an empty stomach. So it’s like, “OK, I have to eat lunch, I have to set a timer, I have to take it, and then I have to set another timer,” because it has to be on an empty stomach, so I wonder if that plays into it as well, how compliant patients can be with it.
DR: Right. Well, I have patients take the biofilm agents along with their antimicrobials.
DR: Because here we come back to this position of principles and fundamentals and practicality. I’ve had patients do it both ways. Have I ever seen it make a huge difference one way or the other? No. Do some patients get an upset stomach when they take everything on an empty stomach? Yes. Have I then had them take it with food and still seen many infections clear? Yes. So just through a little bit of thinking for myself there and testing a previous assumption, I’ve pretty much ruled out the fact that these things have to be taken on an empty stomach to make a huge difference.
SM: That’s interesting because I’ve always been told that the antimicrobials don’t need to be taken on an empty stomach but the InterFase Plus you need to make sure to take it on an empty stomach, so I’m going to start playing around with that.
DR: You know, the best treatment is going to be the one that the patient is consistent with.
SM: Right, exactly. I used to do some amino acids with clients, and the adherence, the compliance was absolutely dismal because they had to take them on an empty stomach. And I think it was Kalish that said you don’t really need to take them on an empty stomach if you can’t get compliance.
DR: Exactly. Yeah, I remember Dr. Kalish saying that also, and I made note of that, and I said, “Hmm. That’s interesting. I wonder if this is going to apply to other things.”
DR: And certainly I think it does. I think sometimes in this functional and natural medicine space we make way too big of a deal of stuff, and sometimes we just need to calm down!
SM: I know.
DR: All right, so that’s what we did. We had two antimicrobials for the first month, two different ones for the second month, and then the allicillin with the biofilm agents administered for the duration of the two-month treatment. And it was striking to see that after that, everything was completely normal. Now, when I say “everything,” I mean her SIBO retest came back completely normal. Hydrogen was normalized and methane was normalized. And for methane, that is a remarkable shift, right?
DR: Now, what I could do is blast this all over the internet, shout it from the rooftops, and try to make myself sound like a big deal, but what I’ll tell you is sometimes you see a miracle with treatment, and sometimes you’ll do the same thing for someone else and you’ll see, like, a 4-point shift. OK? Just because there was this great result here, I don’t want people to think this is the magic protocol and you have to go to great lengths to do this. In fact, if you’re struggling with SIBO, I would recommend that you don’t do the protocol I just went through, but rather you find a good clinician to treat you because the real magic here is in a clinician being able to figure out what treatments work best for you.
SIBO prevention maintenance
DR: So after that, she was pretty much asymptomatic, meaning she had no more symptoms and she was in a great place. We kept her on the probiotics and the enzymes and the acid that we mentioned from before, and then we reverted to our SIBO preventative strategies just like we’ve talked about in many other podcasts, which would be low FODMAP along with a prokinetic—in this case, we used Iberogast—and then we monitored her. And a couple of months later, she started to symptomatically relapse, and when we retested, her methane was back to 43.
DR: So we treated again with the same protocol, and this time we only saw a 10-point reduction in the methane, but her symptoms were much, much, much better. So we then decided to do the elemental diet because, of course, we were seeing a diminishing return with the herbals in this case. After doing the elemental diet, her methane then came down another 10 points, but her hydrogen now was positive again. Her hydrogen had been negative up until now, and all of a sudden, the methane went down another 10 points, so now she’s at about 23, so she’s still positive for methane, but all of a sudden, the hydrogen shoots up. Her symptoms were doing very, very well, though. In fact, her symptoms were almost completely ameliorated at this point. So I’m saying to myself, “Hmm. She’s still positive, but symptomatically she’s doing great.”
Then we treated one more time with the elemental diet, and we followed that by a course of herbal antimicrobials, and her symptoms went from just a few that were still kind of lingering to all gone. But when we retested—and this will be her final retest that will be in the notes—she still had a hydrogen of 40 and a methane of 38, yet all of her symptoms were gone. And this is the main thing I wanted to introduce with the video that Christine and I put out, which was—in my opinion, anyway—you can have a positive SIBO test and still be fully asymptomatic.
Now, that wasn’t just a snapshot in time. We’ve been following her three months since that retest, and she has maintained all of her improvements. And I want to tell you more about the treatment that we did… her maintenance program, I guess I should say, not really treatment, her maintenance program. But let me just check back in with her symptoms. She had no more food reactions. She had lost a little over 40 pounds.
DR: Her sleep was much better, her bowels were regular, her energy was back, her mental clarity was improved, her mild headaches were gone, and her chemical sensitivities were gone. And she says in the video she feels better now than she did when she was 25.
SM: Oh, wow. That’s great.
“We kept her on the probiotics and the enzymes and the acid that we mentioned from before, and then we reverted to our SIBO preventative strategies just like we’ve talked about in many other podcasts…”
DR: Now, one of the things I discuss in the video is, depending on how I was framing this for her, she could feel like a failure and she could be walking around with chronic fear that, “Oh my god, I still have SIBO positive,” right?
DR: If I had framed this the wrong way, this could be looked at as almost a failure. I mean, yes, her symptoms are better and she’s happy about that, but I see in my mind a different type of provider, that type of provider that, I think, is hard on patients, which the dialogue would look something like this: “You’re still positive. We have to keep going with treatment. You have problem in your gut, and that problem in the gut could cause autoimmune conditions, and you may have degeneration of your brain or degeneration of your thyroid,” blah, blah, blah, and just have a patient who feels like shit about themselves—pardon my French—but because this is framed the wrong way, the patient now feels bad about themselves and has this lingering fear. I can’t overemphasize how damaging I think that can be.
So what we’re doing with Christine now is we’ve reverted to something that Dr. Steven Sandberg-Lewis introduced at the year before last’s SIBO Symposium, which he termed “cyclical low-dose antimicrobial therapy.” Essentially—and this probably comes from Dr. Sandberg-Lewis just thinking for himself and thinking through this practically—what we’ve now done with her is we have her on one antimicrobial agent at a time at a very low dose. So she may be taking two oil of oregano pearls a day for a month, and then we’ll switch to another herbal antimicrobial, and that seems to be working very well right now in conjunction with Iberogast in preventing relapse.
Now, something else that she’s doing is if she feels like things are getting kind of funky, she will periodically do a one-day liquid fast using the elemental diet, and I think the main utility here is more antiinflammatory than it is anti-SIBO. Fasting has been shown to be a very effective antiinflammatory tool, and now, if you want to really get all distracted with mechanisms—which I don’t think we should; I think we should focus on the clinical presentation and how this works for a patient clinically—but a mechanism here could be that by using the one-day elemental diet periodically, that’s helping to have an anti-inflammatory effect. We know that the interstitial cells of Cajal cannot fully recover if there’s a highly proinflammatory environment, so it may be working to restore motility, but it’s working nonetheless.
So she’s three months out. Maybe a couple of days a month she’ll do one day of an elemental diet when things feel funky, and she’ll be cycling a different low-dose antimicrobial along with some probiotics, and now for a probiotic we have her on Ther-Biotic Complete, which is a lactic acid probiotic blend; we have her on saccharomyces; and we also have her on Iberogast.
Now, is she eating like a crazy person? No. She’s gone through her elimination on the autoimmune paleo diet, and she’s gone through a reintroduction of allergens, and she’s settled into a pretty diverse array of foods. And she’s also gone through the FODMAP reintroduction, and she’s able to eat a fairly diverse amount of FODMAPs, but she does find that some starches really trouble her, and so she’s just made a note of that, and she avoids these few starches. So she’s three months out. We just had a followup actually last week, and she’s still doing great. She has a day here or there where things get a little bit funky, and when she does, she does the elemental diet. But she certainly is doing—as I ran through with her symptoms—she is doing so much better than she was before. And equally as important, she’s happy with where she’s at, she doesn’t have any lingering fear, and I’ve explained to her that in some cases this low-level SIBO positive lab value is OK because we’re supposed to use these labs to guide our treatment, but ultimately they’re guiding our treatment to treat a patient, not to just blindly treat a lab value.
SM: Right, and everybody is different. Maybe for her, that’s her normal.
SM: Just because some lab comes up with a number, if she has no symptoms, then that should be the guiding factor, not a number on a piece of paper.
DR: Exactly. So she has done really, really well. And we’ve used a blend of different treatments, and we’ve seen some treatments worked beautifully at first and their lab-changing properties diminished, but their clinical utility was still maintained. And we’ve found a good mixture that works well for her.
There’s another concept I’d like to introduce, but before I do, Susan, is there anything there that you would like to ask or for me to expand on?
SM: Yeah, well, just the patience factor, I guess. People want things fast sometimes, and when you went through Christine’s story, it wasn’t a two-week thing. It was, “OK. The first protocol was 60 days, and then we had a little bit of relapse and we went again,” so people need to be patient. These things take time when we’re trying to restore the health of your body and the homeostasis of your body.
DR: That’s true, and you make a great point. We treated Christine for about a year.
DR: And in the video I remark that she was an easy one from the perspective—and let me explain how I say “the easy one” when it’s someone who’s been treated for just over a year—her symptoms responded very well to the initial treatment, and so even a month into the first round of treatment, she was already seeing quite a bit of symptomatic improvement. Not everyone is so lucky. Some people don’t start to see improvement until the labs are normal or close to normal and then the gut has healed for several weeks after that. That’s kind of how I was. I didn’t notice immediate change when I treated my amoeba, but then my gut slowly started to heal, and I started to gradually improve week after week after week, and it wasn’t months until after I cleared my amoeba that I really saw appreciable change.
So I say Christine was an easy one because she saw improvement so quickly, but again, there are other people that they may have to go through this process of treat, retest, see some improvement, relapse, treat again, see some improvement in the labs, relapse a little bit, try a different treatment, retest the labs, finally have things at an acceptable level, and then only from once you’ve hit finally have things an acceptable level, a few months after that see improvement. And that’s why we consider a hard case not because it’s any more clinically challenging, but it’s harder for the patient to stay in the game, and that’s why I’ve repeatedly said find a clinician, and as long as you have confidence in that clinician, give them the time to work through the process because this is a process-oriented treatment. It’s not “Dr. So-and-so is going to have the magic protocol.” Now, again, that’s heavily contingent upon you having confidence in your provider, but I don’t think any provider has a magic protocol. It’s more just working through these things, trying to figure out what protocol or mix of protocols are going to work for a patient.
SM: And then I think you made the point about finding a provider that just because you think you have SIBO because I think sometimes there becomes, like, a disease dujour, you know? SIBO is talked about a lot now. Say, you eat FODMAPs and you get gas and bloating. That’s one of the telltale symptoms. For me, I went and I had some of those symptoms, and I swore I had SIBO. I really thought I had SIBO, and I was all ready, so I went to my provider, and I said, “Test me to SIBO!” He says, “You don’t have SIBO.” And I said, “But I’m bloated.” He said, “That is your colon, and your colon is inflamed.” That’s how I got my IBD diagnosed because I had to go through a colonoscopy and all that stuff. So if I would have just listened to a podcast, and then that’s why I think you were hesitant to talk about the protocol, not to talk about it, but it may not be for everyone, especially if you don’t have SIBO.
DR: Exactly. Your point is a beautiful one. And just to kind of expand on that, there is a lot that your doctor—a good doctor—will process when you first present, right?
DR: You may go online and read a list of symptoms and 8 of 10 of those symptoms you have, and so now you diagnose yourself with that condition. But there are so many conditions that have overlap with the symptoms of other conditions, that doing that is incredibly ill informed. It’s something I really want to caution people against doing. Just like you said, Susan, you may really think that you have hydrogen-positive IBS or SIBO, but you may actually have IBD. It’s a little bit different of a game, and so, yeah, it’s work going through the steps, and I get it. Seeing a doctor, especially usually the initial exam visits, can be expensive. It’s time and it’s money, and I get people not wanting to invest that, but if you’ve tried one of these self-help courses and you haven’t gotten there yet, I really think it’s worth going to see a doctor. This is the same thing I did. I had an amoeba, I tested positive, and then I thought after I treated it everything was all done, but I still wasn’t feeling a lot better, so I went and I tried to put together my own thyroid protocol and my own testosterone protocol. And I wasted a lot of money and got no better over six months, and then I finally retested and the infection was cleared.
So, yeah, it’s worth getting some help and something, I think, is really, really important for people to hear. If your car broke down and we let you into the mechanic’s shop, would you be able to fix your car?
SM: Not me!
DR: Right? Most of us wouldn’t be able to. Just because you have access to tools doesn’t mean you know how to use those tools. That’s one of the challenges in healthcare. It’s “Well, we have access to these herbs, or I can maybe ask my GP to write a script for this if I have a good relationship with him,” but it doesn’t mean you know how to use these things. It’s the same thing with the mechanic analogy.
Prebiotic responder in SIBO
DR: All right, the final point here I’d like to chime in is there’s something I’ve been observing in the clinic, and I haven’t made my mind up on this fully yet, but it’s something that I’ve been noticing in a handful of patients, and I actually just had a conversation with Dr. Siebecker. We go back and forth periodically, and we kind of compare notes, and there’s this concept that I’m terming “prebiotic responders in SIBO.”
What I’ve seen in a handful of patients is during their history—again, this is where the doctor listens to you, gets to know the patient, listens to what the patient says, hears the patient’s story—I’ve heard some patients report that they feel better when they eat more carbs. OK, so I make a note of that. And when we work these people up, we find SIBO. We find mild to moderate SIBO, not a severe case of SIBO. We go through SIBO treatment, and we get their values down, sometimes normal, sometimes just a low-level SIBO, but these patients don’t tend to respond much.
So the thing that I had in the back of my head with some of these people that noticed they felt better on a higher-carb diet, I said, “Well, maybe if we push the needle forward in that direction more, we’ll get an even better response.” And I should mention that when people have noticed previously that they do better on a little bit more carbs, I would usually have them just eat a little bit more carbs. I mean, who would have thought?! I’m not following protocol I got from X seminar. It’s like, “OK, great. If you notice you do better on carbs, that probably means you have a certain metabolism or a certain flora that needs that, so let’s go with that.” So these people would be on a little bit more carb, we’d treat them for SIBO, they wouldn’t really respond ideally, and so then I’d revert to a more symbiotic approach, where we would start doing the opposite of what you should do in someone that has SIBO, but we would start treating them with higher-dose prebiotics, higher doses of fiber, everything that kind of feeds bacterial growth, and for the handful of patients I’ve done this with thus far, they’ve responded really, really well.
The way I think about this—and again, I think about this; I don’t just follow a protocol blindly—is the gut is kind of like a garden and some people may need more weeding and other people may just need more fertilizer, to put it really loosely. But if you’re tending the garden well and you’re observing what happens in the garden, a lot of this just has to do with learning how to mind the ecosystem. So I don’t necessarily know the “why,” but what I observe is that the approach of getting rid of SIBO in some people doesn’t seem to work well, but the approach of feeding bacteria in some people seems to work really well.
This is something I’m going to keep an eye on and see if I can firm up, but so far what I’ve noticed in this regard with what I’m loosely terming “prebiotic responders in SIBO” is patients that have previously reported they do better on a little bit more carbs rather than a little bit less and have SIBO, but not severe SIBO, have mild to moderate SIBO, may do better with an approach that is the opposite of what we would typically do for SIBO. It would be an approach that really favors fermentable substrates like fibers and prebiotics.
SM: And when you’re talking about a little more carbs, you’re not talking about Wonder Bread and Fruit Loops.
SM: You’re just talking about a little more good real food.
DR: Yeah. Gluten-free grains and starches.
SM: You never know what people are going to take when you say “a little bit more carbs.”
DR: Thank you. Yeah!
SM: Ice cream!
DR: “Well, Dr. Ruscio said eat gluten if you have SIBO.” Yeah, I could see that.
SM: OK. Well, we’re getting near to the end of our time. Is there anything you want to leave everybody with?
DR: No. That’s really it. Hopefully this helps people. For the people that wanted the specific protocol, there are the specifics, but I’m hoping that people take away from this a more thought-process-driven approach rather than a protocol-driven approach. On the transcript page that accompanies this, if you have thoughts or feedback, feel free to chime in, and we will keep keeping you abreast of important stuff with SIBO as it becomes available.
SM: Yeah, and remember, like I said, everybody is different.
SM: What works for your neighbor might not work for you.
SM: OK, guys, thanks. We’ll talk to you next week.
DR: Thanks, guys.
What do you think? I would like to hear your thoughts or experience with this.
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