Challenging the Low FODMAP Diet with Angela Pifer: Rational Wellness Podcast 142
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Angela Pifer Challenges the Efficacy and the Research Behind the Low FODMAP Diet with Dr. Ben Weitz.
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Podcast Highlights
This discussion with Angela Pifer is based on the following two articles that she wrote and which were published in September and October 2019 in Today’s Practitioner that critically assess the benefits and the research that supports the low FODMAP diet for patients with SIBO:
Part 1: The Pervasive Misunderstanding of What The FODMAP Diet Does And Does Not Do
PART 2: The Pervasive Misuderstanding of What the FODMAP Diet Does and Doesn’t Do
4:00 Today Angela Pifer is going to set the SIBO community straight about the low FODMAP diet and what the studies actually show about it. There are a number of problems with this diet, including that patients get stuck on it for too long a period of time.
IBS is a chronic gastrointestinal condition that is marked by abdominal pain or discomfort, diarrhea (IBS-D), constipation (IBS-C), or alternating of the two (Mixed IBS).
SIBO refers to an overgrowth of the bacteria in the small intestine and it is usually secondary to another condition, such as hypothyroidism reducing motility leading to bacterial overgrowth.
The low FODMAP diet is a diet low in fructo-oligosaccharides, disaccharides, monosaccharides, and polyols. It reduces the fiber and starches in food that tend to cause an increase of water into the small intestine and bloating and distension. The low FODMAP diet was created for people with IBS and the SIBO world adopted it and it does tend to calm symptoms in patients with SIBO. But it’s supposed to be an elimination diet and not a long term diet. It’s best to start challenging the patient with the different FODMAP groups after the first month or so to see which foods they can tolerate and which foods they react to.
10:26 The low FODMAP diet is supposed to help starve out the bacteria from the small intestine by not providing the food that these bacteria need to eat. But the studies don’t actually show this and when you look at before and after lactulose breath tests with these patients, the test results do not change. We do not see patients with SIBO have their SIBO go away after being on a low FODMAP diet for months. We have to learn from that. Studies that look at patients who are positive for methane SIBO based on a lactulose breath test and symptoms and we put them on a high FODMAP diet, say 50 gm of FODMAP, and the methane does not go up and when we place patients on a low FODMAP diet, say 7-9 gm of FODMAP per day, and methane levels conversely do not go down. In fact, Angela asserts that if a patient has methane and constipation, then such a low fiber diet, like the low FODMAP diet, should be contraindicated because it will make them more constipated. She pointed out that it is a bad idea to just put everyone with SIBO or IBS on a low FODMAP diet. It is more restrictive than many patients need. While it is likely that all patients with IBS or SIBO will need to modify their diet in some way, this low FODMAP diet is too extreme for what most patients need. But if you have a patient who has severe symptoms and can’t tell what they are reacting to, it can be a good idea to put the patient on low FODMAP for 3-4 weeks to settle things down and then challenge each of those food groups separately and see what you can add back.
18:00 There are three studies that showed a reduction in breath hydrogen with a low FODMAP diet, but these studies were poorly done. They didn’t perform the lactulose breath test the proper way. There is supposed to be a proper low fiber diet the day before followed by a 12 hour/overnight fast. Then you are supposed to drink the lactulose solution with the SIBO breath test and then breath into tubes every 15-30 minutes for 3 hours, during which time you are required to be fasting. Any increase in hydrogen or methane gas after 100-120 minutes is considered to have occurred in the colon, where you are supposed to have fermentation of fiber leading to gas production and this is not considered indicative of SIBO, which is a condition that occurs in the small intestine. These studies did not have the subjects do the proper test prep and in some cases the subjects involved performed the lactulose breath test all day long and they were eating while they were doing the test, which makes the results completely invalid.
20:18 There are three studies that showed a change in hydrogen gas on the breath test, but there were a lot of problems with these studies. When you really look at these studies, you see that they didn’t use the lactulose breath test in the way that it was validated for. The first study is called, “A low FODMAP diet is associated with changes in the microbiota and reduction in breath hydrogen but not colonic volume in healthy subjects.” The group that were described as eating the high FODMAP diet were not really eating high FODMAPs, but were on a low FODMAP diet with the addition of taking an oligofructose supplement. The low FODMAP group were supplemented with maltodextrin, which is a starch made from corn, rice, potatoes, or wheat, and which should not be included in a low FODMAP diet. Essentially, rather than testing low FODMAP vs high FODMAP, this study compared low FODMAP plus maltodextrin vs low FODMAP plus fructans in healthy subjects. The participants in the study were normal and were not suffering with SIBO or IBS, which are the group of patients we are interested in. The subjects did not fast for 12 hours or follow the proper food prep the day prior to the breath test that are needed for the SIBO breath test to be considered valid.
23:05 A second study that found a change in breath hydrogen is Randomised Clinical Trial: Gut microbiome biomarkers are associated with clinical response to a low-FODMAP diet in children with the irritable bowel syndrome. This study only had the children follow the low FODMAP or the high FODMAP for 2 days. And the breath test was conducted over 8 hours rather than the 3 hours that is the standard way to conduct the test. To insure that the hydrogen gas is being produced in the small intestine, there must be a positive result in an increase in breath hydrogen or methane gas within the first 100-120 minutes. And they were eating while conducting the breath test, which also violates the recommended test procedure. The results from this study cannot be considered valid.
24:39 The third study that found an increase in breath hydrogen gas with the low FODMAP diet is Manipulation of dietary short chain carbohydrates alters the pattern of gas production and genesis of symptoms in irritable bowel syndrome. In this study, the subjects only followed the low or high FODMAP diet for two days, which is too short a period of time to really determine if there could be a change in the level of bacteria in the small intestine. But the food they fed them was incredibly unhealthy. The low FODMAP group were fed rice flakes, lactose free milk, tea, rice, bread, margarine, orange juice, an orange, rice, pasta and lemonade with sugar. They were also given snacks of hot chocolate with lactose free milk, and chocolate muffins. This is not representative of a healthy version of the low FODMAP diet. But they didn’t do the proper food prep required for the breath test to be considered valid and they collected data for the lactulose breath test over 14 hours while they ate instead of over 3 hours while fasting. The results cannot be considered valid. The high FODMAP group was also given high fructose corn syrup soda and gum with sorbitol, a sugar alcohol. And there is a study that shows that if you combine sorbitol gum and high fructose corn syrup, it exacerbates symptoms by swiftly delivering malabsorbed carbohydrates to the colon.
28:36 There is one other study that is often quoted that saw a change in breath hydrogen, which was by Mcintosh et al. called FODMAPs alter symptoms and the metabolome of patients with IBS: A randomised controlled trial, published in Gut in 2017. They claimed to have seen a change in breath hydrogen levels when comparing baseline data to post intervention data, but while there was a very small difference but it did not reach statistical significance. So at this point we do not have a single valid study that demonstrates that a low FODMAP diet lowers hydrogen or methane levels in patients with SIBO using a lactulose breath test.
30:31 If you have been on a low FODMAP diet for a long time and it has helped to manage your symptoms, that’s great. But even if you still have SIBO, then it doesn’t make sense to continue to have such a restrictive diet that negatively affects your microbiome and provides a lack of nutrients. You have to understand that if you eat something and you have a symptom flare, it doesn’t mean that your SIBO is growing or that it is getting worse. You should pick your five favorite foods, other than garlic and onions, and see if you can try a tablespoon of something and slowly build up your ability to tolerate these foods again. Your enzymes that enable you to digest these foods have become down-regulated because you haven’t eaten them in while. This is where adding some digestive enzymes, like Intolerase by Vita Aid, can help to break down those starches and indigestible fibers. You should go slow and trickle the foods back in. You have to get past the mindset that because you have SIBO you have to be on such a restrictive diet, with all the anxiety and food disorder type of behavior that accompanies it.
37:07 If the low FODMAP diet has not been shown to be effective for curing SIBO, are there any other diets that have been proven to be effective for SIBO, such as the Specific Carbohydrate Diet (SCD) or the GAPS diet? Angela said that GAPS has a lot of fermented foods, so it is not good for SIBO and while SCD has some research behind it’s efficacy, it is more for Ulcerative Colitis that it is for SIBO. Angela prefers to find the food groups that the patient is reacting to, like fructans (onions, garlic, leeks), or fuctose, or lactose, or sucrose, and see which is the most problematic and pull these out for 3-4 weeks and then test them back in. Restricting our diet down to 7 to 9 grams of FODMAPs per day is not going to starve our SIBO out.
41:25 Angela suggests that doing a more conventional elimination style for 3-4 weeks for SIBO patients rather using a highly restrictive low FODMAP diet and then testing back those foods will likely to be more effective.
Angela Pifer is one of nation’s foremost Functional Medicine nutritionists in Seattle, Washington with a focus on Gastrointestinal Disorders like SIBO and IBS. Angela is known as the SIBO Guru. Her website is SIBOGuru.com and she has launched a gut prescription recipe site, Simply SIBO and a FODMAP-free line of bone broths, Gut Rx Gurus Bone Broth.
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.
Podcast Transcript
Dr. Weitz: Hey, this is Dr. Ben Weitz, host of the Rational Wellness podcast. I talk to the leading health and nutrition experts, and researchers in the field, to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness podcast for weekly updates, and to learn more, check out my website, drweitz.com. Thanks for joining me, and let’s jump into the podcast. Hello, Rational Wellness podcasters. Thank you so much for joining me again today. For those of you enjoying listening to our Rational Wellness podcast, please give us a ratings and review on Apple Podcasts or wherever you listen to the podcast. Also, if you’d like to watch a video version, go to my YouTube page. And if you go to my website, drweitz.com, you can find detailed show notes and a complete transcript.
Today our topic is the low-FODMAP diet with SIBO Guru, Angela Pifer. The low-FODMAP diet is often touted as a beneficial diet for patients with small intestinal bacterial overgrowth, commonly found in 60% to 80% of patients suffering with irritable bowel syndrome, one of the most common gastrointestinal conditions. Irritable Bowel Syndrome, or IBS, is marked by stomach pain, gas and bloating, constipation, diarrhea, alternating of the two, as well as a host of other symptoms. Small intestinal bacterial overgrowth is a condition marked by having higher concentrations of bacteria in the small intestine than normal, and treatments often include a low-FODMAP diet or a similar diet such as a specific carbohydrate diet, a GAPs diet, or Nirala Jacobi’s SIBO biphasic diet, in order to starve the bacteria. Since these bacteria eat fiber as their food. Some studies, Angela is shaking her head now, some studies, and some practitioners are claiming at a low-FODMAP diet, may be all the treatment that’s needed for six patients. Of course, Angela is going to set them right today. Or they may combine the low-FODMAP diet with antimicrobials, motility agents, probiotics, and other treatment protocols.
Angela: Yes. Which I wholeheartedly agree with. Yes. And not to starve them out with a FODMAP diet.
Dr. Weitz: Our guest today, Angela Pifer has recently published two articles warning that we may be mistaken about what the research shows about the low-FODMAP diet, but the benefits of the low-FODMAP diet are, and what are the dangers of the low-FODMAP diet, especially followed for a long period of time. Angela Pifer is one of the nation’s foremost functional medicine nutritionist with a practice in the state of Washington and her practice is focused on functional gastrointestinal disorders, especially SIBO and IBS. She is known as the SIBO guru and she’s launched a gut prescription recipe site, GutRX Guru and a FODMAP free line of Bone Broths, GutRX Gurus Bone Broths, of course, if we don’t need the low-FODMAP diet, I guess we don’t need-
Angela: I know. We’ll talk about that in a second.
Dr. Weitz: But that’s great.
Angela: The take home message is I know FODMAP, I think I’m going to switch with that.
Dr. Weitz: Angela’s recently published two articles, part one and part two. The pervasive misunderstanding of what the FODMAP diet does and does not do. And these are the basis for the discussion we will have today.
Angela: Yes, please.
Dr. Weitz: Angela thank you so much for joining me.
Angela: Of course. Of course. Thank you for having me. I appreciate it.
Dr. Weitz: So today we’re going to set the SIBO community straight.
Angela: We’re going to set anybody that thinks about the FODMAP diet straight, and the use of FODMAP and what the studies actually show because, oh my gosh, the amount of conjecture. And I think wishful thinking that is happening online and even how some people are implementing this in their clinic leaves a bit to be desired. I think people are getting stuck on this long term. It’s causing a lot of anxiety. Just taking a group of people who already have IBS or SIBO that are dealing with chronic presentation symptoms feeling socially isolated already because they can’t just go eat whatever they want and they have to deal with that.
Now they’re on an even more restrictive plan, which causes more anxiety and stress. And we’ve got to figure out as clinicians why we’re so quick to jump to this study, when, excuse me, sorry. Why we’re so close to quick to jump to this diet, when we start to really dissect the studies. I think it’ll make a little bit more sense. But we’ve got to be mindful that we’re not just putting people on this as we’re thinking clinically, Oh, I’m going to starve out the organisms or I’m going to drop histamines or I’m going to favorably alter the microbiome, because none of those have been proven. In fact, they’ve all been disproven, as we start to look at the studies. So-
Dr. Weitz: So, just to make sure everybody’s on the same page, including people listening who are not that familiar with IBS or SIBO. How about if we define some terms, can you basically define what is IBS? What is SIBO? And what is the low-FODMAP diet?
Angela: Yeah, absolutely. So IBS, there’s multiple presentations within IBS, but it, depending on, there’s ROME criteria for actually diagnosing it, but it’s a chronic nature of symptoms in irritableness, diarrhea or constipation or a mixed presentation. And there’s very specific criteria that somebody would look at for diagnosing that. Oftentimes it’s a diagnosis of exclusion. Everything else has been cleared off. It’s not that, here’s what you have. Sometimes it’s been perhaps used as a catchall. You’ve got chronic symptoms, but we haven’t figured out what it is, you have IBS.
SIBO is a small intestinal, I like to say, bowel overgrowth because it’s not all bacteria that can be overgrown, but basically SIBO is an overgrowth of a microbiota within the small intestine. And for people moving through life and trying to consume a normal diet, some of what they are eating might ramp symptoms up and cause bloating and gas. And sometimes it can be debilitating if it is ramping up another condition that they have, somebody has a hyperthyroid condition, which might slow motility, which might affect the microbiota and build up in the small intestine. All of that is kind of making things worse than that feedback. So it’s a very complex condition, it’s secondary, it’s never a primary, so it’s always there because of something else that’s happening.
And when we look at something like the FODMAP diet, which the FODMAP diet is fructo-oligosaccharides, disaccharides, monosaccharides, and polyols, they are the fibers and starches within the foods that we eat that are known to cause an osmotic shift if eaten in larger amounts within the small intestine so they can cause water movement and fluid moving into the intestine, rapidly moving things causes some bloating and distension and not feeling so great. And then with SIBO, as it moves through, not only can you get the osmotic shift. But if you have an overgrowth of organisms in the small intestine, you can have those organisms be able to break down some of those indigestible fibers and consume them. And they basically off gas and that fermentation produces gases. And now we’ve got a bloat going on as well.
So when we look at the FODMAP diet, the FODMAP diet was really created to help people with IBS. And the SIBO world, shall we say, readily adopted it because pretty much everybody with, most people with SIBO, also have IBS symptom presentation. And so it can very quickly for, I’d say the majority of people with SIBO, calm symptoms down. The problem is, is that as we look at the FODMAP diet, the way that it is supposed to be used is as an elimination diet. It’s not meant as a, oh, you have IBS or SIBO, here’s your diet, thank you for coming. They should not be stuck on this long term. There should be a three or four week elimination diet where you ramp down the loads of all those FODMAPs and then on the end of that you’re going to start challenging the different FODMAP groups to see which ones you react to. That’s how it’s supposed to be used. It’s not being used that way. So I’ve been in practice about 16 years now. Long time… I can say, maybe seven, eight years focusing on SIBO. I am as guilty as all the other clinicians. As all of this kind of came into being, we use the FODMAP diet. When I first started, everybody who went on that had SIBO, and that’s just what we did. As a matter of fact, when somebody walks through the door, we can calm your symptoms down. People feel better at least from getting that calmed down. But the longer and longer you’re in practice treating SIBO, the more and more people you see that have been on the FODMAP diet for two months, six months, two years. I had somebody a month ago come to me, that came to me that had been on it for seven years. And more often than not, when you run a SIBO test and you have a test back when to compare it to, their numbers are similar. So if you’re on a diet that’s supposedly starving out anything like the FODMAP diet is supposed to, a lot of people think that it’s going to starve out the organisms because you’re not sending those fibers that they can break down and consume and produce that gas with…
Dr. Weitz: Logically it makes sense, you have this bacteria, the bacteria eat fermentable fiber, if we eat foods that are high in fermentable fiber, it’s going to feed the bacteria, the bacteria will grow and we’re trying to get rid of the bacteria, so.
Angela: It makes sense. But unfortunately, or fortunately, as you look at it, when you actually look at the studies, it’s not what the studies are showing. And clinically, as we step back. If we ignore the studies. As clinicians, again, we’ve all seen the person that had been on this for two months, six months, two years, seven years, and they still have SIBO. So if the diet treated, if the diet starved anything out, wouldn’t that be all they needed? Wouldn’t that be the fix? It might take them longer to start things out, but that’s not what we see clinically. In fact, I would love any practitioner to talk with me about, oh I just put somebody on a low-FODMAP diet for six months and their SIBO test is negative, here we are. We just don’t see it. So we have to learn from that and we have to look at the studies as well. So when we actually look at the studies around the lactulose breath test and using a FODMAP diet. So the lactulose breath test, would you like me to explain that one for just a second?
Dr. Weitz: Sure.
Angela: Just to make sense for people. So basically what we’re trying to figure out is, do you have too much gas production in the small intestine? Thereby we can identify SIBO. That overgrowth in the small intestine. What we have is, studies where they put people on a high FODMAP diet, and they put people on a low-FODMAP diet and then they tested their breath test prior to putting them on it and after they put them on it. And we’re starting to, are there any changes? So when we look at methane production. It’s really interesting because as we start to think about, this makes sense, if we put somebody in a low-FODMAP diet, it’s going to start things out.
We should see after someone’s on a FODMAP diet, we should see methane go down. We should see hydrogen go down. So when someone has SIBO and they have an overgrowth of organisms in their small intestine, the gas production is hydrogen, methane or hydrogen sulfide. Right now we have the ability to test for methane and hydrogen. The hydrogen sulfide test is in the works. Hopefully it will be here soon. When we look at the test, when somebody with SIBO is put on a high FODMAP diet and that’s going to be 50 grams of FODMAP a day, to understand where the average person, is basically going to consume around 20 to 24 grams of FODMAP a day. So at least twice what the average person is consuming. You take somebody with SIBO, you give them 50 grams of FODMAP a day in a diet for three weeks or six weeks, depending on the study.
Methane does not go up. So what we know of methane is that when methane is present, transit time slows down. So if we’re feeding more and more FODMAP, that should be feeding more and more methanogens or the archaea that actually produce methane, which means we should see more and more slow down. We should see a bigger niche created for those organisms to grow up to larger numbers producing more methane. We just see that go up and we don’t. So three weeks on a high FODMAP diet or six weeks on a high FODMAP diet and methane doesn’t go up. Conversely, on a low-FODMAP diet on seven to nine grams of FODMAP a day, which is extremely low, methane doesn’t go down at all. It’s not statistically significant.
Dr. Weitz: Now could this be?
Angela: What?
Dr. Weitz: Could this be because what happens with methane is you have these methanogens and the methanogens eat the hydrogen. So it’s a secondary factor. So if the low-FODMAP diet reduced the food for the hydrogen eating organisms, couldn’t it just take a longer period of time before the methanogens were secondarily affected by starving out the hydrogen organisms? In other words, could it be that you just need a longer period of time and could that correlate with why practitioners sometimes see that treating methane SIBO is more difficult and often takes a longer period of time?
Angela: I don’t see that for methane taking a longer period of time. I think you just have to be really specific about how you’re treating it and from the start support motility. I don’t wait until after treatment to add in motility support. And there’s other things to do with that I think to make that a little bit more effective. What I would say is that we need longer studies. We need standardized-
Dr. Weitz: And we need better studies.
Angela: … longer studies. But feeding studies are incredibly difficult because how do you control for population, feeding them all the same thing. It’s incredibly expensive. What would be the benefit? Some of the studies looked at a FODMAP diet for two days. What are we supposed to do with this? So, we definitely need longer studies. I would say clinically when we see patients come in that have been on a low-FODMAP diet for, again two months, six months, two years, they still have SIBO. Methane does not go down. In fact, I find, and many practitioners find it’s, and it just is, the FODMAP diet is actually contraindicated. If somebody has methane because you’re basically likely going to make them more constipated by pulling the fiber that’s keeping them regular. So, putting somebody on a low-FODMAP diet is probably not a good idea when somebody has methane production. And I’ll, if we could back up for a second, because I have a bone broth company that has, it’s low-FODMAP ingredients. People who have SIBO and people who have IBS, will likely need to adapt their diet in some way.
What I’m cautioning people about and downright saying don’t do it, is that everybody with IBS and everybody with SIBO does not need to go on this diet full force, even as an elimination diet. Where this diet shines a bit more is when somebody has symptoms that are so deep irritating all over the place, they don’t know what they’re reacting to. And then, great, let’s do the elimination diet three to four weeks, settle things down, challenge each of those groups separately and see what you can add back in. That’s a really good use of that diet, but blanketly going out and saying everybody has to be on this and then insinuating, perhaps with all the info that’s online that we just can’t get away from at this point, or even clinicians still doing it, saying, well, we need to starve things out with this. And it makes people really worried. Really freaked out about anytime they eat and they get a symptom, SIBO’s getting worse. But when we look at methane, if you produce, or if you, pardon me, feed them, 50 grams of FODMAP a day for three weeks or six weeks, nothing doesn’t go up. SIBO’s not getting worse. So we need to look at these studies to gather that info. There’s actually three studies that showed a change in hydrogen, but when you really look at those studies, they didn’t use the lactulose breath test in a way that it was validated for. So, well actually-
Dr. Weitz: I was amazed to read your article where you broke this down. Anybody who’s treated patients with SIBO, anybody who’s had SIBO who’s seen a reasonable practitioner, especially somebody in the functional medicine world, knows that there’s a specific protocol you have to follow before you take the lactulose breath test, you do it for two or three hours. It’s very specific in it. The timing is very important because you want to make sure that if there is gas that it’s being produced in the small intestine. And these studies, it’s amazing how poorly they were done. They were doing, having them do the breath tests like all day long. They were eating at the same time. It’s unbelievable.
Angela: It really is. So they’ll actualize the breath test. I mean, basically you can see lactulose, as the substrate, this fermentable sugar that we don’t really absorb and you breathe out a tube at 15 or 20 minute intervals over a three hour period. And as that moves through the small intestine, if there’s an overgrowth, you’re just going to have a little bit of production because your small intestine is not sterile.
But as that moves past the overgrowth, you’re going to get a larger fermentation reaction, more gas production, and that’s going to cross your intestinal track into the bloodstream. Exchanges in your lungs and comes out your breath. It’s fascinating. But the crux of it is, it was only validated when you do a 12 hour food prep, basically eating chicken and rice, reducing the fermentation that is always going on in the large intestine so you can get a clear read in the small intestine and then you follow that 12 hour food prep with a 12 hour fast basically, again, to decrease the colonic fermentation. When we’re looking at the test time range, to diagnose you. But we’re looking at the 100 to 120 minute mark with the task, not three hours in, because it’s in the colon at that point.
So the three studies that looked at this, I mean one was so interesting, it’s called “A low FODMAP diet is associated with changes in the microbiota and reduction in breath hydrogen but not colonic volume in healthy subjects.” So first of all, healthy subjects, they ate their habitual diet, their regular diet for seven days. They were provided 24 hours worth of food, which is a standard package. So at least they’re all doing the same thing. Right? It wasn’t low-FODMAP. They did the lactulose breath test the next day and then they took the group as a whole, divided it in two. The low-FODMAP group, they were given maltodextrin, which we see repeated in other studies where maltodextrin is basically a starch made from corn, rice, potatoes, or wheat.
Dr. Weitz: Why do they add that?
Angela: They’re just calling it a control, I guess they feel like, basically it’s a polysaccharide if we’re worried about the FODMAP diet that would be in there. But basically they’re considering that as a control. Nobody really knows why. We’ve seen it in other studies. It doesn’t make any sense issues. So I don’t even know that it’s a comparison. And then the high FODMAP diet group was on a low-FODMAP diet, but then supplemented with oligofructose, which is basically a fiber supplement. So they weren’t even put on a high FODMAP diet. And then they follow that. And then the whole group was given 24 hours worth of food, which was low-FODMAP, and then they did a lactulose breath test. Just at that point, I don’t even know what we’re testing. Like none of this makes sense. But what the problem is, is that when you read the study title and even if you probably look at the summary on PubMed, it all looks like a low-FODMAP diet is responsible for reducing breath hydrogen.
But when you actually look at the study, you can’t even compare the baseline because it wasn’t low-FODMAP. They didn’t do or implement the instructions for the test that made it a validated test. So to speak to that, when we start to look at actual studies on FODMAP diet, some of them actually offer a high FODMAP diet versus low-FODMAP diet just 50 grams in and around for a high FODMAP and seven to nine grams in and around for the small, excuse me, for the low-FODMAP. And then they compare them over a period of time. That’s really the right way to do it. Others, they basically put everyone on a low-FODMAP and put them on starch or FLS or GOS, which is fiber. Or they basically do a low-FODMAP and a high FODMAP, but then add more fiber, there’s nothing standardized within it, it just doesn’t make a lot of sense. The other study that saw a change in hydrogen was called Randomized clinical trial: Gut microbiome biomarker, excuse me. My goodness. Gut microbiome biomarkers are associated with clinical response to a low-FODMAP diet in children with the irritable bowel syndrome. So they looked at 33 kids, and they basically had them follow the diet for two days. Then they did a wash out period for five days and then they cross them over and it was typical kid diet or a low-FODMAP diet just two days. But when they did the lactulose breath test, they actually sampled for over eight hours. And then some of the kids up to 15 hours while they ate. So again, we can’t really draw a lot of conclusions from these tests. We have a third study that kind of hits something very similar.
Dr. Weitz: Completely invalid.
Angela: Yeah.
Dr. Weitz: And this comes to scientific studies and people can cite scientific studies and a lot of times people are trying to make a point, maybe they’re just repeating a citation that somebody else cited and they never went and read the actual paper. And at most they looked at the summary and this goes to show you how just looking at the abstract or the summary of the study is often not accurate. So if you really want to be scientifically accurate, you’ve got to read the whole study and look at how it was done to see if it’s really valid.
Angela: And I think this next study that I’d like to talk about really speaks to that because you have to dig a little bit deeper to figure out a couple of items here, which I, once I found the study, another study on this, I thought it was just fascinating. So the third study that showed a change in hydrogen is Gut microbiome biomarkers are associated with clinical response to a low-FODMAP diet in children with the irritable bowel syndrome. This is one of the studies by Shepherd, the two Shepherds out of Australia. She’s basically the creator of the FODMAP diet. And then Monash University, she had an association with them and they’ve got a great app for FODMAP. So to give them a bit of a shout out there. This study is cited so often. I see this all the time. So basically they had 15 healthy subjects, 15 people with IBS, and they either ate a low-FODMAP diet, nine grams a day, or a high FODMAP diet, 50 grams a day for two days only. This is why it’s like, who looks at anything for two days?
Dr. Weitz: Yeah, two days, so short. Two days.
Angela: So they followed a seven day washout period where they ate their normal diet, and then they cross them over and did the two day diet intervention, which is, you want to have a crossover, make sure there’s no differences between the groups. Food was provided, which is fantastic because then you really get the standard effect. Everyone has fed the same thing. What do we see? So for the low-FODMAP diet, they fed them rice flakes, lactose free milk, tea, rice, bread, margarine, orange juice, an orange, rice, pasta and lemonade with sugar. So really not healthy. Who’s going to stay on that long term? Incredibly whites, nothing, where’s the fiber? Where’s the vital nutrients? Where’s, nobody got an orange in there.
Dr. Weitz: By the way, I read your article and then I read this study, it’s even worse than that. On top of all that, they gave them snacks containing hot chocolate with lactose free milk, and chocolate wheat muffins.
Angela: Yes.
Dr. Weitz: To both groups.
Angela: Yes. Yeah. Really not healthy. Really not healthy, right? So what they found was that there was a change in hydrogen. So what’s interesting, so both groups have higher hydrogen levels and response to the high FODMAP diet. So this is healthy in IBS groups, but the IBS group had higher levels than the controls. So as you did deeper into this, they didn’t do a proper food prep and they didn’t fast for the lactulose breath test. They collected data for the lactulose breath test over 14 hours while they ate. And then they also didn’t control for timing of the meal, so they didn’t feed everybody the same thing at the same time. So I thought that might’ve just been a little bit of an outlier. But what’s so interesting about this that the high FODMAP group was given high fructose corn syrup soda. And they were also given sorbitol gum with sugar alcohols. And there’s a study that actually shows if you combine sorbitol gum and high fructose corn syrup, it exacerbates symptoms by swiftly delivering malabsorbed carbohydrates to the colon. There’s a study on this.
Dr. Weitz: Wow.
Angela: I know, so you can’t, so for the group and the high, people with IBS are already going to be sensitive to that osmotic shift, probably more so than the healthy individuals. And now you give them high fructose corn syrup and sorbitol gum in there, quicker to malabsorb, quicker to have bloating and excess gas and shift things and kick things up. So again, it’s not just the study, but you have to really get in, look at the point by point. Well, what did you feed? What’s different here? What do we have to question?
Because we can’t just take this at face value at all. There’s one other study that saw a change in hydrogen and that was, which we’ll probably talk about a few times here because the study again is one of those that cited everywhere. It’s FODMAPs alter symptoms and the metabolome of patients with IBS, a randomized controlled trial. And that was by Macintosh et al. They claim to have found a difference with hydrogen levels. But when you actually look at the study, there’s no statistical significance when comparing baseline data to post side intervention. There’s none. So we’re done. They went on to have a big discussion about it, but there’s no statistical significance. So I don’t know why they kept talking about it.
Tell you how I really feel. I know. So at this point right here, we have no study that backs up a low-FODMAP diet, lowering hydrogen levels or methane levels and people with IBS or people with SIBO. None. It’s not even controversial, there’s just none there. If you actually look at those, they didn’t do the lactose breath test right. There’s no data to confirm. That’s all we have.
Dr. Weitz: It may or may not work. We just don’t have proof that it does.
Angela: Yeah, and so far it’s pointing towards no, clinically we don’t see it. And when we actually look at the studies where they implemented it properly at three weeks and six weeks, there’s no change to hydrogen and there’s no change to methane.
Dr. Weitz: And because this diet removes lots of healthy foods like broccoli, avocado, we could go on and on about all these healthy foods that are being removed from your diet. And because we know that there’s a negative effect on the microbiome, then what you’re saying is we should all stop using the low-FODMAP diet in patients with SIBO. What about the ones who say they’ve gotten results with it?
Angela: I’d say this, if you have been on a low-FODMAP diet for a long time and your symptoms are managed with it, I get it. I really get it. What I want to connect with that person with, because I have so much empathy for people not feeling well. On one hand, obviously there’s some things to figure out because they still have SIBO with SIBO, otherwise they wouldn’t be reacting that way or there might be some other things that we can add to support them that isn’t just restrictive diet. Additionally, for that connection piece, if we know from the data and again, seeing people on this forever not getting better, in terms of lowering the hydrogen and methane loads on a breath test.
When you eat and have a symptom flare, I know it’s not fun, but it’s not SIBO growing in a Petri dish. SIBO’s not getting worse. So what we want to do is basically, pick your five favorite foods that aren’t garlic and onion because those ones are hard to include back in, and see if you can try a tablespoon of something. Really the unfortunate part of expanding off of a really restrictive diet is that you have to do it really slow, and methodically and it takes time. Rebecca Coombs, love her, she shared a story one time where, it took her, I think about four months to introduce pumpkin again, where she would try a tablespoon of pumpkin, did not go well. Waited a month, tried it again, did not go well and it took her until the third month or fourth month for finally for her system to say, all right, it’s not so bad. So, I think that’s kind of the unfortunate part. This isn’t somebody on, reacting a little bit to dairy and gluten and they eat it on occasion and they don’t quite get a flare up. These are people that if they have, and for a lot of them, if they have a cup of potatoes are going to be down for three days with their symptoms flaring up. So for some people just depending on where they’re at, they’re going to have to go very slow with the reintroduction.
Dr. Weitz: What’s happening? Why can’t they tolerate these foods anymore?
Angela: So, what I consider is that when we were back as hunters and gatherers and running around and looking at things seasonally, we’re going to upregulate or downregulate digestive enzymes based on what we’re consuming on a regular basis. So seasonally, because it doesn’t make sense to me to make a bunch of digestive enzymes to consume certain plant foods that aren’t going to be, if they’re not around all the time. So, when we’re really pairing somebody down, and having them consume little variety and a lot less food, it takes a little bit to start to reintroduce foods to get their body to start to acclimate to that a little bit. I think there’s some support out there that we had that can really help them introduce things a little bit more easily. There’s some really great, Intolerase by Vita Aid is a really great digestive supplement that was made for SIBO that can help with all those different starches and indigestible fibers to help break those down a bit more. So, I think too, maybe to explain it too, if you haven’t had, let’s say non-SIBO people, just healthy individuals running around.
If you haven’t eaten beans in a year and a half and you go have a cup of beans, you’re going to have probably some gastric distress from the gas production. But if you eat beans on a regular basis, your body will get used to it and acclimate. So I see that with FODMAP, like the more and more we restrict, the first couple of forays into expanding foods. If they do it too fast, they react. So we just go really slow as we trickle that food in, as we start the expansion. But it’s also getting past the mindset because the mindset has been, I have SIBO, I have to starve this out. Every time I have a reaction, it’s SIBO growing in a Petri dish and I’m making this worse. I’m never going to get better. I need to restrict. And that whole mindset, I mean that’s why I basically, there was a whole, at the SIBO symposium last year, there is a full tract on anxiety and food related disorders based in and around SIBO. Because everybody’s restricting a lot. And I think unnecessarily for a big degree.
Dr. Weitz: I wonder if we could make use of low dose immunotherapy in such a situation to start getting your body be able to tolerate some of these foods.
Angela: Possibly. Possibly. I think.
Dr. Weitz: It’s interesting how these enzymes are really specific to the exact types of foods that we consume.
Angela: And that’s where I think something, honestly, like Intolerase comes in. It’s a really broad spectrum, covers a lot of bases in terms of some of these ingestible fibers and stuff. We can do that. If we can go, tablespoon worth the food. Give it a couple of days, double it, give it a couple of days, double it. If all that’s going well, then we can start to increase some of those loads for people and just start to get their body used to it a bit more. And breed some confidence for the person too, which I think is really important. Cooking grains longer, adding more water, cooking them longer, understanding that if you cook something like rice.
Dr. Weitz: Using a pressure cooker.
Angela: I love it.
Dr. Weitz: Soaking grains, overnight-
Angela: All of that can help.
Dr. Weitz: The lectins.
Angela: Yes, yeah, I think that can help. I’d say also-
Dr. Weitz: The deadly lectins.
Angela: Mm-hmm, I’d say that also if you’re, so some people know too, if you cook rice as normal in water on the stove when you boil that and then cool it, you create resistant starch. And so you might do fine as you eat that cooked initially, but if you keep it in the fridge day after day, the more you heat and cool that the more resistant starch is created and that might be a little bit of a key that person reacting more and more as they introduce that. There’s different types of white rice too. If you don’t do well with Jasmine rice, it doesn’t mean rice is out. There’s different rices and you might do well with another type.
Dr. Weitz: Depending upon whether they’re higher in amylopectin or-
Angela: Yep, exactly, exactly.
Dr. Weitz: If the low-FODMAP diet hasn’t been proven to be effective, are there any other diets that have been proven to be effective for SIBO?
Angela: No, not to date. So, basically we’ve got the low-FODMAP diet, we’ve got the SIBO specific food guide, which basically combines the FODMAP and SCD, and then the Bi Phasic is implementation of the SIBO specific food guide, where the groups of foods are phased in at different times. So we don’t have any studies.
Dr. Weitz: So really no research to back up the Specific Carbohydrate diet or the GAPS diet, either one of those.
Angela: Gaps isn’t often used because gaps has a lot of fermented foods in it. And so I think people shy away from that a little bit with SIBO, a lot with SIBO. Who am I kidding there? They really shy away from it.
Dr. Weitz: But Specific Carbohydrate?
Angela: SCD actually has some fairly good studies behind it, but not for this. It’s more related in and around to ulcerative colitis and some other things, but not specifically for SIBO. So and I’ll say there’s, different practitioners have a different way of getting a patient from A to B. I’m not trying to get in the way of that. I’m trying to have a discussion on what we’re trying to do with the low-FODMAP diet. And I see so many patients come to me having been on this for so long and it’s almost like you see their shoulders go, huh, when you say, I give you permission to eat, please go eat. Because I’ve even had people come to me and they said, “Oh, you’re probably going to, I’ve been cheating, you’ll probably going to tighten up my diet.” And I’m like, “Go eat whatever you want.” Of course it’s going to be healthy and we’re going to work on it, but I give you permission to eat. What are the next five foods you want to try? Let’s do it methodically with purpose. Let’s start to expand. Give them something to look forward to. So many people expanded with their diet and they’re better for it. They’re not worse. SIBOs not getting worse. They’re better for it because they have better endurance, they get better emotionally. They’ve got more nutrition coming in. It’s all positive. It’s not ever going to be a negative with that. So we just have to look at this from that perspective. I’d say again, if you’re working with a practitioner and you’re listening and they really love the SCD, or they really love a FODMAP or the SIBO specific or Biphasic, and they have an in and out plan, that’s fine. But the in and out plan is three to four weeks. It’s not, you’re going to be on this for four months or five months or this is just the diet you do because you have X, Y, and Z.
So I would challenge the practitioner you’re working with and ask them why they’re choosing this diet, how long you’re going to be on it, what is the plan and when are you going to start expanding your diet? If you can get all of that in writing, the three to four weeks of a regroup could be fine based on what they see. I think it’s, again, the elimination diet as a whole for a FODMAP diet to me is really reserved for people that just cannot figure out what they’re reacting to and through conversation with your clinician, we’re not able to pick it out off the top of their head because it sounds like you’re reacting to everything. Great case for an elimination diet, but for the rest of the groups, then we look at fructose and lactose and it’s just the sucrose, even for some, we reverse engineer it. You don’t have to pull everything. Fructans are probably the one, like garlic and onion and leeks. Those are the ones that usually are suspect. And the problem is of course, is they’re looking, onion is in everything. If they’re trying to eat out and that would be the first thing that we look at and have suspect about for people reacting and then fructose and lactose. So it’s not that you have to just pull everything. We might learn a little bit from the FODMAP diet and what people are less likely to react to, and what we can gravitate towards. That’s great. But the whole idea that we have to restrict down to seven to nine grams of FODMAP a day and stay on that to starve something out is ridiculous.
Dr. Weitz: Essentially, you’re suggesting that we do something like a conventional elimination diet. We just pick two, four, six, eight foods, something like that, eliminate it for a specific period of time, and then try to test them back in and bring those foods back.
Angela: I am suggesting that, but that’s also what the studies are suggesting. Time and time again, the studies are suggesting this is a three to four week diet plan. This is not a long term diet. We need longer studies on this. This should never just be put, have somebody put on long term. So this is the study, is in their commentary and summarizing their investigation study after study after study, says this is a three to four week plan. So I am suggesting that for people that have more deep irritating symptoms, that from this three to four weeks as an elimination diet pull everything, and then there’s really good, Kate Scarlata has info on what to challenge. There’s people online that have found what to challenge. You can get that info for free. I really recommend that you do this with a practitioner. However, not only that, all the effort you put into doing this over a month, if you’re not realizing, oh, X, Y and Z are actually high in FODMAP, they’re just not on any list. You want to make all your efforts count. So work with somebody as you do this because it’s fairly restrictive.
Dr. Weitz: It’s pretty much what I do. But I typically do it for four to eight weeks rather than two to three weeks, but.
Angela: Three to four weeks is usually the timeline that is recommended within the studies, and enough time to let symptoms settle down because again, this isn’t food sensitivity. We all learned the elimination diet way back when as pulling gluten, corn, soy and wheat, eggs, all of that. And then some, but that was more sometimes a month, sometimes two months. It was more like a month, month and a half. But we’re calming down the immune response as well as we challenge that. We’re getting kind of a reset button on that. So for this, this is really more what’s ramping up symptoms, osmotic shift and maybe the bloat response from that fermentation piece.
Dr. Weitz: And isn’t it interesting that gluten and dairy and soy are some of the same foods in the low-FODMAP diet too that you take out.
Angela: Yeah. Yup. It definitely is. Definitely is. The other thing I would say I think is really interesting and maybe to make the point here. I’m in the clinician group on Facebook for SIBO and we’re often discussing cases and points and it comes up time and time again that if there’s a pediatric case of SIBO, you completely throw the SIBO test out, ignore it, and you basically fix the foundational parts, clean up the diet, probably dairy and gluten free. Support the child nutritionally and see and try to figure out really what’s stirring up the emotional piece, what’s adding, where’s the stress coming from. We ignore it because we don’t want to over-treat and that’s that. I mean that’s said by everyone, Mona, Lisa, Shiva, everyone. So as we start to look at all this, which I will heartedly, I don’t work with a ton of pediatric cases, but I wholeheartedly agree with that. But I feel like we should have also be doing that in adults. So if somebody comes to me with five SIBO tests in a row, I still set them aside. We look at everything else. What else could it be? Let’s start with the basics. Let’s clean things up. Let’s settle things down. Let’s work on motility. So many people aren’t doing that and then wrap back to that and see if we even need to treat. So, I think we just don’t want to jump the gun. I think we get again this, when you have a way of testing for SIBO, that’s fairly easy, fairly affordable for some or most, and you get these test results back and you’re like, aha, that’s it. Well, it’s secondary. You still haven’t figured out the root cause of it and you can very quickly throw an antibiotic at it or herbals at it and put them on a low-FODMAP diet, which might make them feel better, but now they’re stuck on the low-FODMAP diet and SIBO’s maybe not fixed. So, we still want to look at what set this up and treat from that perspective. The other thing that I think is very interesting to me about the FODMAP diet and how quickly people are quick to jump on it and talk about it online and use it, is that we’ve got this idea that if you put people on this low-FODMAP diet, it’s going to cherry pick and reduce the specific species that are causing IBS or SIBO. And again, in the studies that’s just completely unfounded.
There was one great study that found that a low-FODMAP diet made the microbiota more dysbiotic and I loved what they said in their work because the way that they said it is it, it made the microbiota more dysbiotic in a group that already has been shown to have a dysbiotic microbiota. So it’s another study, dysbiosis is causal and IBS, although there’s no direct evidence to support this, being kicked around so much in the studies, then the effect of a strict low-FODMAP diet might be counterproductive. So what are we doing? It’s just really interesting. The one study I mentioned earlier about the hydrogen, altering hydrogen where they didn’t see any statistical significance in pre and post data, FODMAPs alter symptoms and the metabolism of patients with IBS, a randomized control trial.
That study again is one of those foundational studies within the SIBO rule that’s been cited so much. And they found no statistical significance when comparing their baseline data and their posts, diet intervention data with the microbiome. But again, they had a page and a half of summary because then they went on to actually just compare their post intervention data. So we can’t, we’ve got to look at these studies and this is the one study that actually kicked my whole, wait a second, what the hell is happening? You got to be kidding me, moments because this one study again that everybody talks about, it’s always cited wherever on everybody’s stuff is they found no statistical significance with hydrogen. They found no statistical significance with the microbiota. They actually said alpha and beta diversity were the same when you compare the pre and post test. They also, and this is the study that kicked off the whole conversation around histamines because what they claimed in their study was that there was an 8 fold decrease in histamines when people follow the low-FODMAP diet versus the high FODMAP diet. And I was looking at that to write an article off of it and there’s an asterisk on the data for the histamine piece. And I was like, wait, what? You can do that? You can put an asterisk on stats. So if you read it, what they had to do to get a correct… the statistical significance was that basically I think they started out with like 37 people. They went down to 34 people when they were looking at histamines. That didn’t tell us why a few people were discarded. And then there was no difference between pre and post data for histamines. So they only looked at the post data for low-FODMAP and high FODMAP and they had to adjust that subject group down four more times for age and gender, and IBS subtype to actually see a difference between a couple of people. And so-
Dr. Weitz: Wow.
Angela: I know, and then you back up and you kind of, you look at what they actually did to test histamines and they did a single point. You’re in test first thing in the morning, which for histamines, for urine histamines we look at a 24 hour collection because histamine is up and down all day long. So they didn’t test it correctly. There was no difference in pre and post data. That citation is in 50 other studies that the low-FODMAP diet alters histamines. And then whenever you look at those other studies, they make that citation and go into everything that’s happening with the immune system because we know that it lowers histamine. It’s all complete conjecture because that study didn’t show it. So it’s really, it was absolutely interesting. I sent it to all my colleagues. I sent it to a friend who’s a colleague who’s a gastrointestinal doctor. Like am I seeing what I think I’m seeing? And he’s just like, “Oh my God, this makes no sense.” So it’s just interesting. It’s interesting, it’s really sad, I mean if you go online and search for FODMAP and histamine, you get a hundred thousand plus results. It’s just everywhere. And it’s, I don’t know what to say. And when we actually look at the study, it doesn’t show it.
Dr. Weitz: And its being recently embraced by conventional gastroenterologists now too?
Angela: Yes.
Dr. Weitz: The ones who are involved with diagnosing and treating SIBO.
Angela: Yes, and that’s where, I think it’s really, it’s like it’s fortunate unfortunate. I saw the about shift with the GI docs. It was like at the front of, maybe it was like two years ago at the start of the year. They all thought SIBO was crazy, at the end of the year. I don’t know what conference it was presented all of a sudden SIBO exist, and the FODMAP diet is great. And that’s not for all of them. I’m sure there’s lot of them that still think it’s crazy. But enough of them are treating that, it’s just here’s the test, here’s the antibiotics, here’s the FODMAP diet. Thank you for coming. And your GI doc is not who you see on a regular basis. I hope it’s not. That means you got a lot of gut stuff going on. Ulcerative colitis patient, you’re going to see your GI doc a lot. It’s just is what it is. But for the most part, that’s not where you go for primary care. And so, are you going to even see them again in six months? Now you’re stuck on that diet because you’re supposed to follow this. There’s not a lot of follow through or follow up with that.
Dr. Weitz: I think Dr Pimentel’s research has been very influential and we know that IBS is the most common gastrointestinal condition. And though, I’m sure a lot of GI docs feel like, wow, we’ve got all these patients with IBS and we don’t really have a lot of tools right now. And so, maybe now we have a strategy that makes sense. We have a diagnosis, we have a drug that goes with it, and we can throw in a diet too.
Angela: Yeah, yeah. It’s true. It’s true. It’s true. And then they again, in the IB, and the study is looking at FODMAP and IBS, they’re showing that about 40-45% of people will improve on a FODMAP diet, again, as an elimination diet. So it’s not everybody, but that’s a pretty big chunk that somebody can make a difference with a handout. But then, how long are they following it, and what issues come from that?
Dr. Weitz: Okay, awesome. Thank you, Angela.
Angela: Yeah, of course.
Dr. Weitz: We’re going to shake up the SIBO world a little bit.
Angela: I hope so. I hope so. Thank you for having me. It was a great conversation, and I hope to continue it.
Dr. Weitz: Good, good, good. And so how can listeners get a hold of you and find out about your programs and your products?
Angela: Best site to reach me through is my website, siboguru.com. And then my bone broth is definitely out there, a gutrxbonebroth.com and everything’s linked for my website, so you can just come through me and find info there.
Dr. Weitz: Awesome. Thank you.
Angela: Thanks Ben.
