SIBO with Dr. Mona Morstein: Rational Wellness Podcast 348

Dr. Mona Morstein discusses Small Intestinal Bacterial Overgrowth with Dr. Ben Weitz.

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Podcast Highlights

4:15  SIBO is small intestine bacterial overgrowth and this diagnosis was brought to us by Dr. Mark Pimentel, based on his research at Cedars-Sinai.

5:38  It’s interesting that Dr. Pimentel, who’s really a conventional gastroenterologist, but yet his research was initially shunned by the conventional gastroenterology community and it was largely picked up by the Integrative, Functional Medicine community.  While some gastros still don’t believe in the SIBO concept, some have bought a QuinTron machine and do testing in their offices but do not really offer a comprehensive form of care. Such gastros will often only prescribe Rifaximin and they do not retest for six months or so, since this is when insurance will consider paying for another test.  And they do not offer a comprehensive form of care. They often do not address motility or biofilms or diet or food sensitivities, which are all important in getting patients better.  




Dr. Mona Morstein is a naturopathic doctor who is practicing Functional Medicine at Arizona Integrative Medical Solutions in Mesa, Arizona with a focus on treating patients with autoimmune diseases, hormonal conditions, diabetes, thyroid, and gastrointestinal disorders like SIBO and IBS.  She is the author of the best-selling book Master Your Diabetes: A Comprehensive, Integrative Approach for Both Type I and Type II Diabetes and she lectures frequently at medical conferences. She can be reached through the Arizona Integrative Medical solutions website, AZIMSolutions.com.

Dr. Ben Weitz is available for Functional Nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure.  Dr. Weitz has also successfully helped many patients with managing their weight and improving their athletic performance, 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. Today we’ll be speaking with Dr. Mona Morstein about SIBO, one of our favorite topics, Dr. Mona Morstein is a naturopathic doctor in Tempe, Arizona, who is practicing functional medicine at Arizona Integrative Medical Solutions in Mesa, Arizona. Right?

Dr. Morstein:                     Yeah, Mesa.

Dr. Weitz:                          With a focus on treating patients with autoimmune diseases, hormonal conditions, diabetes, thyroid and gastrointestinal disorders like SIBO and IBS. She’s the author of the bestselling book, Master Your Diabetes, and she lectures frequently at medical conferences. So, Mona, thank you so much for joining us again today.

Dr. Morstein:                     Thank you, Ben, for the invite.

Dr. Weitz:                          Yeah, we’ve had previous conversations about thyroid and about diabetes, so it’s about time we talk about the gut and SIBO.

Dr. Morstein:                     That’s fantastic. It’s a big part of my practice, so I’m happy to discuss it.

Dr. Weitz:                          Maybe before we get into exactly what SIBO is and how we test for it and how we treat it, how has your approach to SIBO changed over the years?

Dr. Morstein:                     Well, I think probably the biggest way that it’s changed is trying to figure out the best protocols to put together. New botanicals, come into play. I hear other docs, or even sometimes new medications come into play. So new ideas. Every quarter I meet with other well-known SIBO experts, and we go over what’s working and what’s not and how to adapt things.

Dr. Weitz:                          Wait a minute, wait a minute. How do I get into that meeting?

Dr. Morstein:                     I don’t have the key, but I can certainly give you the contact.

Dr. Weitz:                          What happened to the SIBO conferences? We used to have SIBO conferences.

Dr. Morstein:                     Well, of course now mostly there’s this SIBO SOS Summit.

Dr. Weitz:                          Right. With Shivan.

Dr. Morstein:                     With Shivan and Doctor-

Dr. Weitz:                          Siebecker.

Dr. Morstein:                     … Siebecker and so I think that’s what they’re really focusing on, and there haven’t really been a specific SIBO conference for physicians outside of that. Now I’m part of the Gastro AMP, which is a specialty organization in naturopathic medicine for gastroenterology, and we have a yearly conference. I spoke on bile acids back in October, but obviously SIBO can easily be a part of that conference.

Dr. Weitz:                          Maybe that would be a meeting to go to, because I miss the SIBO conferences.

Dr. Morstein:                     Yeah, those were very good. And potentially also Dr. Pimentel may be too busy, I don’t know.  So it all crashed with COVID and then Dr. Siebecker…

Dr. Weitz:                          COVID messed a lot of stuff up. It really has.

Dr. Morstein:                     I know Dr. Siebecker is all the SIBO SOS and doing her own classes if docs want to join her lessons and so forth.

Dr. Weitz:                          It makes sense. It makes sense, economically especially.

Dr. Morstein:                     Yeah, I’m sure it does.

Dr. Weitz:                          Let’s talk about SIBO. What is SIBO?

Dr. Morstein:                     SIBO is small intestine bacterial overgrowth. And so for whatever reason, I remember at the very first conference we were discussing should it SIBO or SIBO, and I think everybody just went to SIBO. I think it’s easier to pronounce. So this is Dr. Mark Pimentel, The IBS Solution. He wrote a book coming on 15 years ago, bringing SIBO into the world, based on his research at Cedars-Sinai. And then it took a while, like some things do a few years, but then it started really entering the consciousness of physicians. And so this is when bacteria wind up, generally… The most common methodology is a bacterial wash from the colon to the small gut, generally based on the nervous system in the small gut called the migrating motor complex, not being able to effectively move things forward. So when things don’t move forward in the gut, then it’s likely things are going to move back.

Dr. Weitz:                            By the way, it’s interesting how Dr. Pimentel, who’s really a conventional gastroenterologist who went off track and his research was really largely picked up by the integrative functional medicine community and was initially completely shunned by the conventional gastrointestinal community.

Dr. Morstein:                     It’s very interesting. You still have a lot of gastros who don’t know about it, don’t believe in it, or if they do, they’ll give you a, “Here’s your dose of rifaximin and I don’t want to see you again. That should be it.”

Dr. Weitz:                            Exactly.

Dr. Morstein:                     And then we have the exact opposite of gastros who have a QuinTron in their office and they’re testing and probably because they can make a lot of money with insurance with it, but at least they’re embracing and testing patients. And then you have the whole spectrum of, in the gastroenterologist world, I will say this though, the vast majority of gastros who even if they know or are willing to treat it, they don’t treat it well, unfortunately. So patients are not getting that comprehensive care that they need.

Dr. Weitz:                            Like you say, basically, “Here’s some rifaximin,” maybe, “Here’s some rifaximin and neomycin.” “Here’s a tear off on a low FODMAP diet. Maybe follow the low fiber Cedars-Sinai diet,” and that’s about it.

Dr. Morstein:                     And because I think it’s probably related to insurance, if they do test in their office, they don’t retest, they have to wait, I think it’s three or even six months before insurance will allow them to retest. I think it’s very important to retest after treatment. One, to analyze is it eradicated or not? And two, to analyze was this protocol effective? “Did you get a lot better but not cured? Well, we can stay with it.” “Did it really not treat it? Then we need to change it.” But there’s a lot of patients unfortunately, that waste a lot of time doing a protocol and not having any idea if it’s effective or not without getting the retest. And they may be on protocols, oftentimes that are not effective, but they’re wasting time just because they can’t get a retest.

Dr. Weitz:                            Once again, we have the healthcare system being run by insurance companies. Patients, a lot of times, don’t understand this. They were like, “Okay, why do I have to? How?” They have no idea, and the doctors don’t actually tell them. That’s one of the interesting things. It seems like it’s wrong, but I understand why they do it, which is when medical doctors know something’s not covered, but they think it would be a good thing. Why don’t they say, “I would like to do this test, or I would like to order this test, but your insurance won’t cover it. Here’s how much it would cost.” Because when they do that, then the insurance companies send them threatening letters and they don’t want them telling the patients, “Don’t use this alternative lab,” et cetera, et cetera. So there we have the insurance companies behind the scenes running things, and patients don’t even realize that.

Dr. Morstein:                     Yeah. Well, I think they do. A lot of times now with medications they’ve been on for years, all of a sudden, “We’re not going to cover it,” or, “You need to have it pre-auth.” Like, “I’ve been taking it for years,” and now, “You can’t take it anymore.” And I think there’s a lot of good-hearted docs who would love to practice in a better way in their hamstring by their corporate clinic or insurance and I think a lot of patients really understand how frustrating insurance can be at times.

Dr. Weitz:                            When you say the corporate clinic, what you mean is that most of these medical groups have been bought by the hospitals and then they’re run like corporations?

Dr. Morstein:                     It’s true. And a lot of it is because it’s just very difficult for any individual MD relying on insurance, and with the minimum wage going up, which I’m not against an elevated minimum wage, I’m just saying that it’s very hard for a single doc. I just had screws taken out of my elbow and my orthopedic surgeon said he’s probably going to earn around $200 for that surgery.

Dr. Weitz:                            Oh, I know. It’s a travesty.

Dr. Morstein:                     He’s wondering, can he stay in business because of the amount of money they get back from insurance?

Dr. Weitz:                            I had a hernia surgery and the surgeon got $400 for all that time, expertise, including the co-pay. It was embarrassing.

Dr. Morstein:                     It’s embarrassing. So now luckily, however, there are you, me, there’s integrative physicians, naturopathic that are outside of that. And while it does cost a little bit more out of pocket for patients, they do get the really high quality care that they need. So it is worthwhile.

Dr. Weitz:                            Good. So let’s continue. So SIBO is a small intestinal bacterial overgrowth, pioneered by Dr. Pimentel, and I’m not so sure that we necessarily accept that the bacteria overgrown from the large intestine anymore. We think that some of the bacteria have come down from above and just take up residence there.

Dr. Morstein:                     No, no. We actually can identify now pretty much which bacteria are causing SIBO and no, they’re large intestine bugs. So the oral bacteria obviously do get into the gut, but they’re not overgrowing and they’re not in the list of the bacteria or the archive with methane, not quite bacteria, that are the most associated with SIBO.

Dr. Weitz:                            Right. And then we believe that SIBO is the main cause of IBS in the majority cases.

Dr. Morstein:                     I don’t know if it’s the majority. Maybe Dr. Pimentel wants to believe that. I think there are many reasons. I think fungal overgrowth is probably-

Dr. Weitz:                            I think 60% to 70%, numbers been thrown around quite a bit by Dr. Pimentel, and some of those data indicates that.

Dr. Morstein:                     I take some of the things, God bless him, Dr. Pimentel, says with a grain of salt, personally.

Dr. Weitz:                            So what percentage of IBS cases do you think are caused by SIBO?

Dr. Morstein:                     I don’t know. I don’t really think in… It doesn’t matter to me what percent.

Dr. Weitz:                            I’m just curious.

Dr. Morstein:                     Did you know that 15% of Americans, which is millions and millions have IBS? Whatever percent is SIBO, it’s pronoun and it is millions as well.

Dr. Weitz:                            And IBS is basically the set of symptoms?

Dr. Morstein:                     Right. IBS is a umbrella of irritable bowel syndrome that can be caused by everything from food sensitivities to EPI to too much or too little bile, to fungal overgrowth, to bacterial overgrowth, to SIBO, to stress, to vagus nerve hypersensitivity.

Dr. Weitz:                            To LIBO, to dysbiosis.

Dr. Morstein:                     Exactly. So many things can impact onto IBS.

Dr. Weitz:                            So the symptoms of IBS are basically gas, bloating, diarrhea or constipation or alternating, abdominal pain. And then there’s a bunch of other non-intestinal symptoms. We have nausea, we have skin problems, we have, et cetera, et cetera.

Dr. Morstein:                     Yeah. I take some of those systemic symptoms with a grain of salt as well, just because I’ve had patients who had rosacea and SIBO and I’ve cured their SIBO and they have just as much rosacea as they did before. So maybe it’s associated with these things, but my experience is not that eradicating SIBO innately eradicates systemic symptomatology that oftentimes those have to be addressed in their own way as well. But yes, you are right. It’s very difficult to… A patient might come in and say, “Hey, I have diarrhea or I have constipation. I’d like to get tested for SIBO.” And I will say, ‘Do you have gas, distention, bloating?” And if they say no, that is taking away from my confidence in SIBO. However, I’ve had patients who just had microscopic colitis have SIBO. I’ll always test them. And I’ve had a few patients that when we eradicated SIBO that eradicated their diarrhea. So we really expect some gas and distention, but it doesn’t honestly seem that it’s in a hundred percent of the patients all the time as the key symptom we’re looking for.

Dr. Weitz:                            So when you have a patient that you suspect of having SIBO, what test and or tests do you run?

Dr. Morstein:                     So we have to be very, very, very, very clear on this. There’s only one way to diagnose SIBO, and that’s a breath test. Now you cannot do anything with the stool.

Dr. Weitz:                            Well, wait. What about IMO?

Dr. Morstein:                     That’s intestinal. IMO is intestinal methanogen overgrowth. So that has to be shown-

Dr. Weitz:                            That could be large intestine as well.

Dr. Morstein:                     No, you cannot diagnose SIBO. If you’re looking for a SIBO IMO, full diagnosis, it’s breath. That’s it. It’s breath.

Dr. Weitz:                            But if it’s not just in a small intestine, it’s part of IMO?

Dr. Morstein:                     You can say that, but talk to anybody in the group. It’s only the breath. That’s it. It’s the breath that diagnoses this and is what-

Dr. Weitz:                            But if it’s not just in a small intestine, and-

Dr. Morstein:                     Ben, you’ve said that three times now.

Dr. Weitz:                            Well, how else would you know it’s elsewhere?

Dr. Morstein:                     You have to see that in the breath. It has to be shown on the breath because-

Dr. Weitz:                            So what you’re saying is for it to be IMO, it could be in other parts of the intestinal tract, but it has to be in a small intestine.

Dr. Morstein:                     So here’s the deal. IMO, again, you’re working again off of Pimentel. Now, again, I take Pimentel, I respect him, but I don’t follow everything he says. I do a breath test if I’ve got-

Dr. Weitz:                            By the way, which breath test are you doing most of the time?

Dr. Morstein:                     So there’s really just two options. One is a QuinTron, and then one is the trio-smart, which is the Gemelli.

Dr. Weitz:                            And then we also have the use of different substrates?

Dr. Morstein:                     Yeah, but I mean, no, you really don’t. It has to be lactulose.

Dr. Weitz:                            Not everybody agrees with that.

Dr. Morstein:                     No, again, talk to Dr. Siebecker, talk to the group. The studies are clear. It has to be lactulose. It has to be ideally, Quin-Tron or trio-smart.

Dr. Weitz:                            Dr. Hawrelak has his patients get lactulose, fructose and glucose.

Dr. Morstein:                     He talked about that. We’ve talked about that. First of all, I don’t know how he can have patients spend $600 or if you’re doing trio-smart, $1,000. But in reality, this is really over. It’s lactulose. So it’s been decided. It’s a lactulose breath test. Okay? So the other ones, can I mention a lab not to use, or are you going to get… I don’t want to get you sued.

Dr. Weitz:                            No, it’s okay. I’m not being sponsored by any labs right now.

Dr. Morstein:                     So Commonwealth is the one lab. You blow in a straw, then you screw top it on. It’s just nobody would ever use Commonwealth who treats SIBO seriously. So you’ve got QuinTron, and then you’ve got trio-smart. And then different labs use QuinTron. I’m a fan of Aerodiagnostics, which is run by Gary Stapleton. You’re using a lactulose test. Ideally it should be a three-hour test. Now, what were we talking about? Oh, Pimentel. So here’s the deal. So generally there’s different ways to interpret a SIBO test. The classic is that from the smallest number to the largest number in 120 minutes. For methane it has to be 12 or above. For hydrogen, it has to be 20 or above. Now, Dr. Pimentel said, “No, we have to make the test 90 minutes, ’cause when it’s out of the small gut.” Well, that’s not when it’s out of the small gut for everybody. So the test was originated at 120 minutes.

Dr. Weitz:                            Wasn’t it 105, the cut-off at some point as well?

Dr. Morstein:                     No, the classic is 120. Now different labs will listen, obviously to Dr. Pimentel, who is obviously very respected in this world. So his trio-smart ends at 90, Genova ends at 90, s doesn’t end at 90 in terms of analysis. So you have to decide when you want to end the test. If we end-

Dr. Weitz:                            So you go till 120 minutes.

Dr. Morstein:                     Generally, I do.

Dr. Weitz:                            And you’re only measuring two gases rather than three?

Dr. Morstein:                     Well, yes, exactly. Now we can get into hydrogen sulfide and the accuracy of that testing.

Dr. Weitz:                            So for those who aren’t familiar with what we’re talking about. The gases are hydrogen, methane, and then the third gas is hydrogen sulfide, which is the one that’s only included in the trio-smart test.

Dr. Morstein:                     QuinTron is just the hydrogen and methane, and then hydrogen sulfide can be extrapolated with flat lines of both gases in the QuinTron analysis. Now we’re getting back to IMO. So Dr. Pimentel came out and said, “Here’s the deal. Methane should never be over 10. And if you ever see a box that’s 10 or above, they have intestinal methanogen overgrowth, whether in the small gut or the colon. And so I am not going to follow that rule personally because I’ll see people that have eight, eight, four, five, this, and then they’ve got one number in their colon that’s 11. This is going to overtreat, this is going to falsely send people down SIBO treatment.

Dr. Weitz:                            At one point I heard Dr. Pimentel say that he thought that even though this wasn’t accepted by the North American Consensus, that he thought anything over three was problem.

Dr. Morstein:                     That was way back when. But remember, the North American Consensus is not some scientific… This was the opinion of 17 clinics in North America.

Dr. Weitz:                            This is the way medicine is practiced. You have all these consensus groups that make determinations about when people should get colonoscopies, when they should get a PSA test, when they should get a…

Dr. Morstein:                     Yeah, but a lot of them have done more with analysis with large group populations, and then they create a consensus. Like the US task force, they’re not just all sitting around saying, “Well, what do you guys think?” They’re looking at the data of thousands and thousands of patients and what they had done and what the results were. So I’m just saying that the NAC didn’t have, that was just the opinion that was created years ago with these 17 clinics. So look, I have a brain in my head and I have thirty-five years of practice under my belt. So I am open to listening to other people, but I don’t bow down at anyone’s altar. I’m going to practice with my patients in the way I feel is best responsible. So that’s me. I am a pretty good [inaudible 00:23:40], and I’m going to work with my patients the best that I see. And if it fits what’s out there, that’s great and if it doesn’t, I still feel comfortable with it myself.

Dr. Weitz:                            Okay, so go on. How do you diagnose the SIBO breath test?

Dr. Morstein:                     So the SIBO breath test, so you’ve got the classic ways, which is the rise of 12, the rise of 20. You also have sometimes that people just have high numbers throughout the whole test, but they don’t reach 12 or they don’t reach 20. And this is what we call elevated and sustained. And elevated and sustained can be considered a positive if it fits the clinical picture of the patient. And then even without that classic rise, it can be elevated and sustained.

Dr. Weitz:                            So hydrogen starts out at 40 and stays at 40?

Dr. Morstein:                     Exactly. That’s just too high. And it’s the same with methane. Now methane, in terms of this 10 or above, I’m not going to ever treat someone with SIBO with one box at 10 or so. But half of it is 10 or above, based on Pimentel’s research, then I’m going to be more suspicious, especially if they do have constipation, they do have the gas and bloating and so forth.

Dr. Weitz:                            What if the test is negative and right at 120 it shoots up?

Dr. Morstein:                     So that is a great question because unfortunately that happens more than you think, and that’s annoying.

Dr. Weitz:                            I know.

Dr. Morstein:                     They either went in the colon and it’s a negative or it’s still in the small gut and it’s just right at the terminal ilium, they have SIBO or IMO or whatever, so that is… God, I hate that result. And you just have to talk with the patient and say, “We don’t know, but we-“

Dr. Weitz:                            Now, if the cutoff is 120, why do three hours?

Dr. Morstein:                     We do three hours to see that rise, and you’re just confirming that lactulose got into the colon. You want to see that rise.

Dr. Weitz:                            But we’re going to ignore everything after one 20. So why do it?

Dr. Morstein:                     You don’t ignore it. If there’s tens or something before and then it shoots up, I’m more suspicious. But we do just need to ensure, one, believe it or not, it verifies that they actually drank the lactulose because sometimes people have forgotten to drink the lactulose. So it also can help confirm a hydrogen sulfide. If we have a flat line in the small gut and it goes up in the colon, that’s not hydrogen sulfide. But if we have flat line all the way across, now we can be looking at hydrogen sulfide. So there are really helpful ways of having that three hour.

Dr. Weitz:                            If we do the trio-smart, then we’ve already got hydrogen sulfide, so we don’t care about that.

Dr. Morstein:                     If it’s an accurate test and if it finds hydrogen sulfide

Dr. Weitz:                            And you have reason to think it’s not an accurate test.

Dr. Morstein:                     I just listened to a lot of other docs who haven’t found hydrogen sulfide positive on the trio-smart in a year. So I don’t know. For me, if patients have to pay out of pocket, the trio-smart is $369, Aerodiagnostics is $209. That adds up. So if I’m going to choose between the two, and I know hydrogen sulfide is not that common a gas at all, and that I am probably going to go with the much less expensive because I do want a follow-up test. You’ve got $400 versus $700. People are paying out of pocket a lot, and that can add up.

Dr. Weitz:                            Besides the breath test, are there any other tests that you regularly run on patients with [inaudible 00:28:04]?

Dr. Morstein:                     So if they come in to see me and they’re SIBO, IBS newbies, I do SIBO then I want to do a stool test to try to uncover the colonic health. So now we have all 25 feet of the intestinal tract. And I may also do a food sensitivity test. That’s the triad, walking in the door if nothing’s been done.

Dr. Weitz:                            Okay. And your favorite food sensitivity test?

Dr. Morstein:                     Oh, a hundred percent is Alletess, for sure. Absolutely. I’ve been using them for 20 years. I’ve been to their lab. I know. I’m a hundred percent set with Alletess, foodallergy.com.

Dr. Weitz:                            Let’s talk about treatment. You get a positive breath test. How do you treat it? How do you treat the different forms of SIBO differently?

Dr. Morstein:                     There’s five or so different treatments. If it’s hydrogen or methane, you can use antibiotics. Now with rifaximin, there’s been two good studies. One showing that just adding guar gum increased the eradication rate from 62% to 87%. So I always throw in guar gum, and there’s another study saying that using bile significantly increases rifaximin’s effect. Now, rifaximin is, for a naturopathic-

Dr. Weitz:                            So this is ox bile?

Dr. Morstein:                     Ox bile, right. So for a naturopathic physician, if a patient comes to me with a sinus infection or strep or bronchitis, I don’t do antibiotics because I can treat that naturopathically. And so do that. I don’t like antibiotics. But the reason so many of us are doing rifaximin is for three main reasons. One is it’s 99.9% active only in the small gut. So it is not really active in the colon. It doesn’t wipe out the microbiome like regular antibiotics do. In fact, one study said that what it did, its activity in the colon was to increase bifidobacterium. I’m good with that. So two, rifaximin is a large molecule, so it is a hundred percent unabsorbed by the human gut. It doesn’t get to the liver. You can’t have an internal negative reaction because it doesn’t enter the body.  And then Pimentel said also that this research shows it does not cause trans-generational resistance. So bugs aren’t getting resistant to it. We’re not breeding super SIBO bugs with rifaximin. So for all of these three reasons, it’s why so many functional docs are so open to using rifaximin. But Rifaximin by itself is good with hydrogen. I’ll use guar gum, I’ll use bile, I’ll use a BioFilm Buster product, but if it’s methane, we have to add in something else.

Dr. Weitz:                            What BioFilm Buster product will you use? And does it depend?

Dr. Morstein:                     What?

Dr. Weitz:                            Does it depend? Do you use different BioFilm Buster products?

Dr. Morstein:                     For SIBO, I’ll use, generally, Advanced Two BioFilm.

Dr. Weitz:                            The Paul Anderson product?

Dr. Morstein:                     Yeah, his supplement, not his prescription.

Dr. Weitz:                            This is the one with bismuth?

Dr. Morstein:                     Yeah. So now his prescription formula is a little different, but Priority One makes his supplement version. There’s also InterFase Plus by Klaire that many people use. Some people just use NAC. But I like that Advanced Phase-2 product. So that’s what I’ll use in that regard. And then if it’s methane and you’re using antibiotics then you’ve got to throw another one in. I don’t use neomycin at all. I have had people get ear damage, ringing in the ear. I’m done. No more. Forget it. So metronidazole is such a big gut irritant and I don’t want to use it. So right now for methane, if I’m using medication I’m using Alinia, nitazoxanide, which is mostly antiparasitic.

                                                So now it’s even more expensive than rifaximin, so generally I have to get both of those from Canada. And sometimes the rifaximin will go through if they have IBS-D, if they have IBS diarrhea. But if they have IBS constipation, you’re not going to ever get it then. You still have to pre-authorize it, and it’s still a pain in the butt. So a lot of times I’m getting it through Canada, and that’s for two weeks. Every now and then I might do it for three weeks, but it’s generally for two weeks. And then now also there are supplements. So there are many different supplements out there.

Dr. Weitz:                            So you may have some patients who see you who’ve already failed rifaximin or who don’t want to take.

Dr. Morstein:                     Yeah, exactly. Or we just decide, “Okay, let’s do the botanicals.” There are very good botanicals out there.

Dr. Weitz:                            And studies showing that some of these botanicals are comparable to rifaximin.

Dr. Morstein:                     Yeah. That one study with Dysbiocide and FC-Cidal was not [inaudible 00:34:13]

Dr. Weitz:                            And also CandiBactin-AR, BR.

Dr. Morstein:                     I’m just saying that one wasn’t fair ’cause the rifaximin was dosed only twice a day, so you can’t really say it was as equal to it ’cause they didn’t dose it correctly. So that was just a study that we’re just like, “Okay.” So we have these supplements and different supplements. We know, we have some supplements that are methane and hydrogen, and we have some that are just hydrogen and some that are just methane. So you have to put them together. And now we have newer ones, a little bit that I’m playing with. And so we have to create a supplement regimen.

Dr. Weitz:                            Tell us some of your favorite ones. Why don’t we start with hydrogen, then we’ll go to methane, then we’ll go to hydrogen sulfide.

Dr. Morstein:                     Hydrogen, berberine of course is hydrogen. Neem is hydrogen, clove, pomegranate, oregano oil, these are all good hydrogen. Garlic is a little more with methane. Oregano is also methane. Neem is also methane. So those type of products you can easily mix and match. The classic starter is garlic, berberine, and neem. But then I use now a lot of clove and pomegranate and that is from Hawrelak?

Dr. Weitz:                            Yeah, Hawrelak is really big on pomegranate.

Dr. Morstein:                     Yeah, he is. And I like it. And it’s easy, there’s-

Dr. Weitz:                            What is the pomegranate product that you use?

Dr. Morstein:                     There’s only one company right now that makes pomegranate peel capsules because it’s not pomegranate extract. That’s for your prostate or your antioxidants. But it’s pomegranate peel. Now there’s a bunch of products on Amazon where you can get it in a powder form, but in the capsules, there’s a company called Terravita that makes pomegranate peel capsules. So that’s nice and that’s convenient. A lot of people don’t like the powder. It’s not like it’s good tasting or anything. It’s not bad tasting, you can mix it with a yogurt or something. But anyway, the capsules are convenient for many people. So we do the botanicals for a month, and I also add in a BioFilm Buster, but there’s no need for the guar gum or the ox bile because-

Dr. Weitz:                            And what about after a month? Do you rotate botanicals?

Dr. Morstein:                     No. After a month, I’m going to retest.

Dr. Weitz:                            One month. That’s it?

Dr. Morstein:                     Yeah.

Dr. Weitz:                            You have patients on a short fuse.

Dr. Morstein:                     Well, that’s ’cause a lot of them get better. And also, I’m not going to continue a protocol that’s not effective. I get so many people, “Oh, I was on this protocol and I still had SIBO, and they put me on the protocol again, and I still had SIBO. I did it for eight weeks.” There’s many different protocols out there.

Dr. Weitz:                            But what if they feel like 50%, 60% better?

Dr. Morstein:                     If feeling is good, let’s see. If it’s working, we’ll continue it, but I’m not going to waste patient’s time and money on ineffective protocols ’cause they come to me. They’ve already been on ineffective-

Dr. Weitz:                            But now they got to wait until they see you. Then you got to send them for the test, and then it’s a couple of weeks to get the test results back.

Dr. Morstein:                     That’s completely untrue. First of all, we set up the protocol and I give them the test. When they’re done with the protocol, they do the test, they start on the prokinetic, which if it is eradicated, we’re just moving-

Dr. Weitz:                            Now, wait a minute, can they even do the test right away because they just didn’t take any antimicrobials? Don’t you have to have [inaudible 00:38:06]?

Dr. Morstein:                     If I take antimicrobials for my sinus infection, do I have to wait two weeks to see is my sinus infection gone? If I take antimicrobials for my bladder infection, do I have to wait two weeks to see if my bladder infection is gone? Where in medicine do we have to wait if we’re trying to kill something to see in that regard? So I used to wait, and now I just make it pretty short. And guess what? Some people still have SIBO, some people are eradicated. I don’t think it’s caused any irregular testing. And then I get my test back in five days and then we have a follow-up. So it’s a pretty seamless process for patients in that regard.

Dr. Weitz:                            What about the use of, you said bile, what about the use of digestive enzymes or HCL or herbal bitters as part of the protocol?

Dr. Morstein:                     No. Why would I do that in eradication? So you’ve, you’ve got prescription, you’ve got antibiotics. The third one is mixing these two together. Sometimes they don’t want to do [inaudible 00:39:20]. You can do an antibiotic and supplements together. There’s no reason to not do that. And when I have patients who come to me and they’ve been treating it for two years, I may do that and go nuclear, and that can be really effective. We also have, of course, either an elemental diet or I have done with two patients who didn’t want to do the elemental diet-

Dr. Weitz:                            How often do you do the elemental diet?

Dr. Morstein:                     Let me just finish this. Hold on. We have the elemental diet or we have a carnivore diet. I’ve only had two patients who did a carnivore diet and had success in eradicating SIBO doing that diet instead of the elemental. But these are all the treatment options. We just have to-

Dr. Weitz:                            When you’re treating the patient with the antimicrobials, do you change their diet?

Dr. Morstein:                     Personally, I do not. So here’s how I work. I work first on eradication.

Dr. Weitz:                            Because some docs will use a low FODMAP.

Dr. Morstein:                     I know. So I do eradication. After it’s eradicated. People are not generally symptom free. They still can have some… So that’s when I do, “Okay, we got rid of the bug, now let’s heal the gut. We’ll get you on a diet. We’re going to heal the gut, we’re going to help with digestion, and we’re going to get your gut now back on track, but we can’t get it back on track until the bugs that are causing it or eradicated.” So for me, I do eradication and then I do everything else to heal the gut, heal the leaky gut, get the digestion better, get everything needed that we need to have it be a really healthy gut again.

Dr. Weitz:                            What about the use of probiotics?

Dr. Morstein:                     I used to add probiotics into the eradication protocol, and there are studies that show that can help actually.

Dr. Weitz:                            There’s practitioners and that’s their first line treatment.

Dr. Morstein:                     Yeah. Right now I add it in. My eradication protocols are pretty successful, so I wait for the probiotic now at the end, unless the patient really wants one, then I am using very SIBO specific probiotics.

Dr. Weitz:                            Some docs like to use a spore-based probiotic.

Dr. Morstein:                     Yeah, I don’t like those, so I don’t use those. I know a lot that other docs. Personally I’m not a big spore person. Or if I did spore, I would still do a lacto bifidobacteria product. We all know that different docs do different things and have different results. I haven’t ever really seen a lot of supportive things for me and my patients using spores personally, but I know other docs find it very, very helpful. I use though regular type probiotics for SIBO patients.

Dr. Weitz:                            Okay. Do you address motility?

Dr. Morstein:                     Yeah. You have to. That’s like I say, my protocol is you do the eradication and then you’re going to retest. On the same day you retest, you start the prokinetic right away because if it is eradicated, I may take me five days or so to get the test back, we don’t want it to be coming back, so you have to get on a prokinetic immediately. And prokinetics can be supplements, compounded medicines or drugs. So you’ve got one or the other and you have to choose which one is best. And then with supplements, you’ve got stronger ones and then weaker ones versus ones to give a person with constipation versus ones to give a patient with diarrhea. So I would give a stronger one for the constipation and a weaker one for the diarrhea. But they’re both-

Dr. Weitz:                            What’s a weaker and stronger natural prokinetic?

Dr. Morstein:                     I think the strong, for me, the strongest supplement is SIBO MMC. That’s the one that I find the most success with. For just regular people that have normal bowel movements or diarrhea, then anything like GI Motility Activator, Motility Complex, just your ginger artichoke or when some people are so sensitive to ginger, then just artichoke extract.

Dr. Weitz:                            What does the MMC product tap besides ginger and artichoke?

Dr. Morstein:                     So has 5-HTP. It has ginger artichoke. It has a couple of herbs that other products don’t have jujube. I have to look them up. Off the top of my head. But there’s a couple of Asian herbs that other products don’t have.

Dr. Weitz:                            And you feel that’s a stronger product?

Dr. Morstein:                     I do, yeah, I do. Definitely, for my patients.

Dr. Weitz:                            Do you do anything else for the constipation with the IMO methane patients?   Magnesium citrate, et cetera?

Dr. Morstein:                     Obviously I’m trying to not just dump people on laxatives. They can do laxatives on their own. Magnesium is a laxative.

Dr. Weitz:                            Oh, I mean, it’s a natural mineral.

Dr. Morstein:                     It’s a laxative. Like milk of magnesia. That’s not magnesium supplement, that’s a laxative. So they’re taking magnesium in these high doses as a laxative, I’d really like to work with them as much as possible and get their own guts working as best we can, before we just say, “Oh, you know what? Just here, take a bunch of magnesium and there you go.” And we’re not really healing their gut of constipation. Now, some patients, they may need to be on Motegrity and they have idiopathic constipation and they won’t have a bowel movement for a week or so at a time. So there are patients where that is their life, but I’m first going to try other things before I just say, “Hey, wind up on. Just take a laxative.”

Dr. Weitz:                            You mentioned elemental diet.

Dr. Morstein:                     I did mention elemental diet.

Dr. Weitz:                            What’s your protocol? How often do you use that?

Dr. Morstein:                     I don’t use it too much just because, one, patients don’t want to be on it. And two, the other protocols, I generally do elemental diet when there’s just been systemic failure with the other protocols or a patient is willing to do it or whatever. But I generally use the ITI physician-

Dr. Weitz:                            Integrative Therapeutics product.

Dr. Morstein:                     Right. And dextrose free. We have to always use dextrose-free. Elemental diets are not dextrose free, and that is going to grow a bunch of yeast and guts almost invariably. So if that has to be taken with an antifungal or just switch to a dextrose-free one. So then generally you’re just figuring out what their calorie need is. Say they need 1500, a woman, or I had one guy do 2,700 a day, that was his calorie needs, and two scoops is 300 calories. Mix it with eight or 10 ounces generally of cold water or chipped ice and sip on it with a straw for 30 minutes. You have to ingest it very slowly and then just repeat how many times you need to get your calories in for the day.

Dr. Weitz:                            Okay.

Dr. Morstein:                     Yeah.

Dr. Weitz:                            You find that often effective?

Dr. Morstein:                     It can be effective and it cannot be effective, like everything else. Or like with everything else with medicine. So it can be effective. There have been, Dr. Siebecker reported on people actually having worse methane sometimes with an elemental diet. So that was interesting. Generally when I’ve done it’s been successful. So my experience hasn’t been that patients have historically gotten worse on it.

Dr. Weitz:                            After the killing phase, what does your next phase consist of?

Dr. Morstein:                     After the killing phase, and they’re on the prokinetics, so I have a diet handout. I don’t do FODMAPs. I do a modified special carbohydrate diet starting out strict, and then each week getting less and less strict and the diet’s about five weeks. And then we’re going to try to start just eating normally again. And so I go through the handout with them. I add in product to help heal the gut lining, product SIBO-Rebuild. I might do for sure a digestive enzyme, a multiple vitamin, fish oil, the prokinetic, and then a probiotic as well. That’s its own entity. So I can’t really throw that in with the eradication.

                                                And I also like this mind-body connection. So say for the first part, their whole thing is, “I’m eradicating, I’m eradicating,” connecting with their body versus, “I’m eradicating and I’m on the diet and I’m taking a [inaudible 00:49:06].” So I like it pure and clean with patients to have it so we eradicate, “And now I’m healing, I’m recovering, I’m getting my gut back healthy again.” I know there are docs that do it differently and that’s why medicine is so interesting and patients just have to find the right doc that they best resonate with.

Dr. Weitz:                            Now, you mentioned that you do a stool test as well. When do the results of the stool test come in? If you see, let’s say you see high strep and staph and you’ve eradicated their SIBO. Now, do you assume that’s probably reduced the staph and strep, or do you try to address that separately? Do you address some of the other things on the stool test?

Dr. Morstein:                     If there’s a pathogen, then they’re going to do sensitivity testing. And so I’ll know, say they had elevated klebsiella or citrobacter or proteus, those are going to cultured and I’m going to know what kills them. And so I’ll have a treatment sheet where we’ll say-

Dr. Weitz:                            Well, if you do a stool test, they’re cultures.

Dr. Morstein:                     I do. That’s the only one I do. Yeah, for sure. And that’s one of the best reasons I do it is I know for sure what-

Dr. Weitz:                            Are you using Genova or Doctor’s Data?

Dr. Morstein:                     I use Doctor’s Data generally. So then their treatment sheet will be, say, I also do send them home with a diet diary. So for a week and also a candida questionnaire, the original two-part questionnaire from Dr. Crooks book, The Yeast Syndrome from 1984.

Dr. Weitz:                            Do you also do food sensitivity test? Okay, let’s finish with the stool.

Dr. Morstein:                     No, let me finish.

Dr. Weitz:                            Sorry, I’m all over the place.

Dr. Morstein:                     You are all over the place. So with the stool, we’re going to have, “Okay, they’ve got SIBO.” We’ll have that protocol. Underneath, they may have fungus overgrowth. We know with SIFO, at least 40% of patients with SIBO has SIFO. We also know it can be in the colon as well. So I’ll set up the fungal protocol after SIBO, and then we also have then say there is klebsiella, well then we have healing the gut. Maybe they’re low on beneficial bacteria and we’ll have to do prebiotics after we eradicate the SIBO. Or maybe they have low butyrate or something. But there’s a triad. We’re going to start with SIBO. We’re going to do fungal after then heal up the colon as well. Or maybe if we have to order the medications from Canada, which can take a month, then I’ll just start with the fungal protocol. We’ll do that first. Why waste the month? My fungal protocol. So we’ll just start with that, and then we’ll follow up with SIBO when we have those medications. So there’s a lot of fluidity in that regard.

Dr. Weitz:                            It is your fungal protocol prescription or herbal?

Dr. Morstein:                     It’s a combo. I love nystatin. And then I mix it with Kolorex, the Horopito, which is an antifungal. And it looks like it has some capacity to also be a BioFilm Buster for fungus. So I mix that together within then a probiotic. Of course, if they have SIBO, I’ll give them a probiotic that is good for a SIBO gut and that they won’t react to.

Dr. Weitz:                            What probiotic is good for a SIBO gut.

Dr. Morstein:                     I usually do two. One is Klaire’s Lactoprime Plus, and then Xymogen has a Probiomax DF that has [inaudible 00:53:16], which is a good one for more constipated patients ’cause it helps move the gut forward. So those are the two that I usually choose from. And then food sensitivity. Now, I may or may not do all three of these at one time. At least if I’m doing SIBO, I want to do the colon. Food sensitivity, a lot of patients, they come in on these restricted diets, they’ve already pulled this and that and this out, and so it may be helpful or it may not be helpful. And so I have to analyze that with the patient. If they’re just eating a regular normal diet and they’re having IBS and just coming to see me, I may do that first before the SIBO and the stool and just see if we pull that food out that they’re all better. So I may start with that and say, “Let’s just do this for a month and see what happens.” And sometimes they come back, “I’m all good.” And if they don’t, then we can do the deeper other investigations.

Dr. Weitz:                            Good, good. A lot of really good information.

Dr. Morstein:                     I hope so.

Dr. Weitz:                            I’m ready to bring it to a close. Do you have additional things you want to talk about or mention?

Dr. Morstein:                     No, no. This was lively.

Dr. Weitz:                            I like to keep it lively. All right, Dr. Morstein. How can patients find out more about you if they want to work with you and have you help them?

Dr. Morstein:                     Basically I’m at drmorstein.com. And also I’m at nevyhealth.com. So I’m at both sites. I’m in Mesa. I do telemedicine 480-833-0302. So there you go.

Dr. Weitz:                            And do you have courses for practitioners?

Dr. Morstein:                     Yeah, I did a SIBO course through the AZNMA, that’s Arizona Naturopathic Medical Association, so aznma.org. They have a SIBO class that I did archive.

Dr. Weitz:                            And then you did one for SIBO SOS as well?

Dr. Morstein:                     Oh, yeah. I’m a regular speaker on SIBO SOS. I’m on their Gut Summit, which is coming up in I think April or so. I’m very honored to be a regular speaker at the SIBO SOS Summits.

Dr. Weitz:                            That’s great. Thank you Dr. Morstein.

Dr. Morstein:                     Thanks then. Hope you have me back one day.



Dr. Weitz:                            Thank you for making it all the way through this episode of the Rational Wellness Podcast. For those of you who enjoy listening to the Rational Wellness Podcast, I would certainly appreciate it if you could go to Apple Podcasts or Spotify and give us a five star ratings and review. That way more people will discover the Rational Wellness Podcast. And I wanted to let everybody know that I do have some openings for new patients, so I can see you for a functional medicine consultation for specific health issues like gut problems, autoimmune diseases, cardio metabolic conditions, or for an executive health screen, and to help you promote longevity and take a deeper dive into some of those factors that can lead to chronic diseases along the way. And that usually means we’re going to do some more detailed lab work, stool testing, sometimes urine testing, and we’re going to look at a lot more details to get a better picture of your overall health from a preventative functional medicine perspective.  So if you’re interested, please call my Santa Monica, Weitz Sports Chiropractic and Nutrition office at 310-395-3111, and we can set you up for a new consultation for functional medicine. I’ll talk to everybody next week.


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