Controversies in SIBO with Dr. Allison Siebecker: Rational Wellness Podcast 359

Dr. Allison Siebecker discusses Controversies in SIBO Testing and Treatment with Dr. Ben Weitz.

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Podcast Highlights

1:28  Testing for SIBO.  Dr. Siebecker still prefers the SIBO breath test that measures hydrogen and methane that has been around for years and she prefers the version where they do it for three hours.  She also likes the Gemelli Labs Trio-Smart test that measure hydrogen, methane, and also hydrogen sulfide gases, which is the newer SIBO breath test.  Dr. Siebecker has a hydrogen sulfide SIBO study group and the consensus in the group is that Trio-Smart under-reports methane.  On the other hand, the studies used to validate the Trio-Smart test were really good.  Using the older SIBO breath test, if there is a flat line for hydrogen, this is often used to indicate hydrogen sulfide SIBO. Dr. Josh Goldberg and Dr. Siebecker and others have found that if patient did both the older SIBO test and the Trio-Smart, there was not a good correlation between the flat line and a positive result for hydrogen sulfide.  On the other hand, Dr. Siebecker pointed out that when patients with a flat line get tested with treatments for hydrogen sulfide, they often improve and feel better.   

7:37  Three hour SIBO breath test.  While it is more common to do the SIBO breath test for two hours, Dr. Siebecker prefers that the test be done for a three hour period of time.  For one thing, while excess hydrogen production is known to occur only in the small intestine, the organisms that cause excess methane and hydrogen sulfide are known to overgrow in the large intestine as well as in the small intestine.  Therefore, doing the SIBO test for 180 minutes instead of only 120 minutes can help, with the assumption that after 120 minutes the lactulose is in the large intestine.

11:50  Fructose as the substrate.  The use of fructose and glucose as well as lactulose as the substrate for the SIBO breath test. While the SIBO breath test is most commonly done with lactulose, some doctors, such as Dr. Jason Hawrelak from Australia, often has patients perform the test with lactulose, glucose, and also fructose. In fact, Dr. Hawrelak has found that fructose is actually more accurate than lactulose for diagnosing SIBO.  If you have a patient who tests negative with lactulose, you might consider having them repeat the test with fructose.

17:57  The Food Marble.  The FoodMarble is a portable SIBO breath testing device that the patient can buy and use at home over and over as needed and this device it threatens to upend the SIBO testing industry.  It can help you to figure out your dietary triggers.  Once you buy one for about the cost of a breath test, it allows you to be able to retest regularly, which otherwise can cost a lot.  And the validation studies on its accuracy seem to be pretty good.


Dr. Allison Siebecker is a Naturopathic Doctor and Acupuncturist specializes in the treatment of Small Intestinal Bacterial Overgrowth and she teaches advanced gastroenterology at the National University of Natural Medicine. She has the most incredible resource of research articles and information about SIBO, siboinfo.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. Allison Siebecker, one of my favorite people, about controversies in testing and treatment for small intestinal bacterial overgrowth.   Dr. Allison Siebecker is the Queen of SIBO. She’s a naturopathic doctor and acupuncturist specializing in the treatment of small intestinal bacterial overgrowth. She teaches advanced gastroenterology at the National University of Natural Medicine. She has the most incredible resource of research articles and information about SIBO at her website, siboinfo.com. Dr. Siebecker has been participating in the SIBO SOS program, which is another incredible resource of courses and information about SIBO. Allison, thank you so much for joining us.

Dr. Siebecker:                    Thank you so much for having me.

Dr. Weitz:                           So let’s start off with testing for SIBO. So which SIBO tests do you currently recommend?

Dr. Siebecker:                    Right, because we have some new additions in here.

Dr. Weitz:                           Yes.

Dr. Siebecker:                    Well, I still like the standard test that most of us have been using, which is a test for hydrogen and methane and uses lactulose. I like it three hour, and I like it when it has… The most samples that it can come with typically on the market is 10, meaning 10 tubes or bags or collection items. So that’s the standard for a very long time, and I still really, really like that. But we do have some newbies. Gemelli Labs has Trio-Smart. That’s been out about three years now, I think, but it still feels new, right? For a lot of us.

Dr. Weitz:                           It’s only available in the United States I think at this point, right?

Dr. Siebecker:                    I think so. Yeah. That one tests for hydrogen sulfide. We were all really excited, waiting for that. I like that test too because it tests for hydrogen sulfide. Then I feel a little bit bad to share this just with the public but I will is that I have a hydrogen sulfide study group that we assembled a bunch of practitioners to basically study when the Trio-Smart came out and help each other with what we were all seeing. From that group, many of the doctors in there, they shared that and basically they saw when they would compare the test against the standard hydrogen methane test because they would run too often on one person that the methane sometimes was lower on the Trio-Smart than on the traditional test.  So some of the docs there, they just felt that it may be under-reported methane, the Trio-Smart. Now when the studies are done, studies were done to validate Trio-Smart against the standard machinery. The studies were great, so it doesn’t line up. This is more of like a clinical happenstance. Studies are great. So just passing that along. Because of that, it’s really hard to explain why I haven’t switched fully over to Trio-Smart, because I’m always very concerned about missing anybody with SIBO. I want to be sure that I find it when it’s really there. By SIBO, I mean the methane type of SIBO as well.

Dr. Weitz:                           How valid do you think the flat line is as a way to diagnose hydrogen sulfide?

Dr. Siebecker:                    Well, this is really interesting. So for years, that’s what we use. We still use it. I found it very effective in that when you treat people with treatments for hydrogen sulfide and they have a flat line, they respond. They get better. You can often see the next, the retest perform like you’ve seen, they’ve gotten better. Meaning it won’t be a flat line anymore. Also, one of the directors of one of the breath testing labs, for years, I had been gathering symptoms that my patients had that they told me they had when they had a flat line. I was able to come up with this little group of symptoms that to me indicated hydrogen sulfide. I shared that with anyone who wanted to know in all my lectures and things.  So the director of this lab started using that and he got back to me and said he found an excellent correlation with this and that people would really respond to treatment. So here’s this clinical data that seems good. But then my friend who’s does a lot of research, Dr. Josh Goldenberg, he and I and several others, he really led the effort, did a survey. In that survey, so this is low quality evidence, but here it is. We actually found that when people compared the flat line with the Trio-Smart. So do people with a flat line actually have hydrogen sulfide gas? There was a very poor relation. What is a flat line then if it’s not actually hydrogen sulfide? I don’t know. Is this definitive? No, because this is just a survey. It’s not good quality evidence.  But it made us think, “Huh, maybe the flatline isn’t what we always thought it was,” except I don’t care. Because when we treat it like it’s hydrogen sulfide, people get better. But that is an interesting thing that we don’t often see. I’m sure other people will have their own evidence, but someone with a flat line testing positive for hydrogen sulfide on our Trio-Smart. I don’t know why.

Dr. Weitz:                           Have you found that the Trio-Smart also has a relatively small number of positive hydrogen sulfides?

Dr. Siebecker:                    Yeah, I mean that makes sense. Hydrogen sulfide is going to be the least common type of SIBO, the least common gas. Never expected.

Dr. Weitz:                           I’ve heard 10 to 15%.

Dr. Siebecker:                    Yeah, I think so. Maybe less. I mean, it’d be interesting to hear what Dr. Pimentel says, who’s probably got the most experience at saying what the percent is, but that makes sense to me. Pretty low, right? So yes, but the thing is it can be this tricky thing. I think where we want to bring in for sure testing and make sure we’re not missing it is in cases that are challenging. If everything’s going great and you’re treating and there’s no issue, you don’t have to think about it.  But what if somebody still has symptoms and you don’t know why and their test looks negative or things like that or the treatments you’re giving for hydrogen or methane aren’t quite working? Geez, maybe they have some hydrogen sulfide there you don’t know about because clearly there can be hydrogen sulfide without there being a flat line. Then you would need to shift your treatments.

Dr. Weitz:                           Now explain why you feel it’s important to do three hours. Because if on average after 100 minutes or certainly 120 minutes, you’re now in the colon. How are we diagnosing a small bowel issue with a three-hour test?

Dr. Siebecker:                    Because we have these three types of SIBO, hydrogen, methane, and hydrogen sulfide. Methane even now is not really considered a type of SIBO, though I still consider it that way because that’s so long I’ve thought of it that way. So it’s intestinal methanogen overgrowth. Well, it’s only the hydrogen that is small intestine only. So both methane and hydrogen sulfide, those organisms overgrow in the large intestine as well. On our breath test interpretation, we use the whole three hours for the interpretation. So this is why it’s so important. I mean, I have example after example where we could miss somebody’s methane or hydrogen sulfide if we only had 90 minutes or two hours.

Dr. Weitz:                            So if you see a dramatic rise after 120 minutes, you would still consider that positive in either methane or hydrogen.

Dr. Siebecker:                    Not hydrogen, methane or hydrogen sulfide. That’s the thing. That’s the thing. It’s only hydrogen that we’re using the first two hours. But for methane and hydrogen sulfide, we need that third hour, because it’s not just yes or no because the level of the gas influences our treatment choices. Because amongst our different choices, we may choose a treatment that is better at reducing more gas more quickly. Also, it informs our prognosis because we know most people will need multiple rounds. We know on average how much each treatment lowers gas on average.  So we can calculate how many rounds might be needed by seeing how high the gas goes. So we need that information. The other thing is why wouldn’t you just get all the information that would help you if the person’s going through the test? So it really irritates me when manufacturers only offer two hours or less. It’s like you’re shorting us out here. I mean, the person is going through the effort. They did the prep diet, they’re doing this whole thing. What is one more hour? Let’s get all the information we need.

Dr. Weitz:                            Now, isn’t another argument though that the issue about SIBO is that if this bacterial overgrowth occurs in the small intestine and gas is produced, you’re going to have all these symptoms? But if that same gas is produced in the colon, you’re not necessarily going to get those same symptoms because the colon is this very extensible tube and it easily expands. There’s always bacteria producing gases in there, and that doesn’t typically create symptoms.

Dr. Siebecker:                    I don’t think that’s true. I don’t know. I haven’t read studies to prove this one way or the other.

Dr. Weitz:                           But isn’t fermentation very common in colon and isn’t that good, actually healthy?

Dr. Siebecker:                    Yes, at a certain amount. So I think it’s about the amount. It’s about how rapidly the gas is created and how much. Actually, this is the whole basis of the FODMAP diet is just that rapid and excessive gas creation in the larger intestine leads to a lot of symptoms. It is completely my understanding that you would not escape symptoms if there was a lot of gas in the large intestine.

Dr. Weitz:                           Okay. I thought the purpose of the low-FODMAP diet was not to feed the bacteria in the small.

Dr. Siebecker:                    Yeah, they did have SIBO or the small intestine in mind in some of their early papers but barely. Their main target was the large intestine actually, believe it or not. Also, inflammatory bowel disease. Now it’s changed since then. They’ve morphed, but that was the original intention. What I love about that diet is they’re like, “We don’t know what’s causing it. We’re not even going to try and think about it. We’re just trying to help symptoms.”

Dr. Weitz:                            Some doctors, for example, Dr. Hawrelak likes to use different substrates for the SIBO prep test. He told me that he regularly will have his patients do a test with lactulose, a test with glucose, and a test with fructose.

Dr. Siebecker:                    Yeah, I love this. So this is great. This all came out of a conversation he and I had at a conference when we were lecturing. Because long ago, he was a fan of glucose, and I was never a fan of glucose as a substrate because I knew it absorbed pretty quickly, pretty high up in the small intestine. So it couldn’t test the whole rest of the small or the large intestine. We were just talking about how important that is. So I said to him, I said, “Could you give me more information about the comparison between glucose and lactulose? Tell me what you think.” Well, he’s a researcher. So he’s fabulous. He went in his office and he did this in-office study over years. He didn’t publish it, but then as soon as it was ready, we came and I featured him giving out a class on this.  He’s been telling everybody. He came out with the most fascinating information. He found that, well, glucose was the worst at finding SIBO in somebody who had it. So he ran, like you said, each one of these substrate tests on the same person. Lactulose was second best. Fructose was the best and best of all was lactulose and fructose. He ran these on different days. So I brought up the statistics so I could tell you from a study. So glucose was 67% of a diagnostic rate, lactulose, 73%, and fructose, 85%. When we did the fructose and the lactulose together on separate days, it was 96.5%. So this just blew me away and has changed my mind about a lot of things. So what I’ve been doing is recommending to practitioners who are having trouble getting a lactulose test.

                                                There are companies where you can get the lactulose test, but not everybody knows that or wants to do it. So they can order fructose. This made me feel comfortable, recommending fructose as a substrate. It’s interesting, because in my early testing, I did test people with different substrates. This is like 14 years ago or whatever. I didn’t do as many as Dr. Hawrelak. He did 130. I have it written down here, 130. I didn’t do that many. So you need a lot to figure things out, but I often found that people were not positive on a fructose test who were positive on lactulose. So this really surprised me, and that’s the value of doing a bunch of these. Now I have something else to tell you. Dr. Nirala Jacobi, another one of our colleagues, she has a lab in Australia also.  She is now checking this out for herself, and she is running a lot of these lactulose and fructose. She’s only in preliminary data, so it is too early to speak. Please keep that in mind, but she isn’t finding fructose to be better than lactulose. She didn’t tell me if it was the same or worse, just not better at this point. She’ll come out her with her findings, but I still feel confident based on the data from Dr. Hawrelak. So I think it’s a wonderful thing to think about. Something else that he discussed is that he found people who would be negative on lactulose but positive on fructose. I mean, obviously, that’s the difference between that 73% and 85%. So it’s something to keep in mind if you really feel like somebody, you really suspect SIBO and you test them and they’re negative.  You could run a fructose just to see. That’s also the place where you might want to test with the trio if you weren’t to see if there was hydrogen sulfide, if something’s in your mind going, “But I really feel like they have it.” So I’m generally in favor of it. I haven’t switched over to it.

Dr. Weitz:                           Interesting. So one of the issues for some patients and some practitioners is that… I don’t know if this is across the whole country, but lactulose is considered a prescription drug. I know in California-

Dr. Siebecker:                    It’s so irritating. Oh, no, the whole country.

Dr. Weitz:                           The whole country, okay.

Dr. Siebecker:                    It’s a mistake that it’s on there. I’ve talked to so many people about this, but the problem is it would cost a lot of money to get it off the formulary. So it’s going to stay there and it’s a terrible mistake. It shouldn’t be. So then non-prescribing practitioners technically can’t order it, but there are labs you can order it from. Basically, I can just speak about labs because there’s no CE. So Genova offers it and that you can get that also through Rupa Labs, True Health Labs, direct labs.  So they’re the main way. The other thing is that a lot of times, a patient’s primary care, they can give them a prescription for lactulose as a laxative. It’s often used in veterinary medicine. So you could get it and then you could buy a no substrate or a glucose test kit and then substitute it. But here’s now the fructose as a potential option.

Dr. Weitz:                           Is it the same amount as lactulose?

Dr. Siebecker:                    No, it’s 25 grams. Let me just make positively sure that I got that right. I have a little note. Yeah, 25 grams for fructose, 10 grams for lactulose

Dr. Weitz:                           Mixed in eight ounces of water?

Dr. Siebecker:                    Mixed in eight ounces of water. It has to be diluted. Same with lactulose. Isn’t that fascinating?

Dr. Weitz:                           That is fascinating.

Dr. Siebecker:                    Did you have him on to speak about it?

Dr. Weitz:                           Yeah, we did speak about it.

Dr. Siebecker:                    Yeah, fascinating to me.

Dr. Weitz:                           He continues to use all three.

Dr. Siebecker:                    He says sometimes he uses just two, unless he’s changed. Last I heard he had dropped glucose, but he might. Who knows?  He might’ve brought it back because he’s like, “That’s out.”

Dr. Weitz:                           So what do you think about the new SIBO testing device, the FoodMarble?  Is this threatening to disrupt the whole SIBO testing industry?

Dr. Siebecker:                    Right. I forgot. This is the other newbie on the block here, so I have so many thoughts.

Dr. Weitz:                           For those listening, you might not be aware. There’s a home SIBO testing device. It’s known as the FoodMarble, and you can use it over and over again at home. You can test yourself in whatever way you want exactly. You just breathe into that. It measures hydrogen and methane. I think they’re working on a version that’s going to include hydrogen sulfide, and you could duplicate a SIBO breath test. You could do lactulose or fructose and then do it every 15 or 20 minutes, or you can just see how you react to different foods.

Dr. Siebecker:                    Exactly. Yeah. I think that the original intention was just to help you figure out your dietary triggers really. People love it for that. They just test after eating various types of meals and they see where their gas levels are. The gas report comes as a fermentation score, which goes as high as 10. They’ve now broken out the different hydrogen or methane, and they let you know. So it’s not parts per million like it is in a breath test. It’s just to give you a sense of what’s going on, but it works with an app and it’s very user-friendly. On the app, the challenge function is how you do a formal breath test and then you choose whatever substrate you’re going to use. Like you said, you could just buy glucose or fructose or if you can get a prescription for lactose.

                                                So I think it’s amazing because it’s inexpensive and I love that. So because they claim that this device is able to do accurately many, many, many breath tests, I think 40 or more. I think it’s more than that. So that’s for the price of one. It costs about the same as doing a breath test, and then you can run multiple, multiple tests. That’s just incredible because the budgetary concerns are sometimes the biggest impediment in the whole treatment process with SIBO. I mean the treatments can cost a lot too, but I’m a physician who likes to retest a lot. Otherwise, I just feel blinded. You can’t really judge my symptoms very well. What the heck is actually going on with the overgrowth levels? Because they don’t correlate perfectly.

                                                So this can solve the budgetary issues, the retesting issues. So that’s incredible. It’s also so user-friendly. Anyone who’s ever tried it or used it, they love it. I’ve tried it. I think it’s great. It’s so easy to use. Now the issue is what about the validity? This is what everybody wants to know. Just like Trio-Smart, they have done studies that are great and show excellent validation against our standard testing machinery. A colleague of mine, the one who I did that hydrogen sulfide study with, he said he likes the studies. He feels good about the studies. Everyone has to decide for themselves, but I like that a colleague who was a researcher felt good about the study. So that’s good. So that’s good. Now, what about in real life, right?

                                                So in practice, sometimes we see some odd things like an occasional really high level of gas that just blips up. That’s hard to make sense of. Is it correct? It has an opportunity to potentially be more sensitive and more accurate because it’s analyzing the breath instantly, instead of being shipped off for a week in transit and then being analyzed. Because of that, the FoodMarble has a trend I think to have slightly higher gas levels, probably because it’s being analyzed immediately, although there could be other reasons for that. But a number of us have done side-by-side testing. Whenever we do that, by the way, Dr. Pimentel has recommended giving five minutes apart when you’re breathing into two different devices.

                                                The technicians and the scientists at FoodMarble say even two minutes might be enough, just letting you know for anyone who wants to do this, because you need the gases to be able to equilibrate again. You don’t want to have them completely blown off from one test to the next. So anyway, when we’ve done comparison side-by-sides, people are finding different things. I find in the ones I’ve done only I think one or two of them lined up correctly perfectly. Then I’ve seen it all different ways where hydrogen or methane was higher or lower in my side-by-side tests. I haven’t really quite decided what that means and what I think about it. I can say that I have colleagues who don’t feel good about it because of that, because it’s not perfectly lining up.

                                                So they want to stick with what they’re used to. I have other colleagues that love it and they don’t care if it lines up or not. They feel like the advantages are so great, the studies where they’re validating it, that they’re just using it and they’re recalibrating their clinical sensibilities to the device, to the new data. For me, I’m used to just a lot of data, because as a SIBO specialist, I ran tests all day long every day. I need to see a lot more of their tests until I decide fully what I think of it, but I’m favorable towards the advantages that it has to offer. So what do you think, Ben? Have you tried it?

Dr. Weitz:                            I’ve got one now and I just started fooling around with it. I don’t know yet. I have a couple of patients that are going to be doing side-by-side and I’m curious.

Dr. Siebecker:                    Me too. The other thing that people should note is that to get the parts per million, practitioners can get that. You just have to ask them and sign up for the clinician’s dashboard, I think it’s called. So that’s a website you can go to that’s connected where you immediately see the results in parts per million. They have graphs and things like that, because otherwise, you’ll get the fermentation score. So that’s the one drawback for patients who are using it. If they do a formal SIBO test, they’re only going to see a fermentation score. Someone needs to be a practitioner to get that clinical dashboard and see the parts per million. That’s a limitation that I’m not fond of but they know that, and I’m sure they’re doing whatever they need to do legally. Who knows? Maybe it’ll change.

Dr. Weitz:                           Do you often order a stool test as well to look at the microbiome with your SIBO patients?

Dr. Siebecker:                    Well, I’m not in practice now, but when I was, I wasn’t running microbiome tests. It was like before that became a big hot thing. But I did run functional stool tests a lot, but not microbiome once. Tell me where you’re heading with this one. Have you been doing it? Are you correlating things?

Dr. Weitz:                           Yes, I do. I regularly do a stool test and I like to see what else is going on in their gut. It seems to me a lot of patients with SIBO also have other issues.

Dr. Siebecker:                    Well, that’s for sure. I mean, personally, I think when someone comes in and you suspect that they would have SIBO, you should run expanded screening blood work, the SIBO test, and a stool test. To me, that’s just the fundamentals. It would be sure great if you could also run a really good hormone test.

Dr. Weitz:                           Right, absolutely.

Dr. Siebecker:                    But for certainly stool and breath, because yeah, we have to see what’s happening in the large intestine as well.

Dr. Weitz:                           Yes, exactly. So I talked to several practitioners who feel that the bacteria that caused SIBO are migrating up from the colon. It’s my understanding that Dr. Pimentel originally felt that that was the case, but that current data doesn’t really indicate that that’s the case. What do you think about that?

Dr. Siebecker:                    Yes, that’s my understanding. Ben, I just have to say for anyone watching, I don’t know why my face looks so red. I see it on the screen, and Ben was saying he looks orange. We tried to adjust our light beforehand. I don’t know what’s happening. So sorry about that.

Dr. Weitz:                           It’s okay.

Dr. Siebecker:                    Because I just looked over and saw myself. I’m like, “Literally, I have a sunburn.” I don’t know what’s happening. Totally, that’s my understanding. I was never of that belief that it was a back migration. Even though so many articles and studies said it, that just didn’t make sense to me. Then as Pimentel’s research continued, he came to the same conclusion just as you said. At one of our SIBO symposiums, we used to have SIBO symposiums each year at NUNM where I teach. He said that. He said, “Now I think the majority is it’s there in the small intestine already at low levels and then it overgrows.” So I was thrilled because I felt validated. That is my understanding. It is possible some could come up, but I don’t think that’s the majority of what’s happening. So yeah, I think it’s just overgrowing. It’s already there.

Dr. Weitz:                            There seems to be some studies correlating some of the bacteria that appear in the mouth with the bacteria that end up that caused SIBO.

Dr. Siebecker:                    Yeah, that’s interesting. I’m so sorry. I forget the main researcher’s name. There’s one researcher that’s been working on that premise the whole time I’ve known about SIBO like 15 years or more, and now others have been following in his footsteps. So there’s some little group that is into that thinking. They like to separate oral-like bacteria SIBO from small intestine bacteria SIBO. I don’t think Dr. Pimentel is on that train. I don’t think he’s thinking that way. So that’s like an offshoot of a different thinking. Think it’s Dr. Bohm. We had him come speak at one of our conferences one time. So very, very interesting.

Dr. Weitz:                            Currently, what are the best ways to stimulate GI motility? Do you have any experience with Dr. Satish Rao’s vibrating device?

Dr. Siebecker:                    Oh yeah, that is the coolest thing. The vibrant capsule is just so amazing.

Dr. Weitz:                           Which I don’t think is on the market yet.

Dr. Siebecker:                    It is.

Dr. Weitz:                           It is on the market.

Dr. Siebecker:                    Yeah, it is on the market. I can’t remember exactly when, but it’s been out for a good while now. I haven’t used it, but I’ve talked to a couple colleagues who have. As with anything, some people have amazing results and other people it just didn’t do the job. For anyone who doesn’t quite know about this, this is a non-drug treatment for chronic constipation, really meant for the patient where typical treatments don’t work. Actually, laxatives don’t work. Various medicines don’t work. Prosecretory agents, Amitiza, they’re just not doing the job and you’re at your wits end. You could bring this in. Now, I think you could bring it in even before that. If somebody really has chronic constipation, how nice for them not to have to swallow anything.  So this little pill, it’s timed and it’s timed to just give this very gentle vibration when it would be hitting the large intestine. So anyway, in one patient for a colleague of mine, it was an absolute miracle game changer, insane constipation that nothing would do anything about. This gave her the urge and she goes naturally now normally. Another colleague, it just didn’t work for them. So I guess you have to find the person it’s going to be right for, but I think it’s so great we have this option. So that’s a wonderful thing for stimulating large intestine motility. Yeah.

Dr. Weitz:                           How long does it work for?

Dr. Siebecker:                    Oh, I think you take it five. There’s five capsules you take in a week.

Dr. Weitz:                           Okay.

Dr. Siebecker:                    So it’s almost like a daily thing.

Dr. Weitz:                           I see. Okay.

Dr. Siebecker:                    Yeah. It’s not inexpensive either. I know they had an introductory price. Since it’s new, it hadn’t yet been covered by insurances. So I know that I think in both these cases they were paying out of pocket. So let’s hope it gets covered by insurance and the price becomes better, but in a certain situation, it’s going to be the right fit for some people.

Dr. Weitz:                           What would you say is the most effective drug for motility and nutritional product for motility?

Dr. Siebecker:                    I guess it depends on what kind of motility we’re talking about.

Dr. Weitz:                           Okay.

Dr. Siebecker:                    If we’re talking about large intestine motility meant to create a bowel movement, in essence, a laxative, I have my favorites, my favorite supplement. It’s not a stimulant laxative. So it’s not actually creating movement. That would be magnesium oxide or magnesium citrate. I like osmotic laxatives for actually stimulating movement in the large intestine. Many people like the prosecretory agents, Trulance, Ametiza, Linzess. They’re tricky. So magnesium can be tricky too. You have to make sure you’re getting the right dose at the right time or it could be too strong, but some people, that’s a game changer for them. I’m not the hugest fan of stimulant laxatives that are natural, but many people do like them, senna, cascara, aloe, rhubarb, things like that.  But then we could move to the class of drugs that are prokinetics and they’re really aimed more at and natural agents, the upper GI. So more like the esophagus, the stomach, and the small intestine. So those are used more for achalasia, gastroparesis, and for the migrating motor complex in the small intestine. I mean it’s hard to say a favorite, but I would say probably the most effective would be prucalopride, which is still this Motegrity in the US. Amongst all the gastroenterologists I’ve spoken to, they say it’s the best they’ve ever used. Almost no side effects. I mean, people can have reactions, but no adverse concerning side effects.

Dr. Weitz:                           It certainly seems to be Pimentel’s favorite.

Dr. Siebecker:                    Yeah, many, many gastroenterologists I’ve spoken to. Yeah, because many of our prokinetics that were available had cardiac risks and extrapyramidal symptoms, all sorts of awful things. There’s so many practitioners that think prokinetics as a category is dangerous and that’s not so. There are safe options, but that’s really probably the best there. Naturally, the main things we have is Iberogast, which is like a combo herbal product. Actually, there’s like a dupe now for that because it can sometimes be hard to get.

Dr. Weitz:                           Yeah, very hard. Yeah.

Dr. Siebecker:                    That’s by Heron Botanicals, which is a company from fantastic herbalist and naturopathic doctor. They have a product called Gut Motivator, and it uses pretty much all the same ingredients, except I think there’s fennel instead of something else. I can’t remember.

Dr. Weitz:                           Oh, interesting. Gut motivator.

Dr. Siebecker:                    Gut motivator. It’s in glycerin base, which is nice because it’s easier to take straight from the dropper and it tastes a little sweeter. The only problem with it is that they’re still ramping up. They grow a lot of their own herbs and they’re so ramping up their supply of Iberis amara, the main ingredient that gives its name. So they’re only selling to practitioners at this time. So it’s not ready for the general public, but it will be eventually.

Dr. Weitz:                           Is that available through Fullscript?

Dr. Siebecker:                    No, not yet. I’ve asked them to carry it, but you have to get it from Heron Botanicals right now. So just so people know there’s another option. Some of my colleagues are reporting very good results with it, so I’m glad to hear that. But the other really nice prokinetic is for the upper GI’s ginger. So many studies on that. By the way, so many studies on Iberogast. I mean, it’s been around for a long time, amazing studies where head to head against Cisapride and metoclopramide, other prokinetics where it did just as good, if not even better. So amazing. But then ginger also has excellent prokinetic ability, and we have all of these companies now that put it in their formulas. I call them the ginger-containing prokinetic formulas. There’s six of them.

Dr. Weitz:                           Yeah, we use motility activator a lot.

Dr. Siebecker:                    Yeah, that’s a good one. There’s a lot of good ones. So those are some options. I mean, there’s probably other options, but that is generally good.

Dr. Weitz:                           So we know that patients with IBS, 60 to 70% have SIBO. Then the question is what about the other 30 or 40%? So how often do you think patients have SIFO or fungal overgrowth, and what’s the best way to diagnose that?

Dr. Siebecker:                    I think a good amount do. I can’t remember the statistics from Dr. Rao’s studies on this, but I think it was at least a third also have it, if not more. It depends on your patient population, but I think a lot of us see that a lot. When I was first practicing for SIBO, for years and years, I was looking for yeast and a majority of my patients did not have it at the same time as SIBO.

Dr. Weitz:                           How were you trying to look for it?

Dr. Siebecker:                    Okay, so I don’t think the testing options are great. The gold standard is going to be endoscopy, which is impractical.

Dr. Weitz:                            Right.

Dr. Siebecker:                    Yeah, but I was honestly running three tests because people were coming to me as a specialist. I was running the urine organic acid test. That can’t distinguish between small or large intestine, but it can show indicated and overgrowth by metabolites. Then I would run a functional stool test and look for actual overgrowth in the stool, and then I would run a blood test. The Candida Immune Complex and Antibody test, Quest and LabCorp have that. So I would run all three. Then with the blood test, it doesn’t really tell you whether there’s an overgrowth. It more so tells you if there’s a hypersensitivity. There could be an overgrowth, but it could also be that there’s a normal amount of yeast and their immune system has decided to react against it.  So you are telling different things from this, but I lost confidence in doing those tests. I never felt very sure about what was the best and right way. I can say that you recently had Dr. Morstein, I know. She likes to use the questionnaire from The Yeast Connection, the old Yeast Connection book by Dr. Crook, which I think you can see the questionnaire online. She likes to say that it has been shortened. That questionnaire has been shortened to five questions or seven questions, and she doesn’t think that’s adequate. So she likes just use the questionnaire. I always like to ask other practitioners what do they feel confident with in testing. I don’t think we have a perfect way to test.

Dr. Weitz:                            Well, I feel like with the stool test, since it usually does not come positive that when it is positive, I feel pretty confident that there is candida there if it comes up on the stool test.

Dr. Siebecker:                    I would agree.

Dr. Weitz:                            Organic acids seems to come up too often positive potentially. I’m a little skeptical. I haven’t used … I know Dr. Ilana Gurevich, she loves the candida antibodies test.

Dr. Siebecker:                    The blood one. Yeah.

Dr. Weitz:                            Yeah. I haven’t done that test though.

Dr. Siebecker:                    Yeah, I mean, I used to run them all. I can’t remember what happened, but I think I had somebody with a yeast overgrowth infection vaginally and the organic acid test, maybe it wouldn’t because maybe that’s only telling you the intestinal situation. I don’t know. Then the blood test didn’t come positive and I just thought, “Oh, this is hard.” Maybe it wouldn’t, but I don’t know. Just somewhere along the line, I lost confidence and I stopped doing them all. But I do think that to your point, what are the other things that can be IBS that aren’t SIBO?  A lot of times people have other things at the same time. Yeast is really common. I mean, I’m saying that without having a proper way to diagnose it, but it’s like because then you treat it and they get better. Then parasites also I think are very common. I mean, I’ve written differential diagnosis charts on this, and you just get tired of including things. It’s like 40-

Dr. Weitz:                           By the way, I just saw or listened to your podcast that you did with Nirala Jacobi.

Dr. Siebecker:                    Is it out? I didn’t even know.

Dr. Weitz:                           It’s out. I listened to it this morning and it was great podcast. Nirala Jacobi was really good too.

Dr. Siebecker:                    Oh, good. I really enjoyed that.

Dr. Weitz:                           You guys went through all of these different possibilities, and you made a really profound statement, which was that you find that practitioners often find what they look for.

Dr. Siebecker:                    That’s exactly right. It’s like, “Well, what are we testing for? And then what do we know?”

Dr. Weitz:                            I’m a mold expert. I’m looking for mold and I’m finding mold.

Dr. Siebecker:                    That’s right, because it’s what we choose to test for. But then, of course, what if our tests don’t turn anything up? Well, then we got to look over in the area we don’t normally look, but I mean, what are you supposed to do? Also, you can’t test for everything. People can choose their own path where they want to put their attention first. If that works out, great, and if it doesn’t, then we have to look other places.

Dr. Weitz:                            A similar question, which is it’s known that so many patients who get treated with rifaximin or herbal antimicrobials don’t get completely better after one round. Why do they need multiple rounds? Is it because we haven’t effectively reduced the microbes, we haven’t killed enough of them, or is it that they grow back? Is it because there’s biofilms and we can’t get to them? Is it because there’s layers of problems like you’re mentioning other things? So maybe they have SIBO and they have dysbiosis, and we have to correct both of those. Why do we think it takes repeated rounds?

Dr. Siebecker:                    I mean, all of that can be true. So yes, yes, yes. But I think predominantly, what my experience has been is it’s just that it’s different when we have an overgrowth versus an acute infection that we’re used to thinking of where there’s a prescribed acute infection and we know 10 or 14 days of an antibiotic is going to take care of it. Because here in SIBO, we have these levels of which the overgrowth can be and we can see the gas can be 150 or something. In another person, it’s 20. So it seems to correlate the amount of rounds with the overgrowth amount. The gas is a representation of how many bacteria are grown. So I think it just takes time. Basically, it’s thinking of a chronic infection, even though it’s not technically an infection. We treat until we get effects.

                                                We just have to keep going and going at it. So then the question is why can’t we just use one treatment and then just treat for however long it takes until it goes down? For some people, that does work, but unfortunately, what I found happens so often was the treatment would peter out. Its effect would peter out and it would stop working. You’d know because they would have had some improvement and then their symptoms would come back while they’re even taking it. So it’s like it just couldn’t do anymore. It did all it could do. So then you just stop. At that point, I would retest, but you have to switch. You use something else. Thank gosh, we have a lot of tools in our toolbox.

                                                So then that’s the next round. If a patient is sensitive enough to pay attention to these things, some people are, some people aren’t. I think great. If they’re still getting effects, you can keep them on something until it’s not working anymore. But not everyone is paying attention like that or wants to. So that’s why we need, I think, the multiple rounds. Now, what about the biofilms, anti-biofilms? I think that that’s another thing to think about for sure. My experience was that I used a lot of anti-biofilm products for a long time treating SIBO, and then I wouldn’t use them in other people. So I had a good comparison and I was only using the enzyme-based anti-biofilms and the EDTA type of products. I could detect no difference at all in anything at all.

                                                Really, my intention in using them was to try to prevent as much relapse. That’s what I was hoping for, and that was a bust. But I can tell you that Dr. Ruscio did an in-office study on that and presented this at one of our SIBO symposiums. He found that statistically on paper when using the anti-biofilms, it reduced hydrogen gas a little, but he could not detect that clinically at all. There was no clinical representation of that. It was a statistical on paper thing. So just continuing down with this story, I was just very disappointed in anti-biofilms. But then I spoke to Dr. Paul Anderson, this was years and years ago, and he’s an anti-biofilm expert.

                                                He had treated a lot of conditions with very serious infections, and he had done a lot of research and found that bismuth thiol products were very good anti-biofilms and he thought the best. Now, he has an over-the-counter option, but at that time, he just had a prescription formula. So I used that in some of my patients and I found it made a difference. Where it made the difference was in relapse. I didn’t necessarily see as much of a difference in not needing multiple rounds. I think theoretically, it could make a difference. I just didn’t observe that at the time. So I like to recommend if you’re going to use anti-biofilm in SIBO that you use the bismuth thiol. I just couldn’t see any effect for three years of using the other products.  Maybe other people have different experience, but it was a dud for me. So I would say it is definitely worth an option and maybe it could reduce. I know when you’ve had Pimentel on your show in the past, he’s talked about, and even just recently I was doing a Q&A with him, finding that some of the overgrown microbes live in a biofilm along the lining. I know you’ve asked him and I’ve asked him, “Well, then what about anti-biofilms?” I think he’s waiting until he would present research whether it would be truly effective or not.

Dr. Weitz:                            I know particularly the methanogens seem to live in this mucus layer, which is a biofilm that it’s got to be hard to get to those. We know that treating methane seems to be more difficult than hydrogen.

Dr. Siebecker:                    What has your experience been with anti-biofilms?

Dr. Weitz:                            Sometimes I think we get a benefit and other times we don’t. So I haven’t done any systematic analysis of it, but I get the impression that we get some benefit from it.

Dr. Siebecker:                    That’s good. Do you use all the different types or just the bismuth ones?

Dr. Weitz:                            Yeah, no, I use the enzymes. I often start with the enzymes and then use the bismuth ones depending upon exactly what’s going on. I’m a little nervous about using bismuth for long because it is heavy metal.

Dr. Siebecker:                    Yeah, that’s right. We talked about that before. The good news with the bismuth thiol is… Well, this is in the context of treating hydrogen sulfide SIBO is bismuth helps with that, but the bismuth thiol are a much lower dose than what has been studied bismuth for hydrogen sulfide. So I like that we can use a much lower dose with those bismuth thiol ones.

Dr. Weitz:                            Speaking of treating hydrogen sulfide, in fact, any new treatments for especially herbal nutritional for treating SIBO? The traditional antimicrobials that are used are berberine, oregano, allicin. Any new guys on the block that seem to be hitting the radar?

Dr. Siebecker:                    Well, I’d say that bismuth. I mean, that’s not really that new, but it’s worth really mentioning. Other than that, well, Atrantil, we’ve been using that for years. That’s a combo product for methane. I did a bunch of before and afters. That’s not really new, but just mentioning it, right?

Dr. Weitz:                            Correct.

Dr. Siebecker:                    I haven’t really been using anything new, but Dr. Hawrelak has reported using perilla and tincture of oregano, which we already were using oregano, but he actually was reporting that he found that that worked on methane. I had used oregano for methane. I thought it was going to give me a result, and then in the end, it didn’t pan out. So I just wonder, “Huh? Could the tincture be the difference?” Because I really never did see much of an effect from oregano for methane, but perilla is a new one for me. I haven’t used it. So he’s using that one too, but he’s using that only when the standard things aren’t doing the job.

Dr. Weitz:                            Then some of the products have oregano and they also have thyme. The thyme oil seems to be… I find sometimes very beneficial.

Dr. Siebecker:                    Yeah, I mean, that’s a potent.

Dr. Weitz:                            It’s potent. Yeah.

Dr. Siebecker:                    The one problem with that is like what’s in the CandiBactin AR, but the one problem with that is if you’re using CandiBactin AR and BR, that’s great. You’re using berberine and oregano, which is our classic thing that we always use for hydrogen, but there’s nothing in there for methane. So always remember you have to add something in for methane, which would be the allicin-

Dr. Weitz:                            Like allicin.

Dr. Siebecker:                    … or the atrantil. Yeah.

Dr. Weitz:                            Right, absolutely.

Dr. Siebecker:                    If you have hydrogen sulfide, you add in bismuth. We also found high-dose oregano works good for hydrogen sulfide, but you’d probably want that separate then.

Dr. Weitz:                            Right. There are so many patients in this country right now taking GLP-I agonists like Ozempic for weight loss. We know that the way this works is by slowing GI motility. So when all these patients are done, when they’re now suffering with POS, that’s what I call post-Ozempic syndrome. Now their weight is ballooning up because they never changed their diet. Are we going to have a tsunami of patients with SIBO? By the way, I asked Dr. Pimentel about testing patients with Ozempic, and he said, “It’s just a nightmare. Their microbiome is so messed up.”

Dr. Siebecker:                    He said the same thing the other day when I was interviewing him also, I asked him the same question. I wanted to know what he thought. What is he seeing? Yeah, he said, it’s really hard to test it because nothing leaves the stomach. Dr. Morstein had said she is testing… Because she’s a diabetes expert, and she had said she’s testing patients the morning of the day they were going to do their next dose. So it’s like it’s been a week since they’ve taken their dose and on that morning, and she says it’s going fine. I asked Dr. Pimentel about that, because when you look at the studies, it takes weeks before the medicine becomes steady state or leaves the body.

Dr. Weitz:                            So Mona is giving him a SIBO test?

Dr. Siebecker:                    Yes.

Dr. Weitz:                            Okay.

Dr. Siebecker:                    Yeah, yeah, a SIBO test. Yeah. So my concern is, is that enough time? She said, “That’s working for her,” but Pimentel said, “Well, no, the reason you give the dose on seven days before it gets too low, you don’t want people bottoming out.” So he has a very hard time getting accurate results testing anyone on Ozempic. To your point, yeah, there’s a real concern that people could develop SIBO. Of course, we have no data on us at this time, but it’s a real concern. The thing that it seems to do is slow the stomach. Does it also slow the small intestine?  I think so. But the stomach itself, the migrating motor complex, one of the forms or I guess one of the types of migrating motor complex starts in the stomach and continues through the small intestine. That is, from what I’ve read, the more powerful migrating motor complex. That’s our protective wave. That’s our number one body’s protection against SIBO is the migrating motor complex in the small intestine. So I believe it will turn that off. So it’s a real concern. It’s a real concern.

Dr. Weitz:                            Does the motility come back to normal typically with patients once they stop Ozempic?

Dr. Siebecker:                    I don’t know. I don’t know that. I don’t know if anyone’s looked at that. I bet you there’s people that could report about that just in their sensibilities, but I would think it would. Because when you hear about people’s hunger comes back after they get off.

Dr. Weitz:                            That’s why we tend to gain weight again.

Dr. Siebecker:                    On the other hand, you have to weigh it out against what someone’s facing. I would never want anyone to have SIBO, good lord, but diabetes can be fatal. So it depends on how much it’s needed. I guess also how it’s affecting that person. I know there’s people doing things with compounds where they’re going much lower and still getting good effects on blood sugar and things like that, but these are early days, but it’s a real concern. One thing I want to share that I heard from one doctor who said about the people gaining weight afterwards is that what they’ll do is they’ll just give people a much, much lower dose and help them to hold their weight for… If I’m not mistaken, I think she said one or two years.  It might’ve been two, because that’s how the body sets its set point. So if you could hold that, your goal weight or whatever for one or two years. I’m sorry, I don’t remember exactly. This was an expert on this, a doctor, and then they’ll take people off, but they’ll put them way low. That was a fascinating thing to hear about, just to try to work against that problem.

Dr. Weitz:                            One more question on the treatment, a lot of functional practitioners, some of them will also incorporate an immunoglobulin product as part of their SIBO protocol. Some do it specifically because I tend to use it when I see that the secretory IgA is low on the stool test, but some will use it all the time automatically, something like SBI Protect or MegaMucosa. These are also known to bind with the endotoxins and potentially might help with the eradication.

Dr. Siebecker:                    I think it’s a great idea. I love serum bovine immunoglobulins, or for people who are vegetarian, they can do colostrum that has high IgG. I love it. I spent some time really looking into all the studies and just as you said, excellent for LPS. It has straight antibacterial properties. It can prevent food poisoning. I had an experience where I was traveling in Mexico, my husband and a group. We took it the whole time and we didn’t get food poisoning when the other people in our party did.

Dr. Weitz:                            Oh, interesting, because that question comes up a lot is I’m going to Mexico or wherever I’m going and I want to try to avoid getting food poisoning again. Dr. Pimentel’s answer is just to take antibiotics.

Dr. Siebecker:                    Take a half a pill of Rifaximin is what he recommends. I’m not sure that what I did is enough for everybody. What other colleagues will say is take one Allimed pill or two Allimed pills.

Dr. Weitz:                            Yeah. I’ve had patients take one Biocidin.

Dr. Siebecker:                    Yeah, yeah, yeah, things like that. But this worked for me and I was so grateful. It does a lot of amazing things. I mean, it can help with lipids, the IgG. I mean, it’s just so important, anti-inflammatory. It’s expensive is the problem, but I think if someone can afford it, it’s a great thing to have on board for so many reasons. Not just SIBO.

Dr. Weitz:                            What about the use of probiotics for SIBO? A number of practitioners use probiotics. We both know one prominent practitioner who says that’s the first line treatment. Everybody should get three probiotics, Lacto bifido, Saccharomyces boulardii, and a spore based. Some practitioners feel spore based is good because it won’t add to the bacteria in a small intestine. They’re concerned that even giving antimicrobial herbs or antibiotics, we might damage the microbiome. So why don’t we try to beef up the microbiome at the same time? And then we have Dr. Hawrelak who found specific strains like Lactobacillus reuteri, DSM 17938 that reduces methanogens.

Dr. Siebecker:                    Yeah. Okay. So here’s the deal. It’s all good. Then of course, we didn’t mention this. I think still Dr. Pimentel is not a fan of probiotics.

Dr. Weitz:                            Not at all, but part of the reason he’s against probiotics is because of all these meta-analyses that lump in all these different studies on probiotics, and they’re all using different probiotics. They don’t even report on which particular strains. You certainly wouldn’t throw in all antibiotics and say, “Antibiotics are effective for SIBO.” You test a specific one, and here we’re throwing in all these probiotics as if it doesn’t matter which strains and how much of each. Then we go, “Oh, probiotics work.” So he has a problem with that.

Dr. Siebecker:                    I would agree. That is a strange thing, isn’t it?

Dr. Weitz:                            It is.

Dr. Siebecker:                    Okay. So we’re fortunate in that we have a whole bunch of studies on probiotics and SIBO. I mean, right now, I haven’t counted recently, but there should be about 35, maybe even more than 35 studies, which is a surprise to a lot of people that there’s that many. There’s been reviews of these. The most recent one was I think 2017. So this gets quoted a lot, and it’s really astounding what it showed. It showed like a 53%, even with some products, actual eradication rate of SIBO. So this gets everyone excited. Oh, my God. Can I use probiotics for my main treatment of SIBO? The issue with these studies is a lot of them, and let me just preface, here’s the problem, is that clinically, it’s pretty rare for any of us to see those types of results. That’s frustrating.  We want to see these results. Even if you go out and you get the exact same product that was used in a study that had a fantastic decontamination rate, we don’t get those same results. It’s really frustrating. So one thing is that a lot of these studies were small. A lot of them were done on certain conditions with certain age groups. Just as an example, pediatric short bowel syndrome. That may not translate to an adult with IBS SIBO, who doesn’t have an altered anatomy. So maybe that’s what some of the differences, but one way or the other… There haven’t been any duplication studies on any of these.

                                                Maybe that’s why we’re having a clinical difference, but the evidence in the studies is excellent. Certainly, it shows that probiotics can lower gas levels, can lower symptoms, and may even be able to eradicate SIBO. What probiotics? In these studies, just as you said, for the general IBS studies, they use every different type, all different kinds of lactobacillus, all different kinds of bifidus, all different kinds of spore bacterias, and Saccharomyces boulardii. Here’s the thing, all of those different types showed benefits. As you mentioned, Lactobacillus reuteri, everyone says it different. That was amazing for methane. I think it’s like 55% at eliminating methane, but that same strain has been studied to help diarrhea.  So we think of methane with constipation. That same one was also studied, showing reduction of SIBO when you’re on a PPI. So really, really interesting. Bacillus clausii, the spore has excellent studies for hydrogen. Then there’s a lot of studies on combinations where they use yeast and lactobacillus and bifidus or spore and everything. But what are we supposed to do when we try it and then it doesn’t work? So basically, the study also for IBS, they’re pretty good too. I think it’s fine. A good idea to try probiotics, first line, I guess you have to decide where you are in the patient in the journey, because first line, I think that’s a great idea for someone who’s having digestive trouble.  But if they’re suffering with really bad symptoms for really long time, you may not want to do that first. A lot of the studies show that it takes three months to get these results. Well, if someone’s in real acute distress, we may not want to wait that long. So it probably depends on the circumstance. For some people, I think it would be a great first line. I think it’s a great thing to throw in and try at any point. I personally like to try probiotics before I’ve gotten somebody all the way better and they’re all perfect.

                                                I know that what most of our training is the four Rs, and you do the probiotics when you’re done at the end. I did that in the beginning when treating SIBO and I had a lot of problems because of all these multiple rounds that I needed to do, it could sometimes relapse and it would take me a while to get someone all squared away. It might take me a year and then I give them probiotics. It’s like I rock the boat and they would oftentimes have a bad reaction. I don’t want to rock the boat when it’s all good. So I like to start them on probiotics during treatment, or at least before I’m all finished with everything. People have a different ideas about that, but I just think if you do it, then if somebody has a reaction or something’s not right, you have time to fiddle.

                                                You’re in the middle of using antimicrobials. So then which ones? I don’t know. So many different ones seem to have worked in these studies. That’s probably why Dr. Ruscio likes to give those three all three together just in case cover all your bases. The problem also that I didn’t mention is that many people have a bad reaction to probiotics. So that’s where it is probably a good idea to make sure you’re trying the different ones. It might not have a bad reaction to yeast or to spore if they had Lactobacillus.  A lot of people have histamine intolerance and then there’s all people talk about, “Oh, well, there’s some probiotics that are safe for people with low histamine producing,” but then even they can still react. Dr. Hawrelak generally recommends bifidus for people who are sensitive to histamine, but probably that’s going to be very individual. I mean, we know how an individual it is with histamine sensitivities. So that’s an issue too, is that a lot of people can’t handle them, but then they may be able to handle them as they move along in their treatment. So that gets us going on the topic. So tell me what you think.

Dr. Weitz:                            So I was trained with the four R protocol from going all those seminars with Dr. Bland for all those years. I really do miss those. I used to listen to his functional medicine update. We used to get these little cassette tapes and then they were CD of DVDs we would put in the car. Anyway, so I started off doing a four R and then I decided to start adding in probiotics as part of the protocol because I wanted to make sure I didn’t damage a microbiome. That wasn’t really working.  So I went back to the four R program, and it’s a two-phase thing, which is we do the eradication first. Then when we feel like we’ve got the symptoms under control, we start microbiome restoration, rebuilding the gut, rebuilding the gut wall, and use those products. I usually start with the spore-based probiotic. That seems to be the safest. Then gradually expand to other prebiotics, probiotics, and at the same time, we’re slowly expanding the foods that they can eat as well.

Dr. Siebecker:                    That sounds great. So that’s gone well. You haven’t had too many reactions with that.

Dr. Weitz:                           Yeah, that seems to work pretty well, especially when the patients comply.

Dr. Siebecker:                    I mean, my problem is that I saw extremely sensitive patient population, and even the spore ones were… I mean, I used to make a joke about a very popular spore-based combination probiotic, and I said, “It should just be relabeled die off because my patients would react so intensely to it.” But that’s just the sensitive group. So it’s good to hear that your patients are tolerating that well.

Dr. Weitz:                           I know Pimentel had a negative report about lactobacillus.

Dr. Siebecker:                    Well, yeah, they found in one of their studies when they were really assessing what was overgrown in the microbiome, and then they figured out this new assessment for an imbalance or dysbiosis in the small intestine microbiome where they identified disruptors, basically certain bacteria that if they would get too overgrown, they would disrupt the entire ecosystem. They classified lactobacillus one of them. It was just this one little sentence in one of these studies, and we all noticed it. We all started asking about it, and that’s all they can say. They haven’t said anything else.  So all these years following this research as it comes out, I don’t get too excited about one thing or another. I just wait until more information comes out. I mean, look, we’ve been using lactobacillus in our patients forever with good results, unless they have a reaction and then we don’t use it. I’m not worried. We’ll just see what the research shows in the future. Maybe there’ll be some very specific things, but otherwise, I’m not going to worry about it.

Dr. Weitz:                           I was reviewing some of Pimentel’s recent papers, and one of them was the one where he looked at the methanogens and hydrogen sulfide producing bacteria. There’s this interesting information, I wonder if we have anything to do with it, which is that there’s certain bacteria that produce the hydrogen to feed the methanogens. So we have Ruminococcus, Christensenella, and then we have these Enterobacteriaceae that feed the hydrogen sulfide bacteria. It seems like something important, but is there anything we can do with that?

Dr. Siebecker:                    Yeah, this is key. These are the syntrophys. So this is basically what is creating the hydrogen for methanogens or hydrogen sulfide. They call them the syntrophys. What’s really amazing about this is that I and they, everyone just assumed it was the overgrown standard hydrogen bacteria, E. coli and Klebsiella. So we thought, “Okay, we’re aiming at that.” So basically, this is a new target for our treatment, and I haven’t actually spent time going through PubMed looking at various articles on what kills those things, what MIP levels. I haven’t done it yet because what we have works. So we’ve been using it for so long of all the before and after tests.

                                                We already know it works, but what I think is going to happen is, well, I know they’re doing research on it, Pimentel and Rezaie and all that. I think they might have something at this DDW, which is the big gastroenterology conference that happens every year in the spring. So 2024, I think they might have, we’ll see, some treatments to reveal aimed at those. If it’s not this year, it’ll probably be next year. I’m so glad you brought it up. I think that this is going to be the wave of the future. We probably get more specific at targeting when we’re treating methane and hydrogen sulfide, what treats, what aims at those syntrophys. Then they had a paper that came out in December and I don’t have all these organisms memorized, but they had this sequence now where it’s like this leads to this leads to this. It was like a further piece.

Dr. Weitz:                            Really?

Dr. Siebecker:                    Yeah. So sorry I didn’t bring it up in front of me or I could read it to you. For anyone who’s interested, I do a quarterly newsletter. You could just sign up at SiboInfo and I put all the research and I put comments. So I put a big thing all about it, because it was really fascinating. I have yet chance to speak to Dr. Pimentel to ask him to publicly to explain this, because that seems like another target actually. They’re just learning more and more of the specifics of what is overgrown. The whole point is this is going to refine our treatments.

Dr. Weitz:                            Right. Yeah. I’ll make sure to review that next time before I talk to Pimentel. I think they dropped the statin for methanogen.

Dr. Siebecker:                    He’s still working on it.

Dr. Weitz:                            Oh, he’s still working on it. Okay.

Dr. Siebecker:                    Yeah, he hasn’t fully dropped it. It was a disappointment, but so for anyone who doesn’t know, he was working on enterocoded, not exactly like a statin that wouldn’t absorb into the blood. So that you wouldn’t get all those other effects. Statins, it works like Atrantil. It inhibits methane production. It actually disrupts an enzyme in the methanogen, so they can’t make methane. So this was another way to treat, but it just didn’t give them the results they wanted, but they are still working on it.

Dr. Weitz:                            I wonder if any natural practitioners are using red yeast rice for the same purpose.

Dr. Siebecker:                    Oh, yeah. We asked Dr. Rezai about that, and then he said that in a few patients it does work and then in others it doesn’t.

Dr. Weitz:                            Oh, interesting.

Dr. Siebecker:                    Yeah, exactly. That’s all the first thing we think about. Could we just use red yeast rice for this, like an alternate? Atrantil does the same thing.

Dr. Weitz:                           Okay.

Dr. Siebecker:                    Yeah.

Dr. Weitz:                           Interesting.

Dr. Siebecker:                    Actually, I find Atrantil to be very hit or miss, probably just like red yeast rice. It’s in some people it hits like a miracle.

Dr. Weitz:                           Are you using a recommended dosage or are you using a higher dosage?

Dr. Siebecker:                    Using four to six a day.

Dr. Weitz:                           Oh, I think the recommendation is two a day.

Dr. Siebecker:                    Oh, yeah. So yeah, two is what we use for maintenance. Once you get your effect, then anywhere from one to three as your maintenance, because you still need to keep inhibiting that enzyme. Keep inhibiting the methane production.

Dr. Weitz:                            So you’re doing two or three twice a day.

Dr. Siebecker:                    Yeah, that’s right, for standard treatment round for a month. But here’s the thing, I’ve seen before and afters where that just works like a normal herbal antibiotic lowering methane in the same way you would expect, but there’s also these miracle cases that sometimes happen. The real miracle cases that I see are probably going to either be with Rifaximin or Atrantil and then they don’t work like that for the majority, but you get these miracle cases. You always remember them. But what will happen is for some people within just a few days, usually within four to five days, the Atrantil just has removed all constipation just completely. I mean, people in their 70s constipated for they’re entire lives gone in four days.

Dr. Weitz:                            Wow.

Dr. Siebecker:                    But then I find that the miracle, if it’s going to be a miracle like that, it’s usually pretty quick. My frequent educational cohort, Shivan Sarna, she interviewed Ken Brown. She interviews him a lot. He’s the creator of that. He said that he’s seen miracles happen months on. I haven’t. Usually, when you’re doing it for me, when I see him doing it over months, you’re just getting those incremental reductions in gas like you would anything else. I don’t consider that a miracle.

Dr. Weitz:                            Yeah. I haven’t seen any miracles.

Dr. Siebecker:                    Complete and fast. So maybe red yeast rice is the same. It’s like either it works or it doesn’t. That one particular approach I find is a bit more hit or miss.

Dr. Weitz:                            Right. If it lowers your cholesterol at the same time, probably not a bad idea.

Dr. Siebecker:                    You can get other benefits.

Dr. Weitz:                            Have you used any peptides? Some people use BPC 157 supposedly to help heal the gut lining, to help heal leaky gut.

Dr. Siebecker:                    I haven’t used it in patients, but when I found out about it years ago, I was enthralled and I brought in a whole bunch of people to interview for various summits and educational events, Dr. Bar and others speaking.

Dr. Weitz:                           I know he was using it a lot.

Dr. Siebecker:                    He was, speaking very favorably about it. I mean, when you read about it, it seems like a perfect match. Again, it’s expensive, right? I’ve heard some people say it was wonderful for them and not much for others. So I don’t have a ton of experience with it. I was very interested. Did you try it a whole bunch?

Dr. Weitz:                           No, not a whole bunch because of the expense. If I already have patients on four or five different products and then you throw in a product that’s $150 to $300 for a month’s supply-

Dr. Siebecker:                    It’s a lot.

Dr. Weitz:                           It’s a lot.

Dr. Siebecker:                    Yeah. I haven’t heard enough feedback to make me think that’s worth it full bore for most people.

Dr. Weitz:                           When I’ve used it, I found around four capsules a day was about the right dosage, but that means you’re going to go through a bottle in two weeks, so that’s 300 bucks a month.

Dr. Siebecker:                    I mean, I tried it on myself. I always try everything almost, and it was meh, but that’s one person.

Dr. Weitz:                           Yeah, I know. I use it for healing for musculoskeletal injuries as well. I wouldn’t say I’ve seen a lot of miracles, but there seems to be some benefit.

Dr. Siebecker:                    Yeah, and I guess I’ve heard some cases that responded really well.

Dr. Weitz:                           Right. All right. This has been awesome, Allison.

Dr. Siebecker:                    We talked about a lot of different things.

Dr. Weitz:                           We did. Thank you for being so generous with your time.

Dr. Siebecker:                    Oh, it’s been such a pleasure.

Dr. Weitz:                           Tell the viewers about some of your courses and how they can sign up for them.

Dr. Siebecker:                    Oh, yeah. I have a bunch of trainings. If anyone’s interested in learning more about SIBO, I have a full length SIBO training, very comprehensive, 22 hours, got mini trainings on SIBO and testing. I’m doing a testing masterclass here soon. You can find all of this on my website, siboinfo.com that has a lot of information. Of course, signing up for my newsletter. I always send my quarterly newsletter has all the studies. If there’s ever any treatment updates, like in the January one, there was different antibiotics that people are using. I put that in there. So anyway, I’d love for anyone to join me for a training.

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

Dr. Siebecker:                    Thank you so much, Ben.



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 appreciate it if you could go to Apple Podcasts or Spotify and give us a five-star ratings and review. If you would like to work with me personally to help you improve your health, I do accept a limited number of new patients per month for a functional medicine consultation. So many areas I specialize in include helping patients with specific health issues like gut problems, neurodegenerative conditions, autoimmune diseases, cardio metabolic conditions, or for an executive health screen.  To help you promote longevity and take a deeper dive into some of those factors that can lead to chronic diseases along the way, please call my Santa Monica Weitz Sports Chiropractic and Nutrition Office at 310-395-3111. We’ll set you up for a new consultation for functional medicine, and I look forward to speaking to everybody next week.


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