Untangling SIBO: From Diagnosis to Recovery with Dr. Allison Siebecker

Dr. Steven Noseworthy (00:03.694)
Hey everyone, welcome to the Funk Med Nation podcast. I'm your host, Dr. Steve Noseworthy. The views and opinions of guests on this podcast are their own and may differ from my own. But as always, I try to be respectful of other people's opinions, even when we might disagree.
All right, guys, welcome back to the podcast, or I should say podcasts, because this episode is actually going to air on both of my podcasts, both the Inflammation Nation as well as the Funk Med Nation podcast. And the topic today is SIBO, which stands for small intestinal bacterial overgrowth. and I'm sure our conversation is probably going to range a a little bit around just the topic of gut health in general. But my guest today is Dr. Allison Siebecker.
And she's been specializing in SIBO since 2011. She received a lifetime achievement award for her work in SIBO and outstanding contributions to the field from gastro AMP. She's been teaching advanced gastroenterology at National University of Natural Medicine since 2013 and is an award-winning author. She was the co-founder and f former medical director of the SIBO Center for Digestive Health at National University of Natural Medicine, and her integrative SIBO protocols have helped thousands.
worldwide. Alison, I I have first of all, welcome and I'm I'm glad we had a chance to connect. And I I have to tell you that I've been podcasting for a few years now. And from the very beginning, your name was on a short list that I had written down probably three years ago of people that I really wanted to make sure that I connected with. And and I I feel bad and I'm sorry that it's taken me so long to reach out to make this happen.

Dr. Allison Siebecker (01:46.816)
Nice to know I I th I was a name on that list. Thank you.

Dr. Steven Noseworthy (01:49.524)
There you go. Well it's you know, I I th I truly consider you to be one of the expert voices in the field. and and I would say that you know you are to my knowledge you in in our world as clinicians because SIBO research existed before at least certainly before I became aware of it. But you know, it as far as I know from my experience, you were one of the early voices on the clinical side bringing SIBO to the forefront of our
Let's call it our collective awareness. and so I I want to talk a little bit about your background before we get into the nitty-gritty of SIBO. And I'm I'm always interested in people's origin stories, like how you got into natural medicine. So I I kind of want to break it down into two things. Number one is what is it that attracted you to natural medicine to begin with? And then I would like to know what was going on in your mind and in your practice that put SIBO on your radar.
especially to the point where you became one of these leading voices. So let's just start with the origin story. Like what were you doing before you went to naturopathic college? And and why did you pick naturopathy?

Dr. Allison Siebecker (03:01.526)
Well, you know, I I was always interested in natural health and alternative health. I think it started for me maybe in high school where I had some friends who's who were into health food in high school. Like they their parents bought like whole wheat bread instead of white bread. And I I was really attracted to that and I was jealous that like they got the whole wheat brown bread and I had the white bread and

Dr. Steven Noseworthy (03:18.786)
House dreams.

Dr. Allison Siebecker (03:27.586)
I mean my mom did the best she could, but she we she wasn't a health food person. And so I got totally into it and I like lobbied my local health food store to let me start working there and so and I did and so I just got into that whole field. I had also been really into massage, and so that sort of was another sort of gateway into more health the health medical world. and then
And then I worked in health food stores as a career. actually I was a manager at various health food stores before I went to naturopathic school. But what actually, you know, made me want to go to naturopathic school is I would say like a calling, like a it was almost like a spiritual calling. I actually had an experience. I was I was at an herbal medicine conference, just attending that for because I worked, you managed in health food stores. We sold herbs and everything. And I actually had this experience where I felt like a lightning
metaphorical lightning bolt like came down and hit me and I stopped in my tracks. I was walking, stopped I was like, I need to be a naturopathic doctor. I have to go to naturopathic medical school. And I'll tell you what, thank God for that. Because if if I hadn't felt like it was, you know, something divine, I don't know where people get the motivation to make it through medical school. If it if it was just only their own ego or something, like man

Dr. Steven Noseworthy (04:51.842)
Just like a career choice, right?

Dr. Allison Siebecker (04:53.642)
A career choice or just because like they want like a status job or I don't know what the heck motivates people, but it's and I did two degrees at at the same time. I did a master's and a doctorate, and so it was just so so so grueling, you know. So thank God I had that because it was like, Well, I can't say no to you know to that, so I gotta keep going. Yeah, but you know

Dr. Steven Noseworthy (05:15.956)
Fuels the fire as you keep going through the challenges.

Dr. Allison Siebecker (05:19.16)
Totally, totally. And then in terms of, you know, what was I doing in my after I graduated, I was doing general medicine. a lot of I my masters was in oriental medicine, so a lot of acupuncture as well. But really the the thing is is that I had IBS my whole life. I and that turned out to be SIBO. From a not my whole life, from about when I was five, as near as I can tell is when I got it. 'Cause I was born with normal you know
GI function according to my parents. But but since I was about five, I had it and struggled a lot with it. My whole life struggled terribly with it. So saw like so many of our patients' stories, saw so many doctors, tried just about everything you can think of. And I really mean that. Yeah. And went through medical school, still no answers. And it wasn't until afterwards when I found out about SIBO.
from from my gastroenterology professor was it was a friend of mine also and he was writing a book and happened to have just found out about SIBO and just put like a paragraph in his book about it. And I was I was helping edit and review his book. And I was like, what? And I went and looked it up and just went down a rabbit hole. And it was hard back then. I mean that was like fifteen years ago.
But then again, another sort of fire got lit in me. Really what did it for me was when I tried a treatment for it. I actually started with diet. I tried diet for it. I tried the specific carbohydrate diet, SED for short, and within twenty-four hours my pain that I had suffered terribly with abdominal pain was gone. And so you can imagine how that would light a fire. I just thought about all of the patients and people that I know with IBS who struggle.
And to think that they could get that kind of relief, you know, overnight, then that's what lit the fire for me to want to raise awareness. And yes, I sort of took it on as my job to raise awareness of this because nobody knew.

Dr. Steven Noseworthy (07:20.492)
Yeah. And I think, you know, that there's some I elements to the origin story that I think we kind of all share. And and I I won't bore you with with my own, but you know, I was dealing with some orthopedic issues that surgery and steroid injections and different things didn't fix back when I was in my twenties and someone suggested, Well, why don't you go see a chiropractor? And I was like, Well and I'd never seen one before, right? And so I had that personal experience that just changed my life. And I thought, Well, how and and at the time I was working
I was living and working in downtown Toronto. I'm Canadian originally. And and I thought, well, how how neat would it be for if I could change somebody else's life the way that this guy changed mine? and you know that was but but I think that that's a very common thing. Now I do remember like when I was in first year at Logan Chiropractic College in St. Louis, one of our early instructors in the first semester asked for a show of hands, like how many of you
are here because your dad's a chiropractor, your mom's a chiropractor, your uncle and and about half the class raised their hand and the other half didn't. And he said, this is quite interesting because five years ago, everybody would have raised their hand because, you know, being a chiropractor, you would you're kind of raised with chiropractic or raised as chiropractic family. And he said it's an interesting shift that now people are starting to choose chiropractic just simply out of an array of different professions, right?
And so it makes sense to me because I I had wanted to ask you the question like why did you pick naturopathy versus acupuncture? And I know that you're a licensed acupuncturist as well. That I'm assuming that can l came later.

Dr. Allison Siebecker (09:01.792)
No, right at the same time. Well well well where it came was you're right though. The desire to do it came when I was in naturopathic school and they had a program and we all have to take some Chinese medicine classes anyway in naturopathy. And then yes, then I just decided to do it and so I just did it together. But you're right, that desire came later.

Dr. Steven Noseworthy (09:19.106)
Yeah, so let me let me ask you to do this because we're we're bandying around because this podcast is gonna go out to the general public as well as to clinicians. Define naturopathy and and maybe distinguish that between a more umbrella term of a natural medicine doctor, because we use we use these terms kind of like interchangeably and I might tell someone I do functional medicine and they think I'm a naturopath, right? so what like
Just as succinctly as you can, let's say you're talking to general public, how would you define what naturopathy is and what you do as a naturopath naturopathic medicine doctor?

Dr. Allison Siebecker (09:57.442)
Yeah, it's a similar training in sort of the what you see in the books as the basics to an D, a medical doctor. and it's its own degree, it's its own, you know, school training and degree. But it's a similar base training. But then in addition, we add in things like training in different basically we would call treatments or modalities. So we have training in actually manual adjustment. We only do a year.
So, you know, I I personally send everyone to a chiropractor who's sat there four years, you know. So we have some manual adjustment training, we have homeopathy, we have herbal medicine or botanical medicine, we have actually hydrotherapy, which is like use of hot and cold, various sort of old school home treatments that you know, things like that. we learn physical medicine like using tens machines and things like that, some s sort of sports medicine.
And we learn we also like the base training, we also learn ant pharmaceutical antibiotics. So we you know, we have the same base training and we also learn minor surgery. So the same base training is there, but then we add in the natural modalities and of course diet, nutrition and diet is highly stressed as as well as like lifestyle. But we take all the same pathology classes and all that, but we we have different modalities and we also have different philosophy and we actually have classes in like
natural medicine philosophy, you know, first do no harm, really bringing that through. How do we really bring that into our practice? And then I think the other thing I would say is is that the the ability to practice is different state to state. But for naturopathic medicine there are states where we are licensed primary care physicians, which need legally to be covered by insurance. Sometimes they try not to. And then also
We can prescribe. Not in all states. But so that is one thing that's a little different from maybe like a chiropractic degree. I don't think there are any states where chiropractors are al like allowed to prescribe

Dr. Steven Noseworthy (12:03.462)
there there are some very forward thinking states and and state associations. Like there and I I wanna say it's Arizona can do some injections.

Dr. Allison Siebecker (12:12.6)
We can prescribe any medicine, you know, like just anything, any any antibiotic. And we're trained we're trained in it. So so in that way it's kinda like the best of both worlds. But what we don't do, we don't do major surgery. We do only minor. So we don't go below certain level. We're not working in hospitals doing right my major surgery. So and we don't have the same s we have some specialties, but we don't have the same specialties. So you know, so think of it as it's like you're getting your basic training but you're getting all your natural training too.
So it's it's a wonderful thing. And functional medicine that gets confusing too, 'cause I think where that was originally created for MDs who wanted after they've gotten their MD, they they're really attracted to natural medicine and they want to incorporate more of that. And and the big thing there is is that D has quite an emphasis on structural organic problems missing out on some of the function of the body. And that's where the functional medicine came in to sort of fill that gap.

Dr. Steven Noseworthy (13:10.252)
Yeah. Well let let me ask you about this 'cause I've I've asked other other clinicians and and say subject matter experts, like how we can go back to Jeff Bland's original paper on functional medicine and and kind of the rules and the the tenets of that that they developed. But functional medicine I think gets it you know, the term is used very loosely to describe many different things and you can have two clinicians that say they do functional medicine, but they actually do
Two very different things. How would you describe that? How would you like if you were to put pen to paper and outline or framework? This is what functional medicine is. What is it? And and in your opinion, how does that differ from, let's say, the basic philosophies and principles of naturopathy?

Dr. Allison Siebecker (13:58.798)
Well, you know, I haven't gone through the Institute for Functional Medicine Training, but from the outside, what I can say, and I I've taken classes from some people who are functional medicine teachers. So, you know, I'm not sure if I've got it right, but what I would say is philosophically, functional medicine is really trying to focus more on root causes, identifying root causes, which you know, that's the huge criticism in D world is this it's more about fixing the symptoms, right?
and also trying to restore function back to normal as best as can be. And so that's where they may use different test you know, test positive criteria, not just what gives you the disease, but looking at op opening those levels a little to say what's the pre-disease. Let's get let's get you before you get all the way there. So prevention, function, really making sure how well is your thyroid function, how well is everything functioning, things like that.
and you know, I guess the difference is that naturopathy of b of course we have root cause built into everything. Yep. we have both structure and function built into everything. I think it's probably more so the modalities. Like a I think a typical functional medicine practitioner would have been an D that wouldn't receive extensive herbal medicine training or homeopathy training or things like that.
but then they but then they may learn some of that later. They learn a lot of nutritional supplement, I think, in the Institute of Functional Medicine. Of course we learn all that as well. So maybe there's just some modalities or treatments that aren't quite incorporated in to functional medicine, but could be, you know, if if they have classes in that.

Dr. Steven Noseworthy (15:39.118)
Yeah, and there's certainly a lot of crossover and like if you could create a Venn diagram of all the different natural medicine disciplines, there would be a lot of intersection, right? But then there were there would be some things that might be specific and unique to one particular discipline that you typically don't see in the others. let me

Dr. Allison Siebecker (15:59.064)
say that j just generally for me, all of these distinctions, in my mind, I don't care so much so much. I mean, what matters to me is people have good training and are are have good will, good heart, and you know are trying to help people. And you know, we've all met any any discipline can have people that meet those criteria and are doing a phenomenal job and are not
Annoying, you know? And then every profession can ha every discipline can have people that you know you're disappointed in. So Yeah.

Dr. Steven Noseworthy (16:32.482)
Yeah, I I look at things at like I look at human function on a spectrum, and I think it's a it's a note to the amazing resilience and and flexibility of how the human body is framed and designed, that sometimes it doesn't take much of a change or an input to course correct. But then as as conditions evolve as as
As cases become more complicated, it takes a lot more effort, right? And and again again, I go back to some of my early stories when I was being trained in chiropractic. We had this one old he was he was an old I'm gonna call him a geezer. At the time he was probably no older than I am right now, but that was a while ago. And you know, he said he said some people just you just need to hit them in the butt with a boom broomstick and they're gonna get better. And you know, I see that in some of my own clients is that sometimes
the only thing I really needed to do was maybe optimize their diet. Or if we need to do supplementation, it doesn't take much. Like you're not taking six different formulas three times a day for twelve weeks to make something shift and change. But then there might be some cases that do require that. And so there's like this huge wide range of different case presentations. but I you know what I like these conversations about things like principles and concepts and
Because I've always attributed the this next question I'm gonna ask you to naturopathy. And I don't know if I should. I d I'm sure the concepts kind of predate what we consider to be modern naturopathy. But there's this again, I'm gonna say old naturopathic principle that says that health begins in the gut.

Dr. Allison Siebecker (18:14.178)
Yeah, you know, you you sent that to me ahead in an email and when I thought about it I thought that is so great because the saying I think that I've heard that is attributed, who knows if it's true to like, isn't it hi Hippocrates is all disease begins in the gut and I like that you flipped it. All health begins in the gut. I prefer that.

Dr. Steven Noseworthy (18:35.106)
Yeah, well that that just underlies like the difference in how we're trained to think, right? Because I when I work with my own clients, I I don't think that I'm I'm certainly not treating disease. I'm trying to find out where people have lost wellness and how to restore that. Right? That's that's the way my mind works in terms of you know what it is we're doing in an exchange with, you know, clinician and and patient or client. But I I want to ask you about this idea because there are a lot of
Lo and and I'm gonna use loosely naturopathic and functional medicine kind of interchangeably because there is a lot of overlap. So forgive me if I I don't wanna step on any terminology.

Dr. Allison Siebecker (19:14.082)
Bother at all. I don't care about linguistics.

Dr. Steven Noseworthy (19:16.576)
Yeah, there you go. So I I mean, I know that there are a lot of docs that no matter what walks into their office or what someone's clinical presentation is, or really what their underlying true causes are, they're so convinced that health begins in the gut that that's where they start every single time. Now I'm not judging whether that's the right or the wrong thing to do, because I think that judgment has to be done on a case by case basis, mixed in with how the clinician thinks. But let me get your take on that. As someone who's been trained differently than I
Is is that what you believe clinically? And again, I'm not judging one direction or another, but do you do you think that that's always a good thing to do is to figure out what's going on with the gut and to fix that?

Dr. Allison Siebecker (19:56.462)
I can't imagine it's always, always the right thing. I mean, you know, I've heard sayings, other sayings that people in their own disciplines say all disease or all health or all health b begins in their the thing they specialize in, right? So and but but you know, I I can say that there is a lot of truth to it. and you know, SIBO's a fascinating example of it.
in that when we take a look at like I have a educational website, free educational website, and one thing I do is I every time there's new studies come out, I do it quarterly. I add them into this associated disease list. And the associated disease list is like massive. And it it so the what I mean is is that SIBO has links with diseases in all parts of the body, neurological, kidney, cardiovascular and you know, atherosclerosis and
liver and skin, you know, dermatological mood. It goes on and on and on. So I can see the the the underpinning of truth in that statement for sure, even just looking at SIBO. But but I can't imagine it's always the way to go. I think people people have their own ways to practice where they like to start and I I think they develop that over time and everybody has to follow their own medical intuition with how what they want to do, you know.

Dr. Steven Noseworthy (21:20.576)
Exactly. And I totally agree with that. I absolutely agree with that. And you know, I'm thinking about y you know, we're we're gonna have a conversation coming up here in a little bit about causes and consequences of SIBO. Right? 'Cause if somebody has SIBO, something caused it. And if we're really truly concerned about root cause, the question we're asking is not simply do you have SIBO, how do I treat it? It's you have SIBO, why do you have SIBO? Yeah.
Right. Because you know, one of our and and I would say we're probably pretty close of the same mindset that if we were to critique the medical approach, the pharmaceutical approach to SIBO, it's typically, you know, a round of antibiotics or so and not necessarily other any other changes. And that might depend on the knowledge base and experience of the prescribing physician. But the mindset is typically, well, you've got these infections, let's use antibiotics to kill that, and then we're done. You know, we kinda
wipe our hands and walk away unless it recurs and then are gonna see you in three months or six months down the road. But never in in that model or that approach is there this question about what's causing the SIBO. And I let's if you don't mind, let's put a pin in that and come back to it because I think that's a very it's a great conversation, particularly for the clinical side of things. But it might be helpful for anyone out there listening who's not a clinician who thinks they might have SIBO.
Who could look back in their own history and go, maybe that's why. And I I want to keep going, but let me just pause this early. I do have a couple of other questions, just in in in terms of the general realm of discussion, before we get into details. I'm always interested in how other clinicians explain things, especially complex things like SIBO, to their their clients and their patients. So I want you to pretend that I'm a prospective client. I'm sitting in your consult room.
You walk in, we meet for the first time, we go you go through my history. Maybe I've got some labs, maybe I don't and you start thinking in your mind, okay, I think Steve's got SIBO. And then you bring that up and I say, SIBO, what's that?

Dr. Allison Siebecker (23:29.702)
Okay, now I have to tell you something funny. I'm gonna answer the question, but I've been a SIBO specialist since I started in SIBO. I when I went I was a specialist. So everybody who came to me already knew what it was. But I have an answer. And here's here's how I would describe it. So you know, but I'm lucky because I didn't have to have that first conversation, right? Yeah. I would say, you know, so it's small intestinal bacterial overgrowth and that it
It sounds like what its name is in that bacteria don't normally we don't typically have a large amount of bacteria in our small intestine. The place for that is the large intestine. Most people know we have you know, a microbiome that's beneficial in our large intestine. So that's that's good. But typically in the small intestine we don't have a you know, a very large amount. And so what happens is there's like a colonization or an overgrowth of
bacteria there and they mess with the the structure and the function in that area and the function is to digest our food and absorb our food. And so the bacteria just wreak havoc with that. And they they mess up all of our digestion and absorption and they also mess up the structure. They they cause damage to the lining of the small intestine. And so once again that has ramifications on what we're absorbing.
And and it also leads to a whole bunch of symptoms because we're not supposed to have this amount of bacteria there and it it's just not the place for them. It's kind of like location, location, location, right in real estate. So so then we get all these these symptoms like abdominal bloating, bowel movement changes, pain or discomfort, and and the list goes on. So that that's basically it. It's they shouldn't they shouldn't be so many there. They've had the opportunity to grow there. We haven't talked about why, and we need to reduce that.

Dr. Steven Noseworthy (25:21.368)
Well that sounds great, Doc. How do people get SIBO?

Dr. Allison Siebecker (25:24.75)
Great, let's move into the conversation. Okay, but instead of just doing it right like to a patient, I wanna tell you something a little bit more background, which is that I like to think about it in two levels. the physiologic underlying causes, meaning what's gone wrong in the body to allow it to happen. And then for now I'll just call it the causes or the risk factors. So th these are like the diseases and things that lead to it. But if we think about it in the body, we have a lot of protections.
to naturally that make it so we don't get this. I mean this is not the way we're supposed to be. And they've been able to figure out really the most important one is this movement or kind of form of peristalsis in the small intestine, the migrating motor complex. And it it doesn't actually happen with food. It happens when we're fasting and it's called the housekeeper wave because it cleans up after we eat. And one of its main functions is, besides like sort of cleaning up, is to sweep bacteria on a regular basis
a away down into the large intestine to be excreted, keeping it clean. It's just like constantly sweeping away whatever bacteria are accumulating. And we now know that this is one of the main reasons why people get SIBO is this becomes deficient. We don't have as much sweeping cleaning action. And that's really the main underlying cause physiologically of SIBO. And so what would then cause that would be really anything that could damage the smooth muscles or the nerves that
Create this movement. And it's a large list of things. A large list of things. But I can tell you some of them, some of the most common. The most common of all is food poisoning, also called traveler's diarrhea or stomach flu. But really here we're talking about bacterial food poisoning. Because food poisoning can can it's most common from virus, nor norovirus. But this is not that. This is bacterial food poisoning.
And and as as you know, this pathophysiology sequence has been figured out and basically what occurs is an autoimmune situation is triggered, unfortunately. And the body damages its own nerves that create this migrating motor complex. And then those waves diminish. And and just think of it sort of like this. This is this is a great analogy for, you know, just non practitioners as well, is think of it like a flowing river.

Dr. Allison Siebecker (27:44.956)
when a river is flowing, there's not much chance for bacteria to accumulate, but if it becomes stagnant and s and still, we know bacteria overgrow. It becomes like a swamp. So it's like that. If it slows down, it bacteria overgrow. And then small intestine is a dark, warm, moist environment. So without much movement, there you go. That's sort of the main thing. and then let me just I can say the other risk factors for the slow motility, but let me just say the other sort of

Dr. Steven Noseworthy (28:05.634)
Think the sun's gonna grow.

Dr. Allison Siebecker (28:14.806)
Key physiologic reason would be something anatomically, structurally wrong or not normal, we'll say. And the most common for this would be an obstruction. Or really here we're talking about a partial obstruction. And here we can sort of think about it like a log jam in that same river analogy. If some things pile up in a in an area in the river, stuff's gonna back up behind where those locks are.
So d so just physically and so this can be things like like strictures, that's a narrowing of the intestine, it could be a a volvulus which which is a twister, a kink, it could be a tumor. you know, it it could be a compression, an area something's getting compression. Most common is adhesions and adhesions are scar bands, they're s they're a repair substance, they're supposed to be helping, but sometimes they can form in such a way where they compress parts of the small intestine.
causing a narrowing. And then it you know, and then if you have an area like this, the river can't flow as as well and stuff can back up behind it. And so y you know, you'll get an area of narrowing and an area of dilation above it. So and

Dr. Steven Noseworthy (29:23.33)
Dr. Jake I'm sorry to interrupt, but can I ask two questions that are just relevant to things that you're just saying? First question is and I'll get I'll put them too both out that we can just answer them one at a time. Because I like I have that I routinely ask that in my intake form, especially if they have gastrosymptoms that I think look like SIBO. I'll ask them, have you ever had a viral gastroenteritis, ever had food poisoning?
I don't always see it, but I personally I don't know what the percentages would be. I'd be interested in in your feedback. And the other thing about the scar tissue, I I know that abdominal surgery is a risk factor for SIBO. Yeah. And abdominal surgery doesn't necessarily mean intestinal surgery. Right? Because there I've seen some papers that have you know looked at scar tissue
post hysterectomy, for example, or post gallbladder removal. Well, I get technically that's kind of intestine because it's the GI tract. But it doesn't have to be I had surgery on my bowels and that's where

Dr. Allison Siebecker (30:30.87)
Anywhere in the abdomen. Yeah.

Dr. Steven Noseworthy (30:34.338)
Yeah. Okay, so that answers that question. And what what is your impression of yeah. What percentage of all SIBO cases you see have a history of food poisoning that you think is causative?

Dr. Allison Siebecker (30:46.174)
That that's the majority. so, you know, and I was a SIBO specialist, that's all I saw and it you know, at least at least sixty percent I would say. Okay. And here's here's the key thing to note is that many people do not remember having food poisoning who actually have food poisoning as their cause of SIBO. So it's vitally important to ask it in history 'cause you're gonna you're gonna you're gonna grab the most people that way. However, particularly in mystery cases
Very often when you you like you really can't figure out what the underlying causes. And by the way, this is not the easiest thing to do. We haven't really talked it through, but there's a huge list of underlying causes of SIBO, many of which are specialty fields in and of themselves to learn how to diagnose. So it takes referrals. It's not the easiest thing. It's very easy to say, find the root cause, and we need to try, but it's not so easy to to just whip that out, you know? Yeah, right? You know, so it's important to know this so we don't get you know, whatever.

Dr. Steven Noseworthy (31:38.166)
Agreed. Agreed.

Dr. Allison Siebecker (31:43.724)
But we do have a test that's a blood test that checks for this particular cause of SIBO. And in cases where I can't figure it out, I run this very often. I run this and it comes back positive, and the person has no memory of having food poisoning. And that's because, contrary to popular belief, food poisoning can occur with mild symptoms. We all think of the, you know, both ends, coming out both ends.
Horrible. You wish you want you could die, you know. Just awful. But it could just be some mild soft stool one night, and you don't think anything of it. That actually can can correlate. And so I I've seen that very often where people don't remember. And one other thing is that the cause of food poisoning, it can move from food poisoning, the symptoms can change and move right into the SIBO IVS symptoms and you have SIBO. But
More commonly there's a delay. It takes time for that nerve damage to occur from the autoimmune damage, and it's typically three to six months after. And so if it's three months after, people are not linking it. Doctors are not linking it. And so that's a key thing to note for people is this It's not like one right after the other.

Dr. Steven Noseworthy (32:57.35)
Yeah, and that's I think Yeah, maybe a failing in in our collective approach is sometimes we're looking for the cause too proximal to when we're talking to somebody. Like we don't go back ten years, twenty years or you know, whatever the case might be. So I'm I'm interested, what test are you running if you have this like a mystery case? What what test do you use?

Dr. Allison Siebecker (33:20.802)
Yeah, so this test is call it's generally called the IBS blood test. but some of the specific labs are IBS Smart is the main the main test. This is the second generation version of version of this test. IBS Smart. There's also IBS Check was the original version of it. And then I think Vibrant America and Vibrant Wellness and Cyrex have their own versions.

Dr. Steven Noseworthy (33:44.93)
So you're looking for you're looking for antibodies to cytolethal distending toxin. Is that your approach?

Dr. Allison Siebecker (33:51.49)
Yeah, we didn't explain that, but this is the toxin that all the bacteria that cause this food poisoning they all secrete the same toxin. So we're looking for antibodies against that and also antibodies against the nerve the protein that's on the nerve cell that the immune system is damaging and that's called vinculin. So antibodies against vinculin. So that's what this test is. It checks for those two. And there's a different prognosis depending upon which is positive. Vinculin is the is the sort of more severe
form of it. But it it lets us know if this is the cause of SIBO. there are many other causes, right? But it this one. And also it let this will also then let us know that it's the migrating motor complex as the actual physiologic underlying cause, because that is what occurs in this pathophysiology. Doesn't mean there couldn't be other things too, but

Dr. Steven Noseworthy (34:39.734)
No, and and it's probably also good to point out that y you can have more than one cause. Yeah. Right? There's there's no rule that's people like that. You know, thou shalt only have X and you shall not have Y.

Dr. Allison Siebecker (34:52.31)
That's right. And that I I have many patients like that. They have like four, three or four main causes of SEBO. So maybe I'll just quickly mention a few of the others just so people can get a smattering idea. so inflammatory bowel disease, that can cause strictures and all sorts of structural problems. Diabetes, that can cause nerve damage, which can damage the migrating motor complex. We know that many people with diabetes get gastropresis within like five years of their diagnosis.
Gastrocresis is a slow stomach emptying. And there's a migrating motor complex that begins in the stomach. So that sort of automatically affects that. hypothyroid, of course, has slow motility. We know constipation, but it affects the migrating motor complex. Ellers Danlos syndrome, these are all diseases, you know. Ellers Danlos, I don't I don't know how familiar everyone's becoming with it. It's like newer within the last 10 years to many of us, but it's not rare.
And it can have both structural components and migrating motor issues. It's a double whammy. Many people with a very high percentage of people with ailer stamina have SIBO.

Dr. Steven Noseworthy (35:56.532)
And one one of the aspects of that is just like let's say weakened connective tissue, right?

Dr. Allison Siebecker (36:03.244)
Yeah, and that can cause prolapse in the intestines and sort of almost like blind loops and twists and kinks and things. parasites, we don't have a lot of good literature yet, but we're pretty sure it slows the migrating motor complex, various infections.
Some classic sort of risks are like hypochlorhidria. That's one of the body's protections. So many people have hypochlhydria. And then of course there's medications like proton pump inhibitors that on purpose cause hypochlorhidria. So they're a risk factor. Right. Other medicines would be opiate narcotics. We know they cause constipation, painkillers, you know, but they also slow the migrating motor complex. Right. And even antibiotics have been linked with slowing the migrating motor complex.
We use some pharmaceutical antibiotics for SIBO and they work, but there are some antibiotics that could potentially slow the migrating motor complex. And this is important because so many patients come in feeling that medications like this, and including antibiotics, were what caused their SIBO. And so there's there's some truth there. And then we have things like traumatic brain injury. This is considered to be an epidemic these days, that can slow the migrating motor complex.
Parkinson's disease, one of the first signs is constipation and s slowing of the migrating motor complex. We have Lyme and coinfections, slow the migrating motor complex. and then we have, you know, generally adhesions, things that cause that. you know, things like endometriosis, very high degree of SIBO in that. appendicitis. People can have smoldering appendicitis, not just even acute, where where it's get get it gets removed.
And as you mentioned, abdominal surgery, you know, radiation. But honestly, adhesions can be caused by, you know, infection. So that'd be like appendicitis, inflammation, same thing there. or injury. And so a lot of people have adh abdominal adhesions from sporting accidents or just, you know, living their life, falling off a bike, you know, you can car accidents, you can get them from many, many reasons.

Dr. Allison Siebecker (38:10.004)
And that is probably our second most common cause of of SIBO across the board, I'd say. I'd say that adhesions, abdominal adhesions. Or adhesions, yeah. Yeah, which you know, people are not thinking about. And I'd say maybe the right, right? And and I'd say the third most common cause would would be all of these diseases I'm mentioning and and medications, like as a clumped risk factor. So and one last I must mention is mold, toxic mold illness. This is another thing many of us have learned more about in the last
you know, five-ish years, we could say there's an epidemic epidemic of that. You know, water damage in homes, work buildings, cars, and mold illness also slows the migrating motor complex. And mold illness is what's typically involved, one of the first things we think of when we have a very challenging, tough case of SIBO. And actually, while I think of it, there's w one other thing I want to mention. You talked about finding the root cause.
And the relapse rate. And I just wanna say that from the studies that have been done, we know that SIBO has a very high relapse rate. It's it's about a two thirds of cases will relapse. you know, that'll look c just come back. Reason being

Dr. Steven Noseworthy (39:20.982)
And that is and that's independent of the treatment methodology, 'cause I would imagine relapse rate is higher with certain treatments than others.

Dr. Allison Siebecker (39:28.41)
No, that is not true. All treatments have equal efficacy and and equal relapse rates we can tell. Yeah, all the treatments work have the same success rates, so they all work equally. And what are but just briefly, what are those treatments? Pharmaceutical antibiotics, herbal antibiotics, and elemental diet. They all work equally well and relapse has nothing to do with that. What the relapse has to do with is there's an underlying cause there.

Dr. Steven Noseworthy (39:35.158)
That's a new thing for me. Yeah.

Dr. Allison Siebecker (39:54.582)
Like well everything we just mentioned, diabetes. There is no known cure at this time for diabetes. It can be very well managed. Ellers Danlow, same thing. You know, food poisoning, same thing. There's no known cure at this time for the autoimmune damage that is triggered by that. So there are many chronic underlying causes. There are other causes that can be gotten rid of. Lyme and coinfection, that can be gotten rid of. And many other things. You can stop taking opiates, you know. But but
we have to look for these things and there are a lot of underlying causes. So that that's enough for me.

Dr. Steven Noseworthy (40:28.972)
Yeah, no, it's a lot. It's a lot to think about. So back to the the adhesions and the and scar tissue. Are you doing any imaging? Like can we can we see this on MRI diagnostic ultrasound?

Dr. Allison Siebecker (40:41.346)
Such a good question because the best test for this is actually a barium swallow with follow-through. And this is considered to be an outdated old test that's fallen out of favor. And everybody wants to do MRI or CT first. And what I would say is it, you know, if your doc wants to run those tests first, fine, and your insurance will cover it, fine. Let them do what they want to do. But eventually you're going to need to come to the barium swallow. This is not a barium enema, it's a barium that you drink.
And the the thing here is is that it actually needs special instructions because most radiologists will they don't want to do this test and they'll just take five films, five you know, five images or just a few. So I would encourage anybody if you're gonna ask for this test to to write an instruction or ask for this so that the radiologist knows what to do, which is rule out adhesions with multiple spot films and positional changes to visualize.
Each segment of the bowel. Then they will take like thirty films and give you and they know what they're looking for now. Yep. But adhesions can be seen on a barium as right angles. And the radiologist will do the interpretation. We don't need to know how to do this. But just for you know, the the bowel always has curves, but if there's right angles, that's how they'll know. And the other thing they'll see is an area of narrowing 'cause they they can see the white barium with an area of dilation above it. Yeah. And
And they'll let you know. So that's that's a

Dr. Steven Noseworthy (42:10.358)
I'll tell you like that that tip right there is gold. That so are you did you did you go through a period of time where you're looking at MRIs or diagnostic ultrasound and it just couldn't find what you were looking for? Or how did you stumble on I'm gonna do barium swallows?

Dr. Allison Siebecker (42:27.828)
I'm so lucky because we have our lead researcher in in SIBO is Dr. Mark Pimentel. He's out of Cedar Sinai in Los Angeles, and of course we're colleagues and friends, and he is the one who told told me. You know, he's the one who's been teaching so much of this to all of us. So he had spent years figuring this all out. And I mean it was for me talking to him and also the head radiologist who they called like the they had a name something like the the radio
something whisperer. I can't remember. Like he was so good at reading the im images. And I I spent time, you know, with them, following both of them in clinic and spent more than a day with the radiologist and I I asked them for for their advice. How can we get local radiologists to get a good test? And I just took what they said and put it into that little saying I gave you. I sort of made up that little saying from their advice, you know. So no, it was doctor Dr. Pimentel, he's the lead
lead in SIBO and he says you need a barrier and that's how you're gonna find this. So thankfully he he gave me the shortcut.

Dr. Steven Noseworthy (43:32.214)
There you go. Y you know, just thinking about how how things have changed over the last decade or so. Like, when I first heard of SIBO, I thought, that's interesting. I don't think I have any clients like that. And then I started to pay attention and then I started going like, forgive the language, holy crap, everyone's got SIBO. When you start and and I'm just wondering, first of all, is that a common experience for clinicians?

Dr. Allison Siebecker (43:53.664)
Totally right.

Dr. Steven Noseworthy (44:00.266)
is to all of a sudden something just clicks that light bulb and all of a sudden you're seeing things completely different. And you know, I I I've been doing this long enough that I know I'm not making it up in my head. But I just wonder if there are detractors. Like you know how for many, many years and still still today, some clinicians, mostly on the conventional medicine side, say leaky gut's not a real thing.
Do we still have resistance like SIBO's not a real thing? That's just that's just IBS. That's all it is.

Dr. Allison Siebecker (44:32.48)
Still it still exists. It's it's it's kinda crazy, you know. But look, things we know. things take a long time in the medical field to get adopted. And actually it's not the worst thing because you you have to have a lot of studies to prove it. I'm I'm good with that. I like that make sure there's enough evidence that scientific debate needs to go on for some time. I think I would say though that at this point we have
an overabundance of evidence and it's it's a little a little bit over the edge now the people who are still saying that. you know, but but what goes on is is they haven't read all the evidence because they're already opposed to it. So they're not gonna go and read about it. So it's it so then what what changes their mind, I don't know. I wish more people were like you who where they had the click and go, but yes, of course it's common because
look everybody's overwhelmed in life and we all got we have so many things coming at us. If something new comes it's gonna take a little while till till we can integrate it and decide what we think about it. So it's common and I just wish more people would would get that

Dr. Steven Noseworthy (45:38.154)
Really. Yeah, have that the aha moment. you know, we've been talking about SIBO, but I know in the literature there's other terminology like emo, intestinal methane overproduction, or iso iso sulfide, hydrogen sulfide overproduction. And it's been a long time, but I do remember seeing at least a couple of papers that talked about fungal overgrowth or CIFO. Yeah. Is it is it useful to make these distinctions?
either even if it's just to sort out our thought process or even better yet to guide clinical decisions, or is it practical enough that we can just kind of lump all of that into this overarching concept of of Spo, even though it might not actually be bacteria?

Dr. Allison Siebecker (46:24.204)
I know, I sort of feel like both of those are true or good. I still use SIBO as sort of an umbrella term to mean all of it. But let me just quickly define it. So we've already defined SIBO. Emo is intestinal methanogen overgrowth. And what so basically we have a few types of SIBO, and these are based on the gases that the overgrown microbes make, hydrogen, methane, and hydrogen sulfide. And then we can have mixes of those. And the methane SIBO
we found out, actually we've known for quite some time it's not actually bacteria making them, it's archaea, which are also called methanogens. And and so this is just a l a technical linguistic primarily thing, which is that it's not correct to call it bacterial overgrowth because they aren't bacteria. So so no matter what we think, the name kinda had to be changed because that's not technically correct. Even though I still sort of refer to it as SIBO.
Methane SIBO, you know. But so intestinal methanogen overgrowth. And then similar for intestinal sulfide overproduction, ESO is a new term. because there w our bodies make so so hydrogen sulfide gas, not just bacteria. It's bacteria that is making this. And so that's confusing because people look in the literature, they hear about hydrogen sulfide SIBO, they look, they go and read a study that's talking about the benefits of hydrogen sulfide.
And how it helps things and then they get really confused. And it's because it's when it's overproduced. We we can all understand that concept. Normal amount that's healthy, too much, not healthy. So that's why I think they made that terminology, overproduction. But but back to the other point, it is also helpful for our mindset because the treatment is different. That is a key thing, is that particularly for pharmaceutical and herbal antibiotics.
We choose different ones of those based on the gas type. And that's a crucially important point that causes some of the biggest trouble in treating SIBO when people aren't educated. They just think there's one thing they can use for all the types of SIBO. Right.

Dr. Steven Noseworthy (48:33.654)
Right. Right. And and maybe we can come back to that because I think before we get there, can we talk about the testing? And I know before we started recording, we we talked about testing very, very briefly. But I I have for a long time operated under the understanding that there was a very high false negative rate in s in SIBO breath testing, and I'll ask you to explain that here in a second. And so
I traditionally have relied more on symptomatic response to dietary change to either affirm or deny SIBO, insert any other linguistic term you want. and and that's se from a practical standpoint that seems to have worked out quite well. I I feel like I have a decent track record and success rate. I don't fix everybody. I I would never claim No, I would never claim that.

Dr. Allison Siebecker (49:28.606)
But he does.

Dr. Steven Noseworthy (49:31.302)
but I have I have scared clients away over the years from spending money on the breath test because I felt I could get good clinical guidance just simply by changing the the diet for say three to five days and then monitoring the resumable response. And if I had any confusion, we would put some foods back in and see what happened. Now having said that, it almost begs two questions. What is the current understanding? Because my my MO right now.
is based on things that I learned 10, 12 years ago, ish, somewhere around there. And I understand that research changes on a consistent basis. And so I I'm interested to hear from you as the expert. What is the current state of understanding of the value of testing? What tests are best? What are we looking for? And what direction does that lead us in? And then that will lead into perhaps a discussion in terms of effective treatment.
So why don't we just start there? Let's just talk about test or don't test. Like is it sufficient to just change the diet and see what happens to bloating and distention, for example?

Dr. Allison Siebecker (50:41.538)
Well clearly you have a method that's been working clinically. So I would never want to encourage anyone who has a successful method to change it, right? And so we also have to think about the nature of our practices because I as a SIBO specialist was pretty much always seeing people who had already undergone
Treatment and failed. You know, diagnosis and treatment have failed, right? So that puts me in a di different category. I'm not the first first line. I mean, occasionally somebody would come to me right away just because they think they had it and they know I'm a specialist. but so really the role of a specialist is quite different, and at that point, testing is always involved because
patients are absolutely demanding it. It can be the opposite when you're the first line. They do not want testing, right? And they're mad even that other doctors have suggested it. But at this point, it's like it's all about the testing because we have to we absolutely have to figure it out. I'm the specialist, I have to know exactly what's going on, etc. So putting that in context, I always tested. Now in in terms of
what's changed and what's new? Well, maybe I should give you the basis first, like with false negatives. Here's here's what we know. There are different substrates that are used for the test, and these are sugars that are meant to feed the bacteria. Bacteria eat carbohydrates, sugars, and turn them into gas, ferment them. And that's what we're testing in the breath, the hydrogen, the methane, the hydrogen sulfide. Most tests check for hydrogen and methane. There is one test on the market now that checks for hydrogen sulfide additionally.
and that's called Trio Smart, similar to that IBS Smart, same same company there, Jamelli Labs. So these sugar substrates, this is where there's been a huge debate over all the years. And glucose is the one that's used most often in research. That's fine for research, because because basically the issue is it absorbs into our body out of the sm out of the small intestine within about the first two to three feet.

Dr. Allison Siebecker (52:48.15)
of small intestine. So it is only able to check for SIBO or any of the others, overgrowths, in the top three feet of small intestine. SIBO's most common at the end of the small intestine. The small intestine is 18 to 25 feet long. So this is a test that has very high false negatives. Meaning like it because it can't even test the rest of the small intestine. So you can get a negative test when you actually have SIBO. So for this reason
Most of us clinicians don't like glucose. Researchers like it because they just absolutely know for sure if the SIBO is there, it's right there in the top of the small intestine. So we use lactolose. Lactylose is available the entire small and large intestine. That's actually very important because one thing I didn't mention is the methane overgrowth and the hydrogen sulfide overgrowth can overgrow in the large intestine as well, not just the small intestine. So when we do a three-hour test with lactolose,
we can also see what's going on in the large intestine. It's extremely helpful. so, now back to what

Dr. Steven Noseworthy (53:54.228)
Can I ask one question on that? it's my understanding that the lactose, does that not require either a a medical doctor to request or someone like yourself who's licensed like as a chiropractor? And this is it's again, it's been a while since I've looked at this testing, but can any clinician of any credential chiropractor, acupuncturist, naturopath, whatever, can they order a lactulose breath test with Trio Smart, or does there need to be
A different type of licensed clinician to order that for us.

Dr. Allison Siebecker (54:27.394)
Yeah, this is such an important point. Lactilose is a prescription in the US. It shouldn't be. It's kind of a mistake that it's on there. There's no reason for it to be. However, it would cost it costs millions to get something, anything, off of that formulary. So that's never gonna get done. Who's gonna pay for that? So it's very frustrating. However, there's plenty of workarounds. Genova Labs, and all the places you can get the Genova test, like Rupa Labs, True Health Labs, Direct Labs.
They all will will they have like basically they have like a physician on staff that yeah. That will handle that. And so then anyone can order that. And Trio Smart also just contracted with a group that's doing that.

Dr. Steven Noseworthy (55:09.716)
So that must be recent. That must be recent because I was look I was gonna say I like I was looking at this two months ago. Yeah. that's good. That's really good. Yeah.

Dr. Allison Siebecker (55:12.713)
Three weeks ago.

Dr. Allison Siebecker (55:17.12)
It they had it originally when they first came out and then whatever service they were using, I guess they had to stop using, and now they've now they've offered it again. So just so but what I would also say there's plenty of ways for those in the US to like I just mentioned to get lactolose. But a second option would be fructose. You can also use fructose. Lactalose is a little bit better. It's it's more sure that it's gonna be there the whole way. Now what's changed is we should be soon having sort of like a
Big article coming out all about testing, sort of settling this debate. We've been waiting for this article to come out. It hasn't come out yet, but what's changed is that there's been deep sequencing now done in the small intestine, correlating that with lactolose and culture. And I know I'm getting technical here, but actually some new techniques had to be developed for actual sampling in the small intestine. It's difficult to do.
you need you need to protect your sample in a special way because it can get contaminated with oral bacteria on the way back out. And also you need to release some of the bacteria that are stuck in mucus. So Dr. Pimentel actually developed and then validated this new sampling technique, then used deep sequencing, and compared latulos breath testiculture to deep sequencing.
Because the issue in the past was that people didn't think the breath test was accurate enough because they were comparing testing to culture. It turns out culture was not a good gold standard. We call it a tin standard. It it had a lot of problems. Now with these improved techniques and with the DNA sequencing, now the lactose breath testing is lining up perfectly with the deep sequencing, showing that the culture test was the problem.

Dr. Steven Noseworthy (57:13.27)
And when you say culture, you're not talking culture from a stool sample but from endoscopy.

Dr. Allison Siebecker (57:17.976)
From the small intestine, from endoscopy. Small endoscopy. To actually c try to find the small the overgrowth. And you can also imagine there's issues there because where is it? I mean, we talked about the twenty five feet. Where are you?

Dr. Steven Noseworthy (57:28.876)
Yeah, there's the there's almost like this assumption that that a bacterial load is evenly distributed throughout the intestine. And you know, if you stick a stick a claw down there and try to take a sample, you know, you're guaranteed to get a hit. But that's no, that's not true at all. And this is like you know, prior to this, we saw this with say H. pylori, right? Right. With endoscopy and biopsy for H. pylori. biopsy said I didn't have H. pylori. Well, you didn't have it in the spot that they biopsy.

Dr. Allison Siebecker (57:41.41)
Not.

Dr. Allison Siebecker (57:56.766)
Yeah, so it's issues. But the reason I brought that up is just because you've asked sort of what's changed and there has always been a big a big controversy saying glucose test was actually better and the reason why is it lined up with culture better. but there's this massive false negative with glucose and so people but people were worried based on the studies about lactolose. But what I can say is is clinically lactalose is absolutely

Dr. Steven Noseworthy (57:57.82)
That's all we can say.

Dr. Allison Siebecker (58:24.012)
the one to use. Now as to the importance of doing it, I personally would find it very difficult to not test because I'm basing my treatments, so long as aside from elemental diet, because that works for all types, on the gases. And what I find is you can't tell based on symptoms which gases are there. Because we we typically have a pattern where we say diarrhea is correlated with hydrogen and hydrogen sulfide.
Constipation is correlated with methane. But what we actually see clinically is if we just look at say hydrogen sulfide, it's about 50% of the time constipation and 50% diarrhea. Even though the studies say diarrhea clinically, we see 50% of the time constipation. And then we see all the time where people have a a sort of like a a pattern that doesn't quite match with that hydrogen, methane, diarrhea, constipation. It happens a lot.
So we can't really just tell, you have constipation, or or you don't really the issue is you don't have constipation, so you don't have methane. That's really where we get into the trouble. So by doing the breath test, you can see the exact gases, and then also you can see how high they are. So it's not a yes and no test, it's a real informative test. And when we see how high they go, that also informs our treatment. Because if gases are very high, like say 150, we know exactly about how much on average.
Gas comes down per each treatment type we do. It's about 30 parts per million, 30, 35, for antibiotics and herbal antibiotics on average. There are certainly those cases where you see 70. I've got plenty of those cases. But on average. Symptom severity doesn't correlate with.
gas severity. I'd say forty percent of the time it does.

Dr. Steven Noseworthy (01:00:25.846)
Why do you think that is, if y if we can take that money trail for a second?

Dr. Allison Siebecker (01:00:30.282)
I really don't know. I've thought about it. I just y I just don't know. I think it's just the great individual variation. What what was the terrain like before? What is the terrain like now? What you know, like what are all their enzymes doing? What's their hydrochloric acid like?

Dr. Steven Noseworthy (01:00:45.454)
The the gut environment is so complex, right?

Dr. Allison Siebecker (01:00:50.678)
Microbiome and yeah, and th those things, you know, and are they leaning to visceral hypersensitivity or not? Most will have visceral hypersensitivity, but not all, you know. It's the people are just so complex and individual.

Dr. Steven Noseworthy (01:01:03.468)
Have you have you seen to I'm sorry to one more question. Have you seen have you seen any correlation in symptom severity with, say, the degree of elevation of vinculant antibodies or cytolethal distending toxins?

Dr. Allison Siebecker (01:01:17.838)
Let me think about that, 'cause that's a smaller amount of cases that we have those tests for.
No, I can't say I can't say that I have. No. Right, so back to it, since we can't, you know, sometimes the the gas and severity sympt of symptoms do match, but often they don't. So we can't judge by that. So then if we have this gas number, we can see, my gosh, you've got a hundred and fifty parts per million, you know, hydrogen or methane. Why don't we just skip forward, do elemental diet, because we know we're gonna get we could get a hundred, we could even get a hundred and fifty.
parts per million of gas brought down in two weeks and in and then will save you six months of round after round after round of antibiotic or herbal antibiotic. So this is how how come I like the test because it really informs treatment and it it helps us with a prognosis and makes us not be guessing. So those are d those are my thoughts. Yeah.

Dr. Steven Noseworthy (01:02:14.154)
And I I you know, you say herbal herbal antibiotics. I mean, obviously that's a category. There's so many different herbs that fall into that category that have either antibacterial properties specifically or they're just broadly antimicrobial. So I'm I'm interested in whether or not you see correlations. I had I did an interview with a doc who works with doctors data. And a couple of years ago, I think it was they did a an internal study.
Where they looked at microbial sensitivities. You know, they took a thousand different studies and looked at their antimicrobial sensitivities. And it turned out that I call it my gust protocol, grapefruit seed extract, UV Ursian silver tended to have the most favorable antimicrobial effects on the things that they were culturing and then testing inhibitory sensitivities to. And so, you know, that's one lab.
Now it's a thousand people. That's a decent number to look at, but it's one lab. And I don't know if we asked other labs like Genova or whomever Diagnostic Solutions to do the same thing. Would we come up with the same answers? So I have two questions when it comes to treatment. One is choosing specific antimicrobial herbs. And the second thing is talking about the distinctions and utility between
The elemental diet or specific carbohydrate diet and the low FODMAP diet. Because I listened to one of your interviews not long ago, I think it was Dr. Silverman might have been. And you had made a comment that the low FODMAP diet was not made for SIBO and not all not always effective. And so that fast

Dr. Allison Siebecker (01:03:55.478)
That's true.

Dr. Allison Siebecker (01:03:59.63)
It's about one of our le least effective diets.

Dr. Steven Noseworthy (01:04:02.028)
Okay, all right, we gotta get there. So let's back up and let's not

Dr. Allison Siebecker (01:04:05.132)
However, that doesn't really matter and I I can tell you why when we get there.

Dr. Steven Noseworthy (01:04:08.566)
Okay, yeah. So let let's let's talk about the antimicrobial herbs because like when I have conversations, particularly if there are docs that are new to functional medicine, they all want to know what's the best probiotic. That's another question. Do you use them? Do you not? my gosh. what's the best antimicrobial herb? What's the best enzyme? What's the best this? And my answer is I don't know. Like I think you just have to have a reasonable starting point and then
Have the mental flexibility to change your plan if what you initially chose isn't working the way that you want to. And I know that that frustrates people because we want protocols. Do this exactly like this for X amount of time and everything's gonna be fine. And yeah, every once in a while that works out. But I I kind of have a rule. I shared this, I shared this with DeTise, Dr. Carazian once.
I like when I and I teach Ram and and a lot of times if I have a lot of new docs in say like a blood chemistry analysis course and they're just starting out, I'll put up Steve's rules for interpreting blood chemistry. And the very last one is your clients or your patients are under no obligation to follow anything I teach you this weekend.

Dr. Allison Siebecker (01:05:22.166)
Ha ha ha.

Dr. Steven Noseworthy (01:05:24.352)
Right. And that's just clinical reality. It's like we're we're doing the best that we can and we base as much as we can on science and maybe even a scientific method, but even then it doesn't always work. Right. So

Dr. Allison Siebecker (01:05:38.238)
Absolutely. By the way, Datisse is who I learned functional medicine from. Way back. There we go. So glad to hear you teach from love Doctor Carazian.

Dr. Steven Noseworthy (01:05:47.701)
Absolutely, for sure.

Dr. Allison Siebecker (01:05:50.348)
So we actually do have some protocols for for SIBO, and this is hard one. it's from doing before and after testing on every treatment we gave at our SIBO specialty center. Okay. but one thing I want to say about those herbs you mentioned for doctors data, I think that is so incredibly helpful that they have that information. But let's just remember that's stool testing and that's that's different. They've only just recently added in some of the microorganisms
microorganisms that are overgrown in methane or hydrogen sulfide, SIBO that can overgrow in the large intestine, those have just been added in in say the last year or so. they they add smithii in some of these stool tests. And some what's what's overgrown for hydrogen sulfide? It's Previtella, Fusobacterium Varium, I'm sorry, not Previtella, Proteus Proteus, Mirabilis. Fusobacterium Varium and
Disulfovibrio piger. And then for methane it's smithii, methanobrevibacter smithii. But this is just new and we hardly even know what it means and what are the levels. We we're that's totally not even been figured out for

Dr. Steven Noseworthy (01:07:00.598)
Right, and it it almost begs the question like can you can you use a stool test to diagnose SIBO?

Dr. Allison Siebecker (01:07:06.454)
You cannot. You cannot. no, absolutely not. Except now we now that we know what I just said that those bacteria can overgrow in the large intestine. Now maybe we can, but that work hasn't been done yet to figure out what are those levels. Stool tests jumping on board and adding those in, I'm glad. That'll help us figure it out, you know? Yeah. 'cause we used to say absolutely not, the two different organs. And you know, I used to run stool tests on everybody. I did a breath test for
you could see perfect large intestine tests. Amazing I would ever see any of those, but I would with with the ramp SIBO. So, you know, they and because you'd imagine there'd be spillover, right? But no, not necessarily. Okay, so so back to it. yeah, there are distinct things that seem to work for we know the exact bacteria that are overgrown now. That's been years of work. And we only just have those final hydrogen sulfide ones that came out one year ago in with studies.
So that that's been the real thrust of work in the last few years is which exact bacteria methanogens are overgrown in these different types of SIBO. Now we have that information. Now we can really figure out what treatments are going to work. However, clinic, we've been figuring it out for years, right? So so what we know is what what works for hydrogen is oregano, neem, and berberine.
And berberine is a constituent in many herbs. So, you know, golden seal, organ grape, copdis, you know, philodendron, etc. we we know that what works for so here's where we get into trouble is those same things don't necessarily work for methane. These are not bacteria. They're archaea, different things work on them. We know different antibiotics work in different, you know.
infections, you know, I've seen it all the time. People take an antibiotic, it doesn't work, you just switch to a different one. You know, you've got to get the right thing for the right bug you're trying to target. I hate to think so like that, but this is the the truth of it, you know. So for methane, we know that alicin works, the constituent from garlic. We don't like to use whole garlic, aged garlic, garlic oil because it can s trigger symptoms, because garlic is very high fermentable.

Dr. Allison Siebecker (01:09:25.406)
So we really try to use the purified Allison. So we use AliMed or Alimax Pro is the one we tend to use. And that's the one we just we did all our testing on. I mean others may work. We w I'm sure they would, but we that's the one we did the testing on. And when we tried products that were like whole garlic, we just ran into so much aggravation of symptoms. And then also atranteel. That is a little three herb combo that's been tested and shown to reduce methane and it works differently. It's not so much a straight on killer. So it's got peppermint.
Cobracho, red cobracho bark and conquer tree, which is of course chestnut. And what this is doing is actually making it so the methanogens are not being able to produce methane gas. It's not so much killing them. They just are not able to make the gas. And it's the gas that causes the slowing of the of the causes the constipation.

Dr. Steven Noseworthy (01:10:16.856)
So do do you have to just write from a clinical perspective, do you have to use autoontel with something like what did you say kills the alison, the highly purified alicin? Do you have to use other?

Dr. Allison Siebecker (01:10:28.846)
No, you don't. So so you choose one or the other. So what we typically do in I call this the single herb approach. It's not really single, but as opposed to just grabbing a big formula off the shelf that has like twenty-five things in it. because that's another way to to go and we can talk about that. But you choose something for hydrogen because there's always hydrogen there. The reason why, even if you don't see it on a test, is because methane is made from hydrogen. So there are always the bacteria there that are making the hydrogen.
But then the methanogens are turning that hydrogen into methane. Sorry to get so technical, but this is

Dr. Steven Noseworthy (01:11:02.828)
This is exactly what I'm looking for.

Dr. Allison Siebecker (01:11:05.022)
So, so even if you only see methane on a test, you always have to treat hydrogen at the same time. That's the way we do it. So you choose one of the hydrogen herbs, and if we were talking pharmaceutical antibiotics, it'd be the same. You choose one of the hydrogen pharmaceutical antibiotics, and then you add the herb or antibiotic that treats methane. So then you choose either alicin or atrantiel. And so in the in the case where there's methane, you're always doing two. We always do two for hydrogen also.
By the way, let's just take this on. Why don't we just add more and more and more? Because it doesn't increase efficacy. We've tested it. And so more does not equal a bigger reduction in gas. You peter out at about three, three herbs. Now, with the exception of something like atrantil, that's a small little formula, you know, that has three herbs, and so we'll use that with a hydrogen herb. And then for hydrogen sulfide, what we know works is
Bismuth, which is not actually an herb, it's like a mineral. Mineral. and high dose oregano. And high dose oregano is something that came to us from a patient years and years ago, which was originally an old chiropractic blastocystis hominus treatment. it came from the chiropractic world, and it's very high dose. but so typically we're using ADP, the that's like the dry oregano. We're not using the liquid.

Dr. Steven Noseworthy (01:12:20.034)
Say high dose, what do you mean?

Dr. Steven Noseworthy (01:12:28.302)
It's biotics, isn't

Dr. Allison Siebecker (01:12:30.39)
Yes, and the reason the reason we did that is because that came from Dr. Jerry Mullen from Johns Hopkins. He had been using that. He teaches for the Functional Medicine Institute. He'd been using it with success, so we began using it. And what we found was that dry form was better tolerated actually than the oil form. oregano can be pretty caustic on mucous membranes and it even the dry form, but the dry form is better tolerated. So we're talking five pills three times a day for the first week.
That's fifteen pills a day. And then nine pills a day, three pills three times a day for the next three weeks to make a month treatment. That's something we haven't mentioned. Herbs, the typical herbal treatment round is four weeks, can extend to six weeks. Whereas for elemental diet and pharmaceutical antibiotics it's two weeks. So they have the same effectiveness, but herbs just take a little longer. So you just have to

Dr. Steven Noseworthy (01:13:22.688)
And is that is that six week cycle, is that in your opinion unique to SIBO or would you include any large intestine dysbiotic case to be the same rules?

Dr. Allison Siebecker (01:13:34.132)
I don't know because I don't treat Because we all I I right. I've d of course I have treated some LIBO, but I wouldn't want to pin my you know I'd want to ask someone who does run school tests and treat that regular

Dr. Steven Noseworthy (01:13:47.106)
Well, can I share something with you? Because this is like when I first started in and I learned functional medicine from Doctor Karazin as well. And I've been doing it well, I've been teaching for him since two thousand and eight. So sometime before that is when I started learning, but

Dr. Allison Siebecker (01:14:01.656)
Two thousand and eight, did you say?

Dr. Steven Noseworthy (01:14:03.63)
Yeah, watching for Apex and to T since then.

Dr. Allison Siebecker (01:14:06.03)
That's so long. I love it.

Dr. Steven Noseworthy (01:14:08.278)
That's that's you feel like I blinked and now it's twenty twenty five.

Dr. Allison Siebecker (01:14:11.692)
That's amazing. Yeah, I think I f I first started studying with him in two thousand six, I think.

Dr. Steven Noseworthy (01:14:17.196)
Yeah, so Ray yeah, and so we probably got involved with him somewhere around the same time, probably in different parts of the country. I was in Florida at the time. But in the in the like and this is before Datisse and and the company he formulates were called Apex Energetics. Before they started to like increase the number of formulas that Datisse had brought to the market. and so I was doing I was using predominantly Genova's GIFX test.
and I was using in in it's my own podcast, I could mention anything I want. I was using Apex's HPLR and called Mycosyme. I was using those two things in combination. And I would would run and I would probably do two capsules, two things a day of each of those. And I would run a twelve week protocol and I would retest the stool in nine weeks. And ninety percent ish of the time

Dr. Allison Siebecker (01:14:55.958)
Yeah.

Dr. Steven Noseworthy (01:15:15.212)
The sto the second stool test was either perfectly normal or very close to it. Every once in a while you'd see that wacky second test that looked worse than the first one. And it it confused me for such a very long time until I started reading about biofilm. Right. And so I want to bring that to the the SIBO discussion. Do we have to account for s for biofilm with SIBO? If the answer is no, we can move on.
But if the answer is yes, can we talk about biofilm and maybe talk about the strategies that you're using for biofilm disruption?

Dr. Allison Siebecker (01:15:52.438)
Yeah, so this is this is very interesting to me. I think this is s we're still figuring this out. Early on we made an assumption when we were treating. I mean, heck, I mean ninety percent or more of relapsing infection type diseases are biofilm diseases. So could this be the part of the reason why we're seeing so much relapse, right? Is if there's biofilm and we didn't we didn't get it and so the infection sh can just come back.
So on that assumption, we gave many, many of our patients antibiofilms. We worked real hard at it and we used the enzymes, we used EDTA, and we use the well that's mostly it, the seratopeptidase, that was also an enzyme. you know, like lipophos EDTA and all the classic ones, right? and and NAC. We used NAC because NAC is excellent antibiofilm for H. pylori. Yep.
really good studies on that. So we used all of those hardcore, not on everybody. So we had samples to see back and forth. This isn't a formal study, but this is just clinically. I'd say for about two two or more years, maybe like three years. And it seemed to make no difference at all. And we were very disappointed. Okay, so then fast forward, I have a conversation with Dr. Paul Anderson, who's a elder in the naturopathic profession, treats very difficult cases, a lot of biofoam infections.
And he said, well that's because the antibiofilms you were using are not good enough. And you really need to use a bismuth based, a bismuth thiol based antibiofilm. And at the time he had this compounded formula, it's prescription that he he had developed. And not not even every compounding pharmacy could make it. And you had to get it special from certain places. Now more more can make it. So I started using it. That made a difference. That made a difference. That helped.
That moved the needle on some really tough cases. Then, this was quite a long time ago, then he came out with an over the counter version of it. and that is priority one, Biofilm Phase Two Advanced.

Dr. Steven Noseworthy (01:18:00.895)
I use that all the time.

Dr. Allison Siebecker (01:18:02.956)
And I may have those I sometimes I say those words wrong because it's a lot of words. Which one comes? Does advanced come first? I don't know. But I can definitely say it's not as strong as the I I've used it so much and it's not as strong as the compounded. Sometimes that's good, right? You know, but I I think the compounded is more effective. So okay, so there's that piece. What I would say is if you And also I wanna say that so there were a lot of people we didn't treat with antibiofilm that got completely better.
And and we and yes, like the classic scenario in SIBO is it's not cleared with one round. There are one and duns, but that is a smaller, smaller proportion, particularly in a specialty practice. most people will need multiple rounds, but even still with multiple rounds, no antibiofilm, they got all better. So clearly not everybody does biofilms need to be addressed in SIBO. But if you're really having trouble, that's when I would think of it. Okay, so so we have this. Then we have something additional to add.
Just last year out came a study from Dr. Pimentel and team using a special formulation of NaC with rifaxamin. Now, from my understanding, it's complexed with the rifaxamin, and there's a time release situation going on there. and that greatly increased the efficacy of the success of the rifaxamin trick. Raphaxamin, for anyone listening, is our main antibiotic we use for hydrogen.
SIBO. It's also called Cyfaxan. So this was at first when I heard this, I didn't hear the special formulation part. And I was like, what are you talking about? We used NAC for years with zero benefit. I'm like, I am having a hard time believing this. Then I heard about the special formulation because we were just using, you know, immediately absorbed NAC. And so what Dr. Pimentel has said is you really have to get it down into the small intestine. Hence the special formation.
time release situation there. or sustain, you know, there is a sustained release by Jarro, so if anyone is gonna try this with any any of their SIBO treatments, I'd at least recommend that until until whatever they because they're they're developing a product. So until that comes out. So so that's more to add to the biofilm piece. So apparently, you know, Dr. Pimentel tell us talked about how methanogens and certain of these overgrown bacteria are living in biofilms. He's been able to see that with his endoscopy.

Dr. Allison Siebecker (01:20:28.59)
Yeah. The scope going down and this and the sampling. So I think that that could be important. So maybe maybe we should all be adding sustained release NAC to our treatments.

Dr. Steven Noseworthy (01:20:39.866)
You know, I was I was teaching a course in it was West Palm Beach many years ago. And it was around the time where we as a group in the Apex ecosystem were starting to teach on biofilm. And I remember a young guy coming up on a break and he told me that his uncle, if I remember the story, his uncle was a a biofilm researcher at one of the universities in Israel. And
I asked him immediately like what is he seeing is working? And he said the two things that they're seeing is working is cranberry extract and stevia.

Dr. Allison Siebecker (01:21:14.818)
Wow.

Dr. Steven Noseworthy (01:21:15.916)
Yeah. And I know that a lot of people a lot of the docs that are line literate rely a lot on both either Stevia or cranberry as their primary biofilm strategy. Now I I wonder like you hear stuff like that and that's great. You hear stuff about Bismuth and that's great. And then I wonder about individual variability. Like, do we have to account for that? Is Cranberry going to bust all biofilm in all places and all people?

Dr. Allison Siebecker (01:21:18.05)
That's a great tip, thank you.

Dr. Steven Noseworthy (01:21:45.602)
Right? Or are we are we did we have have to have a stable of things to choose from and then we mix and match depending on their response? And and that brings me to the next question. You mentioned some people need multiple rounds and a round I guess roughly is six weeks long. Okay, four weeks.

Dr. Allison Siebecker (01:22:01.358)
I'd say four is a typical round. We'd we'd stretch it to six if they have higher gas.

Dr. Steven Noseworthy (01:22:07.936)
Okay. And then how long in between each round? Is it only when a relapse happened? Or is this pre planned? You're gonna do four weeks, take X amount of time off, do a second round, and if that's the case, or either way, do you change the protocol each time?

Dr. Allison Siebecker (01:22:22.422)
these are such good questions. Okay, so it it brings up the you know, sort of a an underneath question was why not just go longer? Why stop? Why right? We believe me, we tried it. And what we found over and over, now once again, this is in the patient population that we were seeing, which is at a specialty center. so it may not be the same for the first, you know, for primary care or something. But we just found that the that the treatment lost efficacy somewhere around
five or six weeks. and so what would happen is somebody might have had a some improvement in their symptoms and they would just begin relapsing while still on. While still on. So this happened so often. So often. And so this is how we learn, right? And so we so that's why four weeks you really have a potent treatment. You know, even at five weeks we could start seeing some people. Now people are going to say

Dr. Steven Noseworthy (01:23:00.684)
While still on it.

Dr. Allison Siebecker (01:23:19.064)
They're gonna know they're gonna have experienced exceptions to this rule. I will tell you, I have experienced exceptions to this. I've certainly seen people that have been on the same thing for two years. It's working, and they come to me to help me get them off of it. It's the only thing that works, and they don't want to be taking it every day. Of course there are exceptions. Sure. I'm just talking about patterns, right? So so what we do is now this is again, you know, if you have testing and people have to figure out their own way that is gonna work for them. But typically after around
We need to see how the patient is off of the treatment. Because the treatment could be giving them symptoms or die-off or whatever. We have to see. How are they? We have to assess. Are they better? We're we're looking for ninety percent better. So we need a little time to see what that's like. If they are not better, that's when typically we will do a retest and find out what's happened. A lot of times the gases have changed things, you know, it helps again inform our treatment. But the key thing is
You don't want to wait more than about two weeks. And why is this before you start your next treatment if they're still positive? And you can do this without testing, we can talk about that. But why that is is because relapse, or really here, we'll call it backsliding, is so common at about two weeks. it's just classic. And so you

Dr. Steven Noseworthy (01:24:34.316)
That's two weeks after stopping a four week round.

Dr. Allison Siebecker (01:24:37.804)
Yep, and or if it was antibiotics or elemental diet, the two week ground. And it's because we don't want to lose ground. So what we do in this two week period is we put someone on a prokinetic, prokinetics we haven't talked about yet, an absolute essential part of SIBO treatment that gets missed often. You don't you you want a moment or two without them on the prokinetic too, like a day or something if you can, because what if they start to have some sort of reaction to that? You need to see how are you?
Then get them on the prokinetic while you're waiting for the test to come back or figuring out what you're gonna do. But if you wait more than two weeks, you know, if they're not clear of their SIBO, that overgrowth can really start to come back and you lose ground of what you just did. Yeah. So if you don't have a test, let's say you have an initial test and you saw they were, you know, at 70, you can calculate, well, with herbs, it's about 30 parts per million. And by the way, that information is is gold.
comes for just cajillions of before and after tests and it's just an average. okay, so one round we'll expect, you know, seventy minus thirty, they're still positive. We kind of suspect they're gonna need another round. So see how they are after one round, because what if it did it? And you know, if but if they're still symptomatic, maybe you don't go for that next retest due to budget and time and logistics. And then you have in mind what your next round is going to be. So to your next question. I always
typically switch because we're concerned about clinical resistance or clinical clinical tolerance to what we're giving because we see it so commonly we see that happening even to rifaximin which has been studied and shown to have seven repeat rounds with with no antibacterial resistance yet we saw it we saw it a lot so we'll switch. Now you don't have to switch. Let's say somebody was really doing great. They weren't having any backsliding at all.
You take a two week break or a week and a half break, just so you can assess or whatever. You can use the same thing again, if you really think it was working. And if you got some feedback from the patient, yeah, we we do that. but the typical thing is to switch. and you know, switch around, which is then where we start to run out of well, what are all of our options that treat each thing, you know? Yeah. And then just one other thing to just mention here, just briefly, we didn't talk about like big formulas.

Dr. Allison Siebecker (01:26:59.372)
Because there have been some formulas studied for SIBO, candybactin ARBR and FC Cidal and Fidal and Dysbiocide. Those were studied for SIBO and shown to be efficacious. Really, these are gonna work for hydrogen. They don't really have anything in it much for methane. Although oregano sometimes works for methane, and that is in those. it's not as reliable though.
on a day in, day day out basis. The issue for me with these big formulas is that I think I think they're great for primary care when you're not even sure i am I dealing with SIBO. Is could there be LIBO? Is there yeast? We didn't really talk about that. It throws a big net and that is great and I think appropriate. But when you're really trying to dial it in and you're really just trying to treat the SIBO, you do need to get a bit more specific, I I find. You know, if so long as
I mean in maybe that took care of it. I just mean if you are now continuing to struggle with a SIBO, then you need to dial it in. and get get specific with those organisms that are overgrown. And the other thing is the clinical resistance. We know so many people are gonna need multiple rounds, just as a matter of course. Most people need two to five treatment rounds. And we don't want them getting if we have everything in one, what will we use for our next round if they become
So we're just being practical. And lastly, is we see so many sensitive patients. they have histamine intolerance, they have mold, MCAS, all these things, and they have a very hard time with various herbs. Using a lot of herbs at once, how can we figure out what was bothering them if there's twenty five things in there? If we're using two things, we can take one away and then we can easily figure it out. So this is just clinical practic like practicality.

Dr. Steven Noseworthy (01:28:23.544)
Sure.

Dr. Steven Noseworthy (01:28:49.27)
So would it be a a workable framework to perhaps anticipate, whether you actually do it or not, but anticipate multiple rounds, four weeks each, maximum of two weeks in between each round, especially dependent on either return of symptoms or if you post test the results. And maybe up to four or five four week rounds.

Dr. Allison Siebecker (01:29:08.684)
Right. Exactly.

Dr. Allison Siebecker (01:29:13.442)
Yes, that can happen. It's it's common actually. Yeah. Yeah. That's one thing people give up too soon. You know, they're like, Well, I I took a round of something and we see it in the medical world all the time, and I think you alluded to that. They threw Raphaxin at someone or I took a round of something. I'm not better. I must have a tough case or I'll never get rid of it. It's like, No, you just started.

Dr. Steven Noseworthy (01:29:31.439)
Or the doctor's incompetent, right? That's the other option is blame the doctor.

Dr. Allison Siebecker (01:29:35.654)
Or I must not really have SIBO if it wasn't a test. It's like, what? You know, it's like, what? You just did your first round. See if you don't know, it's like, you know, no, you're just getting going.

Dr. Steven Noseworthy (01:29:46.572)
Yeah. And and like in the in the realm of prokinetics, I don't know how long ago, but I would say at least seven years, there's been a lot of talk about vagal stimulation to, you know, drive the the vagal system and increase motility. my experience with that, because I I play with that with clients, i it's hit or miss. It works for some people, not for others. Same thing whether it's you know, anxiety or depression or anything like that.

have you used that? What's been your experience and what's your opinion?

Dr. Allison Siebecker (02:09:25.548)
I tried a little bit of it long ago from what I learned from Dr. Karazian and unfortunately we didn't find much of any help. And it was very different from what Dr. Karazian was finding. He was reporting all these miracles and we were really bummed out. Really bummed out. We just didn't see that at all. I still recommend I I think it's a fine idea. The thing is is that there's two migrating motor complexes. There's one that starts in the stomach and one that starts in the small intestine.
The one that starts in the stomach is vaguely mediated. The one that starts in the small intestine is not. And they they don't even still fully understand all the instigating factors in that. But however, the one that starts in the stomach, from some of the literature I've read, that is supposed to be the stronger migrating motor complex. It starts in the stomach and goes through the whole small intestine. Maybe it's not. Maybe it's not. Maybe the one that starts in the small intestine itself is the more vital one to SIBO.
Is that why the vagal stimulation has been maybe not as helpful as we wished? I don't know. Because it helps with so many things.

Dr. Steven Noseworthy (02:11:04.822)
Yeah, for and other things, you're right. So one thing that I'm playing with lately and and it's way too soon for me to give an opinion on this, but do you have you do you know what the insular cortex is? Yeah, so we I'm

Dr. Allison Siebecker (02:11:17.76)
No. Probably should. I took all of Karazin's brain courses. I don't remember.

Dr. Steven Noseworthy (02:11:23.158)
Well, it's it let's call it a new lobe of the brain. Not that it's new we never had it before, but like our our understanding of it is actually a lobe of the brain. So like when a when a baby is born, we just have the baby has a massive neuron, so there's very little organization. And as the brain grows within the confined space of the skull, it starts to involute, it starts to fold in on itself. And just under the junction of the frontal parietal and temporal lobes, just around the temple, right above the ear.
Underneath the section, there's an infolding of the cortex, and that's what's called the insular cortex. And the insular cortex has a somatotopic representation. no, I that's the wrong word. It has a viscerotopic representation. So in the brain, in the parietal lobe, we have a sensory homunculus, which is basically a a map of the entire body as it relates to sensation. So if someone comes up and touches my shoulder.
My brain shouldn't be confused and think that someone touched my ankle. Right? So there's a picture of every body part in the parietal lobe on both sides so that we understand sensation. There's also a motor homunculus in the primary motor strip, which is a picture of every joint and muscle in the body. So when my brain says, Hey, I want to sh wave my hand, I don't kick my foot out. There is a visceral representation in the insular cortex. And it's
In terms of neurological hierarchy, it's a couple of steps above the vagus, but it integrates with the vagus. And and so my working theory right now, and that's all it is, is that when we have cases where vagal stimulation makes sense, perhaps in some of these cases really what we're doing is we're stimulating the vagus to try to get activity in the insular cortex. Does that make sense? So sometimes I I think the in my in my theory
The cases where vagal stem works is that's the choke point, so to speak. And so the insular cortex might be fine, but some things decrease the frequency of firing of the vagal system, so you stimulate it directly, and now you get great things happening. But what if that system's intact and the problem's higher in the chain? If that makes sense. And so I'm playing right now with using different forms of transgranial direct stimulation to put electrodes over the insular cortex.

Dr. Steven Noseworthy (02:13:47.47)
Trying to get the brain to understand the intestinal system better so that it can more efficiently organize signals going to and from that system.

I'll let you know what happens.

Dr. Allison Siebecker (02:13:59.892)
Great, I'd love to hear.

Dr. Steven Noseworthy (02:14:02.134)
Yeah. Yeah. So like I said, it's it's something recently that I've been playing with and way too early for me to come out and say, Yeah, this is what we need to be doing. But so far so good. I'll say that. Yeah. Well listen, you you have been amazing and so generous with your time. th this has been one of my favorite interviews. I I tend to say that because I get a chance to talk to some really cool people who know things that I don't and and especially on the Funk Med Nation podcast where I
it's really geared towards practitioners. Like I I know that I don't know everything and it it drives me crazy. I quite often joke it just it pisses me off that I don't know everything 'cause I desperately want to. and so when I get to talk to people like you who clearly like you are an expert in your field and I so appreciate not just the facts and the details, but the the clinical nuance. And
And I I think you're just an amazing clinician. and I'm so very happy that you you decided yes you're gonna come on and have this chat with me. So whether it's clinicians or the general public, where can people find you?

Dr. Allison Siebecker (02:15:16.258)
Well, I have a free educational website. It's SIBOINFO.com. And it's for both patients and practitioners. It's been that way for I don't know how long, since 2010 or something. I guess 15 years. And I don't see patients anymore. but what I I mostly just focus on education. And so I have courses. I have courses for patients and for practitioners. I've got a mini course for practitioners, I've got a testing master class, a testing mini course, and a comprehensive training for practice.
practitioners and as I say for patients as well. So you you can see all that on my website. And also signing up for my newsletter is a great idea. I don't send too many. I know people can't stand getting too many things in their emails. But I often give free classes on SIBO and when there's updates, I just update everybody. Like for instance about how Trio Smart started offering lactolose. I just sent an email about that. So you know it keeps people in the know on practical things and there's new research every year. The the big gastroenterology conference
just happened the weekend before we're recording this, DDW, and there's all brand new research and I do an annual interview every year with Dr. Pimentel where we share all the new research. And so that's why I'd say if you sign up for my newsletter, you'll get included in that.

Dr. Steven Noseworthy (02:16:29.356)
Yeah, and that's amazing that you you played that role because it's so easy as a practitioner just to put your head down and treat, treat, treat. And then you you look up five years later and you realize that the clinical world has moved on and things have changed and and all of a sudden you're a dinosaur and you're doing things the old way. Right. So I I appreciate the fact that you've dedicated some of your time to not just stay up on the research yourself.
but to share that with other people and and maybe we can use this as a parting question. Where do you where is SIBO research going right now? What do you think is gonna come out in the next year or so?

Dr. Allison Siebecker (02:17:08.162)
Well, there's always more coming out about treatments. So, you know, I think like that NAC rifaxamin compound thing will come out. And and I think we're gonna learn more about what's best to treat each of the different types of SIBO in those different organisms. I think I think we'll have probably new stuff in testing. I've been seeing articles coming through over the years with developing various capsules and various things like that. it'd be fascinating to see what we develop with that.
But I think I think and also just more on understanding the pathophysiology, we're gonna see more with that. Like I said, we've gotten the bacteria figured out exactly. I think we're gonna learn more about that. Some some complicated things I didn't mention are there's these things called syntrophes. They're actually bacteria that sort of pre make the gas that others make. I think we're gonna see more more on the pathophysiology. It's it's you know, more on the microbiome aspect. Mm-hmm. and how how to treat that, I think.

Dr. Steven Noseworthy (02:18:05.794)
Yeah.

Dr. Allison Siebecker (02:18:06.894)
I mean that's one thing that's fascinating about SIBO is it's a current emerging field. Like I mean the n the i the research is being done now. And it you know and at and when we first entered it was being done and it's being done now. And we are still learning. We do not have all of it figured out yet.

Dr. Steven Noseworthy (02:18:24.322)
Yeah. Yeah, and I I love this this whole field because it's like as a clinician, like you have to evolve or die. N now that's a little extreme, but you know what I'm saying, like things change all the time. And y you know, I've been doing functional medicine now for not quite twenty years, but going close to that. And it's a totally different world than twenty years ago. Right? The cases are different, the the things I have to think about are different, the complexity is different.
And maybe that's just because the more I know, the more I think about. I mean, that's entirely possible as well. I lied. I'm not done yet. I have one question. You t you talked about dosing the prokinetic at night and in the morning. That makes total sense, right? Do you ever because I have done this and and again I'm I'm a little bit undecided on whether or not it's a good idea. Do you ever take your antimicrobials and give them a boldness right before they go to bed?

Dr. Steven Noseworthy (02:19:00.334)
Okay.

Dr. Steven Noseworthy (02:19:17.908)
maybe to take advantage of the slower transit time so it stays in the intestinal system a little longer? Or do you think that's you know, sounds good on paper, but practically that's not gonna really do much.

Dr. Allison Siebecker (02:19:30.626)
Well actually what the studies show is that the migrating motor complex is most active at night when we're sleeping. That's why we dose our prokinetics at night before bed. So in in fact I think the motility in the small intestine would be fastest at night. Right. So pr so I think it makes more sense to take our antimicrobials breakfast, lunch, and dinner. With food or it they don't have to be with food, but in the day. Like during the day when we're eating meals.

Dr. Steven Noseworthy (02:19:45.762)

Dr. Steven Noseworthy (02:19:53.314)
With food.

Dr. Steven Noseworthy (02:20:00.202)
Awesome. Yeah. All right, I I promise I'm gonna let you go now. But let me let me thank you again for for being on the podcast and you're welcome back anytime.

Dr. Allison Siebecker (02:20:10.114)
But thank you so much, been a joy to be here.

• 00:03 — Welcome & guest introduction: Dr. Allison Siebecker's SIBO credentials
• 03:01 — Origin story: how Dr. Siebecker found naturopathic medicine
• 05:19 — Her own decades-long IBS/SIBO journey and the diet that changed everything
• 09:19 — Naturopathy vs. functional medicine, defined and compared
• 18:14 — Does "all health begin in the gut"?
• 23:29 — How to explain SIBO to a patient in plain language
• 25:24 — The real root cause: the migrating motor complex ("housekeeper wave")
• 28:14 — Structural causes: adhesions, strictures, and the river-log-jam analogy
• 30:46 — Food poisoning as the #1 SIBO trigger (and the blood test that proves it)
• 35:56 — Other major causes: diabetes, Ehlers-Danlos, mold, TBI, medications
• 40:41 — The most overlooked SIBO test: the barium swallow
• 44:00 — Why some doctors still dismiss SIBO as "not real"
• 45:38 — EMO and ISO: methane and hydrogen sulfide SIBO explained
• 48:33 — Why so many SIBO breath tests come back falsely negative
• 54:27 — How to actually get a lactulose breath test ordered
• 58:24 — New research validating lactulose testing against deep sequencing
• 1:00:25 — Why symptom severity doesn't predict gas levels
• 1:03:59 — Matching antimicrobial herbs to hydrogen, methane, and hydrogen sulfide SIBO
• 1:13:22 — Does biofilm matter in SIBO? Bismuth-thiol and the new NAC + rifaximin research
• 1:22:01 — The 4-week treatment round framework and why longer isn't better
• 1:29:46 — Why patients (and doctors) give up on treatment too soon
• 1:34:20 — The truth about low FODMAP diet and SIBO
• 1:37:56 — What an elemental diet actually is (and why it's not "just a diet")
• 1:53:09 — The 90% rule: how Dr. Siebecker defines treatment success
• 1:57:58 — Tough cases: mold, mycotoxins, parasites, and MCAS
• 2:02:43 — Prokinetics: the most commonly missed step in SIBO treatment
• 2:10:53 — Vagal stimulation, the insular cortex, and where the science is headed
• 2:15:16 — Where to find Dr. Siebecker (SIBOinfo.com)