Ep. 158 – Root Cause & Treatment For SIBO, A Digestive System Condition: Addressing the Misconceptions With Phoebe Lapine

Presenter: This is Everyday Wellness, a podcast dedicated to helping you achieve your health and wellness goals, and provide practical strategies that you can use in your real life. And now, here’s your host, Nurse Practitioner Cynthia Thurlow.

Cynthia: Today, I’m delighted and excited to have Phoebe Lapine, who is a food and health writer, gluten-free chef, wellness personality, culinary instructor, award-winning blogger, recipe developer, Hashimoto’s advocate, podcast host– or prior podcast host-

Phoebe: [laughs]

Cynthia: -and speaker, born and raised in New York City where she continues to live and eat. Welcome, Phoebe.

Phoebe: Thank you so much for having me. I’ve been looking forward to this.

Cynthia: Yeah, and it’s interesting, when I put out on social media, the people I was connecting with and topics, SIBO or small intestinal bacterial overgrowth was huge. The DMs, my team was laughing, trying to take all the questions down. Clearly, people want to learn more about SIBO, and I was mentioning before we even started recording that my traditional allopathic background, SIBO wasn’t around 20 years ago. When it was only when I dove into the functional pool that I got exposure to it, and I think there’s a lot of misconceptions, there’s a lot of misunderstandings. I like to explain to people that it’s a lot of nuances, and I’m sure, obviously, this is your area of expertise. But one statistic that I read when I was prepping for today, which I thought was really interesting is that 60% of IBS is caused by SIBO. All I could think of was the amount of people that I’ve been exposed to over the years that have IBS, whether it’s diarrhea, constipation, and we’re thinking, “Oh, it’s just irritable bowel,” and it could be something much deeper than that.

Phoebe: Totally. I’m sure as a practitioner, you can think back to that entire group of people that just had that wastebasket diagnosis with no actual [giggles] concrete path forward for treatment. In that sense, even though SIBO is an annoying condition with a lot of nuances, it at least gives you some more direction than just the IBS diagnosis.

Cynthia: Yeah. How did you get so interested– and I’m sure our own health journey is always a great place to start, how did you get so interested in passionate talking about SIBO, learning about SIBO, connecting with people about SIBO, how did that process start for you?

Phoebe: Yeah, it’s almost always based on my own health journey as you mentioned. I joke that I’m in the business of writing books that I wish I had had when I was going through a health struggle. My last book was about Hashimoto’s thyroiditis, which I dealt with 12 years ago, and just wasn’t that much out there at the time. Fast forward, gosh, until three years ago, four years ago, when I got the SIBO diagnosis, it was the same thing. I just fell down the rabbit hole online and found whatever information I could, and luckily, there are some incredible free resources online. But again, getting back to those nuances, there seem to be so many contradictions, there seem to be so many caveats for what we did know, and then, just generally, since it is such a new area of research, there’s just a lot of question marks.

That’s why I decided to start my podcast, which is also called SIBO Made Simple, because so many practitioners who are specializing in this have made discoveries clinically that the research just hasn’t caught up with yet. Also, I have a blog and I’m always writing about my health [laughs] issues de jure, and when I wrote about SIBO similar to what happened when you open that can of worms, I just got this incredible outpouring of questions, and comments, and commiseration, and that always to me is like, “Oh, well, people need these resources,” and I’m a crazy researcher, obsessive. So, I just decided to keep on going. [laughs]

Cynthia: Yeah. I think there are a lot of people that are suffering. I think that’s really what it comes down to when you scratch the surface, and you get a lot of interest in a topic, in a subject, in a post, I always tell my team, if things go wildfire on a particular topic, then it’s clearly some that’s a huge pain point for women and men as well. I would imagine, there’s probably some gender nuances to this as well. Let’s unpack what SIBO actually is, so that listeners can fully appreciate and understand what this encompasses.

Phoebe: Absolutely. As you mentioned, it stands for small intestinal bacterial overgrowth, and I think where we need to start is that a lot of people who are just hearing about gut health in passing, in the wellness zeitgeist, maybe get a watered-down version of what that actually means. I think there are a lot of people out there who don’t really realize that when people talk about our gut microbiome about our “good” gut bacteria, we’re primarily talking about the large intestine. That is where bacteria has a ton of different roles, but primarily with regard to digestion, it has a role in helping you break down these fibers that we ourselves do not digest.

But our small intestine is where we digest our food, where we break it down into essential nutrients, absorb those nutrients into our bloodstream, and truly reap the benefits of what we’re putting into our body. While every organ and area of our digestive system has its own microbiome, its own ecosystem, the small intestine doesn’t have a huge role for bacteria. In fact, when there are large numbers present when there are not supposed to be, it can cause a lot of harm. That’s what we see with SIBO. The primary symptoms dovetail with IBS. It’s the bloating, it’s the abdominal cramping, it’s diarrhea, constipation, or a mixture of the two. But then, there’s this whole other long list of other symptoms that are a result of the damage that the bacteria themselves cause.

When bacteria eat food, they release gas. That gas can be really disturbing to your gut environment. The bacteria themselves can often eat through the mucous layer in your intestinal wall and cause your immune system to get involved. Once that tug of war begins, and there’s a lot of acute inflammation in that area, leaky gut or intestinal permeability becomes a foregone conclusion. That is when a lot of these auto immune spectrum symptoms can creep in. So, a lot of people with SIBO have food sensitivities, and then depending on how your inflammatory reactions manifest, it could be joint pain, it could be skin rashes. It could be, I don’t know, so many different things. It could be dizziness, it could be mood related, it could be anxiety or depression. Depending on what kind of critters are overgrowing, it can be weight loss or weight gain. Then, of course, nutrient deficiencies, again, all of that dysfunction can cause issues with us actually, again, reaping the rewards of the meal, because there are other mouths at play.

Cynthia: There’s so much to it, and I think that you said it best that SIBO is a sign of an imbalance, not a disease. That’s an important distinction. We don’t develop SIBO overnight, and it’s been my clinical experience that it seems to be someone’s been dealing with a lot of things for a while, and then they just don’t seem to get better. That’s when it’s like, “I haven’t tested you for SIBO,” and then all of a sudden, voila, they’ve got SIBO. One of the things I found really interesting is when we’re looking at etiologies or reasons why people will develop SIBO, I love that you touched on the MMC.

So, for listeners, and we’re talking about reasons why people can be prone or develop SIBO. Some of it can just be from slowed motility in the gut, and this is part of the reason why I like fasting so much, as people are not eating frequently but the actual process of the migrating motor complex which– This is a nerdy term, but I promise, once we talk about it, everyone that’s listening will go, “Oh, this makes sense. This is why snacking and mini-meals are really detrimental to our health.” So, let’s talk about the stagnation piece, when the gut is not moving things along in a proper fashion, how that can make us prone to developing SIBO.

Phoebe: Absolutely. Yes. There are a lot of nerdy terms that come into-

Cynthia: [laughs]

Phoebe: -play with SIBO. Even researching my last book, I did a ton of research on gut health, I did not come across anything about the migrating motor complex, which was crazy. This mechanism is fueled by your nerve cells, and is kind of the street sweeper wave that make sure that there’s no debris, bacteria, what have you, anything lingering crumbs if you will, lingering in your very long and winding small intestine. That’s something to keep in mind, too, is that, your small intestine has a greater surface area than a football field. It is not aptly named, even though it’s skinny, it is vast in its way. Which is why it’s so important to have this mechanism to not only– There’s peristalsis, which is the muscular movement of food through your digestive canal. But then, this is literally what cleans up after the meal, the dishwasher setting.

If you don’t have that, you can just think about all the little nooks and crannies where things can get missed and start to accumulate. If you have other overlapping issues, mainly that bacteria naturally coming in through your nose and mouth don’t get killed, which is a whole other bucket of SIBO risk factors and root causes, in which case you do have yeast, or fungi, or bacteria coming into the plant, and then thanks to some of that stagnation, staying for a while. When you also have food accumulating too, you create a ripe environment for an opportunist to just one pull off the highway and stay awhile. That’s what happens with the migrating motor complex piece, and there are a ton of different diseases and overlapping conditions that can lead to dysfunction with the migrating motor complex but I do think that the lifestyle ones are incredibly interesting and important for people at home who have SIBO and like you mentioned, snacking.

The most important thing to know about the migrating motor complex is that, it only kicks in during a fasting state of 90 minutes or more. That means if you’re eating something that’s super healthy, an almond, a carrot stick, it doesn’t matter what it is. But if you’re putting food in your mouth all the time, you are disrupting that essential function. If you think back to the way that humans [laughs] survived in the bush, we didn’t have readily available 100-calorie snack packs around to [laughs] keep us satiated. We were not used to eating around the clock. We probably weren’t even used to eating three well balanced meals a day. But if you think about today’s lifestyle habits, the eating three balanced meals a day and at least spacing things out by three, four, or five hours is going to give you a big leg-up when it comes to SIBO.

Some people have other issues, like Hashimoto’s is actually an interesting example, that cause stagnation across the board that just– You probably know if you’re out there, if you have a sluggish system, and if you are one of those people, you want to think about that meal spacing tactic. I’m not a huge intermittent fasting proponent, though I know a lot of people with SIBO find it helpful. To me, it’s just that meal spacing. Making sure that you give yourself downtime between meals to reset, and also just so people know, your migrating motor complex doesn’t work overnight really either. Your digestive system again, per the way our bodies are designed to function goes into hibernation mode, so that your other organs, mainly your liver can do other essential chores like clean your blood. So, it’s not that huge fasting window overnight is going to allow you to catch up.

Cynthia: I think that’s a really important distinction and really aligns itself, and obviously, a lot of my listeners do intermittent fast. But it also reinforces why we really should space out irrespective whether or not we do fast, if you eat breakfast, lunch and dinner, great. But you want to have four or five hours between your meals, allow yourself to get hungry, be ready to eat. It’s important that we are having episodes of not eating during the day as you mentioned, because we want to optimize digestion. At nighttime, our body is focusing on other things. What I also found really interesting is that, if you’ve had certain types of surgeries, you can get these structural reasons why you can develop SIBO. I, with great interest, read this, because [laughs] I’ve had two C-sections which I wasn’t worried about. But I did two years ago get very sick, almost died, and had a 13-day hospitalization, and then had to go back six weeks later to have my appendix out. My surgeon did it laparoscopically and showed me all the adhesions that had developed just in the six weeks since I’ve been hospitalized. She clipped all of them.

But it had me thinking that there’s a lot of reasons and in my past ER nurse days, I saw tons of older people, 70, 80, 90 years old that would come in with adhesions, they would come in with strictures, they would come in with all types of anatomical things that were going on with the digestive system that were creating surgical emergencies or making them quite sick. If anyone’s listening and has had any of the above, could be a cholecystectomy or your gallbladder out could be laparoscopic surgery to address reproductive organ issues. Just recognizing that each time someone goes into your intraabdominal cavity, there’s an opportunity to develop adhesions.

It’s interesting on a secondary note, the last time I had a conversation with my OB-GYN, and I was just out of curiosity asking about this, and she said, “Well, I think we’ve done such a better job now that we’re not letting people labor for hours and hours and hours. I worry most about patients irrespective of why they’re coming in, if they’ve been having pain for a long period of time, lots of fevers, they’ve got an uncontrolled infection, they’re going to be set up for more adhesions than the average person.” Now, with that being said, I’ve developed it a lot of adhesions just in a six weeks’ period of time. Just imagine what it could be for the average person who’s out there doesn’t need to be hospitalized. In your experience when you were, your podcast was on, were a lot of the physicians that were coming on to speak with you talking a lot about the structural component?

Phoebe: Absolutely. There’s been research on that and I’m not going to be able to pull the statistic off the top of my head but it shows there’s a big correlation between any type of abdominal surgery, laparoscopic or otherwise, and developing SIBO down the line. It is because of these adhesions, like you said, when anyone goes in [laughs] to that area, even if there’s only a small scar on the outside, on the inside, our fascia, our tissue, may have formed in a way that’s not allowing our organs to move as freely as they once did. It can be something that’s incredibly minor. I kind of– again, going back to how long and winding the road of our small intestine is, I liken it to putting some pressure that would make a four-lane highway into a two-lane highway.

Maybe on its own, that’s not going to be that big of a deal for you, it does not guarantee SIBO. If you’ve had an abdominal surgery and you’re worried about this, it doesn’t mean you’re going to get SIBO. But then again, you layer on some of these other risk factors or root causes, the motility, of course, being one of them, you add that slowing that stagnation on top of the bottleneck. Or again, you have low stomach acid, you are immunocompromised, you don’t have these defense mechanisms that your body naturally was designed to have in order to fight bacteria coming in through the nose and mouth, then yeah, again, that can create a breeding ground or an opportunity at least for bacteria to overgrow where it’s not meant to be. I think it’s the area that people are less likely to investigate. The surgeries are something that can easily come to mind if you’re looking through a checklist, but there are a lot of things that are a little bit more insidious, like any sort of fall when you were younger, falling off the monkey bars, a fender bender, just our brain-gut connection is very profound on the one hand, but then also, structurally, the way that our body heals, even if it’s, again, not something invasive, but just alignment wise, that can really have an impact on our digestive systems ability to get the job done.

I personally think that body work that’s really targeted is very important as part of the SIBO healing process even if you think to yourself, “Oh, no, the structural stuff doesn’t apply to me.” Because I didn’t think it applied to me at all. Then, of course, I was like, “Oh, well, yeah. I grew up horseback riding and had fallen off a horse, dozens upon dozens of times, I had a terrible tailbone injury at one point that was really causing me a lot of discomfort. Does that have anything to do with my digestive issues?” Maybe. [laughs]

Cynthia: No, it’s really fascinating. Another point that you brought up in your book was the impact of food poisoning and Lyme disease, and preceding my 13-day hospitalization, in 2018, we were in Morocco, and I got the worst food poisoning I’ve ever had my entire life. I was so sick. While my husband was asleep, the entire time I was sick. We were thinking like, I don’t want to be in a foreign country and have to seek medical care, that would not be ideal. I went about the rest of my trip into another country in got over it, and then, four months after that got food poisoning when I was in Toronto. My functional medicine provider and I believed strongly that it probably set up some type of opportunity to end up developing a septic appendix, which is what ended up happening to me, and that’s why I got so sick.

But I think for anyone that’s listening, we think of food poisoning as being really benign, and it really can be. It might just be benign, self-limiting, meaning, your symptoms go away, and you go on, and do fine. But again, this is that nuance, that insidious nature as you alluded to that these things that seem so innocuous really may not be.

Phoebe: Yeah, and that’s too funny, because I don’t think I talked about in the SIBO Made Simple book, but my food poisoning in Morocco-

Cynthia: Uh-oh.

Phoebe: -also [laughter] stayed for I think

my Hashimoto’s, I was diagnosed six months after I got back, and I had a stomach of steel, and I loved traveling. It happened on day two of the trip and same as you, I was over by the end and went to another country, but then I had some flare-ups every now and then, but regardless, it was just my stomach was never the same again.

Cynthia: Yeah.

Phoebe: I would think it definitely laid the groundwork, whether or not it was a parasite or whatnot, but for some gut issue that preceded an autoimmune disease. SIBO came many years later, I think more tied to the Hashimoto’s than anything, but all of these things in your personal health history do add up over time, and tell a story in some way, in some nerdy obscure way in terms of your balance of hormones, in terms of various nutrient deficiencies. And yeah, so going back to food poisoning and SIBO, which I think is fascinating, it has a direct correlation with the migrating motor complex. It actually falls under that bucket of migrating motor complex stagnation issues.

What’s interesting is, as you said, sometimes, it’s just this acute experience, and you’re completely fine afterwards. Unlike me, you never noticed anything going forward and you forgot about it. You’re just like, “Oh, yeah, that was 24 hours of misery, and then, I’m done.” But for a certain percentage of people who got food poisoning, there’s this acute autoimmune reaction that causes your immune system to accidentally attack the nerve cells of your migrating motor complex. It’s a case of molecular mimicry as they say. Then, again, you don’t develop SIBO overnight, I’m so glad you pointed that out to people. In the days, weeks, months that follow with that stagnation could create, again, the perfect environment for SIBO, and so, it doesn’t necessarily have to do with that acute case of food poisoning. But in the aftermath, your system slowed down and something could develop off the back of that. A lot of people don’t even remember or think, because it’s months down the line that they start to notice the IBS symptoms creeping back in, and they are, of course, less dramatic, often, then, what happened during that food poisoning episode that people don’t necessarily connect the dots.

Cynthia: Yeah, and it’s interesting. I think the joke was, when I got to Spain after being in Morocco, everyone in Spain– [crosstalk]

Phoebe: That’s where I went too. [laughs]

Cynthia: Yeah, everyone in Spain was like, “Oh, everyone gets food poisoning in Morocco.” It just happens to everyone. You’re not special. I said, my husband didn’t have any problems. We eat the same food, but I’m the one that got sick. The other thing that I thought was really interesting, and I see so many people with mold is the impact of mold on SIBO. For listeners, that are listening, that are getting, they’re sweating, or they’re getting concerned, or they’re worried, we’re going to talk about how to test the SIBOs, so don’t stress.

Well, let’s touch on mold. I think mycotoxins are really undervalued and people don’t look deeply enough for them, because I think I have at least three or four clients right now that they had done so well in a protocol, and then they plateaued, and then they’re like, “What’s going on?” I was like, “We have to think about environmental toxins.” Sure enough, each one of them had mold in their homes. I just don’t think there’s enough focus on that as a potential toxin that can make us really sick.

Phoebe: Yeah, no, anything again that suppresses the immune system. Mold is definitely one of those things that can just cause dysfunction in our entire system’s ability to fight off infection. I think there are a lot of other sub reasons, and then there’s everything with mast cell activation syndrome, and that overlapping issue and histamine, which mold certainly contributes to as well. But I think in the broad strokes, I would put that in the bucket of bacteria not killed. There are a lot of studies with SIBO where it’s like, “Oh, well, we can’t say you know, X, Y, or Z for sure.” They look at the medications that have the highest correlation with people getting SIBO. Hormone replacement therapy for Hashimoto’s or hypothyroidism is up there. And then, the second is any immunosuppressant because again, our body is designed to ward off a pathogen that’s entering our body, and in the small intestine, there’s not a whole lot of tolerance for that, because, again, the bacteria is not supposed to be there.

In our large intestine where it has safe harbor, there’s a much larger mucus barrier between your immune system and “other” bacteria, that creates more harmony. But again, we need these protective measures to ensure that something like SIBO doesn’t happen to ensure that food poisoning in the first place, if it really is a pathogen, it doesn’t happen. Because in the case of SIBO, it’s not necessarily bad bacteria that’s taking up residence, it can be perfectly fine bacteria. It’s just a location issue.

Cynthia: Yeah, and that makes sense. One thing I want to talk more about because there are a lot of listeners that have hypothyroidism whether or not they have the autoimmune component, and I recently was talking to someone, and I was like, “Oh, it’s 80% to 85% of people that have hypothyroidism, have Hashimoto’s.” This expert said, “No, it’s actually way higher than that.”

Phoebe: Yeah.

Cynthia: It’s very unusual to have hypothyroidism and not have Hashimoto’s. In the back of my mind, I was like, “Oh, well, I’ve not had Hashimoto’s. I’ve always been told my antibodies were negative. I’ve seen the lab studies,” but a lot of listeners have hypothyroidism. Time out, hearing that there’s a correlation between whether you’re taking synthetic or non-synthetic thyroid replacement therapy to know that puts you add another layer of risk for SIBO will definitely get people very interested in hearing more. I know obviously, this is another area of yours that as your own health journey, you learned more about it. What is it specific– Is it the decreased motility in the gut that is driving a lot of that [crosstalk]?

Phoebe: Yeah, it has nothing to do with the medication itself. I don’t want people to freak out about that. I think it’s what the medication indicates, which is Hashimoto’s or hypothyroidism. It was something that I didn’t quite understand the correlation with myself when I was first diagnosed. But essentially, there’s such a vicious cycle between our hormone levels and our gut health, and they drive each other. That’s why I think back to my Morocco experience [laughs] as well-

Cynthia: [laughs]

Phoebe: -and setting the stage for Hashimoto’s. But essentially, if you don’t have enough of your active thyroid hormone, T3, which by the way as a side note, most people who are taking synthetic thyroid hormones are only taking T4, which then has to be converted in your liver. A lot of people– [laughs] again, the root causes of Hashimoto’s have to do with gut and liver dysfunction. Just keeping in mind that most people who are even medicated are probably not getting enough T3 or don’t have high enough T3 levels, that then affects not only your migrating motor complex, but also your stomach acid. So, it’s kind of a twofer, that low stomach acid, again, going to make you more prone to food poisoning. It’s again, the vicious cycle, and the irony is, for me, personally, it was [laughs] an issue with food poisoning that potentially spurred my autoimmune disease, and then, unfortunately, once that cycle started, it just creates more issues for gut dysfunction and more opportunities for more food poisoning. Which is why I think it’s so important for people to know about that connection.

Then, estrogen dominance is another thing that can disrupt our ability for converting our T4 into T3. Once something goes off with your hormones, there’s a lot of opportunity for it to trickle down into some issue with your gut, whether it’s you’re migrating motor complex, or stomach acid, or some other essential piece of the puzzle.

Cynthia: Yeah, there’s so much to this to really unpack. Now, people who are listening, don’t worry. We’re going to talk about testing. That’s next. How can listeners or people that are connected to the podcast, what is the first line? When you’re looking at testing, what do you feel is the best test to use for SIBO?

Phoebe: Yeah. The leading test is something called a hydrogen/methane breath test. It’s a little bit involved. It’s not as easy as a stool test although some people are like, “Stool tests are not easy.” Blood tests aren’t going to tell you much. Endoscopy, colonoscopy are not going to tell you much. What happens is, you prepare for 24 or 48 hours before, the day before you have a very limited diet of basically just white rice and lean protein to ensure that all the remnant fiber and whatnot has made it through your system. Then, the morning of the test, you drink a synthetic sugar solution. The hypothesis is the only thing that would be consuming the sugar solution is bacteria. Every 15, 20 minutes, depending on the lab, you breathe into a little glass vial. Back at the lab, they test all of those vials for various gas levels. If they see a spike too early on, meaning before that sugar solution has reached your large intestine where you want to see a big spike, because, again, that’s where your bacteria live, then that’s an indication that you may have an issue with SIBO.

Cynthia: Well, it’s interesting to me. I guess Genova is the test that I’ve used, three-hour Genova tests and I’ve had more clients than not have to redo it, because they didn’t follow the instructions or they got mixed up.

Phoebe: [laughs]

Cynthia: You really do. It’s 30-minute increments in the beginning. People have to really set a timer and just stay on top of it. But I think what’s really important is that, again, a lot of nuances with SIBO and there’s a couple different kinds of SIBO.

Phoebe: Yes.

Cynthia: I think that’s important to touch on. People could be constipation dominant, diarrhea dominant, and that usually aligns itself with specific types of SIBO. But let’s talk about that.

Phoebe: Yes. Hydrogen and methane are the two main gases. There’s also a third gas called hydrogen sulfide, which up until, I want to say, January of this past year or maybe the year before, there was no official test for it. I used to do Genova as well. But now, there’s a new test called Trio that will test all three. That’s an interesting one to look into just to make sure that you’re covering your bases. It’s so funny. These things change so quickly. At the time that my book was off being printed, the test came out, and I was like, “Ah, darn.” Now, I try and talk about it so people know.

But essentially, depending on which of those dominant gases is your issue and it is possible to have a mixture of several, that’s going to indicate what treatment options you need to use, because for methane SIBO, you’re talking about methanogens, those actually aren’t even considered bacteria. They’re archaea, different kind of organism altogether. So, the regular antibiotic for SIBO doesn’t necessarily work as well. You need a second antibiotic or in the case of the natural approach, these herbal antimicrobials, you need an extra agent to target the methanogens. Then, for hydrogen sulfide SIBO, that’s an issue with your sulfur pathways. So, there’s a dual path you can take to supplement or support your body through diet in clearing those pathways so that, again, you don’t have some overgrowth issue.

Then, hydrogen is the main gas associated with the food poisoning or postinfectious IBS version of SIBO. It usually correlates with diarrhea though people can have a mixed bag with that. There’s exceptions to every rule with each of the gases, but methane tends to be more constipation. Hydrogen, more diarrhea. Methane also tends to be weight gain versus weight loss, because the way that the methanogens actually metabolize your food, causes you to hold on to fat and energy in a way that other critters do not. Then, hydrogen sulfide can have just really tricky symptom matrix. You can have flatulence that smells like rotten eggs, you can be really sensitive to again sulfur-containing foods, Epsom salt baths, if you have hydrogen sulfide, SIBO might be actually irritating to you, and it tends to just be heightened symptoms of any of the aforementioned ones that we talked about earlier.

Cynthia: Once someone has a diagnosis– I know that a lot of what you talk about in the book, and I love that you focus on the lifestyle piece, because you can take all the antibiotics, and all the anti-microbials, and all the biofilm breakers, but if you don’t address these pieces too, you’re not nearly going to be as successful. Let’s dive into the impact of lifestyle choices on how well we can bounce back from SIBO.

Phoebe: Absolutely. Most people and most practitioners recommend one “kill phase” or another, and that would be the two paths of the herbals or the antibiotics I mentioned or this thing called the elemental diet, which isn’t really a diet, but a medical shake that allows you to feed the person, but starve the bacteria. Then, there’s all these dietary approaches that get a little bit muddied in the treatment buckets but I personally think are more about symptom control, and then therapeutically, just helping you heal after SIBO. There are a lot of different approaches in terms of layering diet on top of your kill phase or doing diet afterwards, and it really depends on what your unique situation is. I dedicate a lot of pages in the book to helping you find your own path, because unfortunately, there is just no one recipe for everyone. Everyone has different mixes of bacteria/critters, overgrowing, everyone has different symptoms as a result. Our microbiome in our large intestine is more unique than a fingerprint. That gives you a sense of how much any overgrowth can differ from one another. Some treatments might not work for some people, some might work for others.

Then, again, when it comes to healing, healing is so different than the treatment itself. Oftentimes, these kill protocols can be very hard on the body, hard on your system, and require a whole other level of healing on the other end to begin with. That’s why I always try and manage people’s expectations with SIBO. It is a long process in terms of the damage that you’re trying to address in the healing phase. As you mentioned before, some people have been dealing with SIBO without their own knowledge for years and years and years. I know a lot of the practitioners who I talked to who got into it through their own personal experiences and also some non-practitioner people who have gotten into the advocacy space like me, they think they’ve had SIBO since their childhood. That gives you a sense of how long unfortunately, it may take to truly get things back on track to heal that intestinal lining, and again, to heal some of the reactivity with food since unfortunately, with SIBO, it can breed a lot of food fear, since your symptoms do really come from the act of eating. It’s not in your head you’re reacting to food, because your bacteria is reacting to the food.

In terms of the lifestyle changes, I actually think that addressing how you’re eating is so much more important than what you’re eating, especially, in terms of dovetailing with the “kill phase.” Some of the things like we talked about, meal spacing, it should be a no brainer for SIBO folks to try out. Simply chewing your food, supporting your stomach acid, especially if you’re someone who knows that you have something in your medical chart like Hashimoto’s that would preclude you to having low stomach acid or a stomach acid issue. I think just the timing of our meals, eating at least a few hours before bedtime. Again, once you go horizontal and you know that your digestive system slows down, you don’t have food just sitting and festering in your small intestine that hasn’t made it all the way through yet, because if you’re eating dinner at 9 o’clock and going to bed at 10 o’clock, it’s just physically impossible to have it made its way [laughs] all the way to the large intestine at that point.

Yeah, I think for women, too, thinking about what you’re wearing, how tight your pants are. I think it’s an underappreciated structural impediment that [laughs] our digestive system maybe not as intense as an adhesion. Wouldn’t put it under the actual list of root causes, but I do think that it’s something to think about, especially for the fashion ladies out there wearing the really tight high-waisted Spanx or skinny jeans. If you’re doing that night after night, and it does make a difference. I’ve learned as much just from personal experience.

Trying to think of other lifestyle things. Of course, stress, sleep, hydration, all of these things factor in. In fact, I get messages all the time from people who are saying, “What if I can’t find my root cause? I can’t find my root cause.” I’m like, “Well, stress is a root cause. Are you a person who doesn’t [laughs] experience stress?” I think for me, personally, my SIBO diagnosis, I can’t think of any other acutes experience that would have caused me to develop SIBO when I did than stress. I obviously have a lot of risk factors but I’ve had those risk factors for a decade. I didn’t have the IBS issues that I had with SIBO for that decade. They definitely came out of nowhere, and I took notice and got diagnosed.

But it was actually that my last book, The Wellness Project, came out. I was on an intense book tour. I was not as much as I had all these habits, all these tools in my back pocket. I wasn’t truly sticking with my routine that I knew allowed me to live my best life. So, that coupled with the added stress was enough to put me over the edge.

Cynthia: Well, I think it’s also being very human. For the past 15, 16 months, there’s no one listening that hasn’t had more stress in their life than they had before, and I think a lot of people– We all have different coping mechanisms. Some are more maladaptive than others. I think a lot of people ate to deal with the stress. I tend to be an exerciser, and not that I was overexercising but that was the only thing I felt I could control. But I think for a lot of people, the food piece is really a huge contributor. The stress is not acknowledged enough and obviously, if most of us are sympathetic dominant, most of us our bodies are in chronic fight or flight, and so really finding strategies that can tap into that rest and repose side, I’m a huge advocate of meditation. But if you don’t like that, if you like gadgets, I’m a gadget person. I love the Apollo Neuro. That’s definitely been something that I can wear during the day, and I don’t have to stop to meditate, but I can program the Apollo Neuro, and it was initially designed for PTSD victims. They extrapolated the data, and it’s based on neuroscience. It’s like tapping, but I wear it on my ankle during the day. It looks like a home monitoring device.

Phoebe: [laughs]

Cynthia: My kids are always embarrassed. They’re like, “We don’t want anyone thinking you’re a thief who escaped.”

Phoebe: [laughs]

Cynthia: I wear it during the day. But I wear it during the day, and I put it on a more stimulatory setting, and then I wear it when I go to bed. There’s no EMF, so it’s very benign. That has been very helpful. But I think each one of us have to acknowledge that we all need to work harder at stress. There’s probably very few of us that are in ideal circumstances, because we’re dealing with unprecedented times, and not even getting political. Just saying it’s unprecedented times that have contributed to additional stress.

Phoebe: Yeah, and I will say that for my book, I really tried to just curate all of the information that we have about SIBO. But I do think that from talking to people, from talking to practitioners, there is something to be said for, if you can identify your root causes, just tackling those first. If you’re wary of getting on the merry-go-round of antibiotics or herbals. Try something that’s less invasive. Try tackling it from the emotional side first. There’s hypnotherapy for IBS that has incredible data associated with it. We have to assume and there has been some data that’s come out since I published the book about SIBO and hypnotherapy specifically, but again, that should just tell you a little bit of what you need to know about how powerful our mind-gut connection is, and how much improvement you can see without even “eradicating” through pills the overgrowth itself.

Cynthia: Yeah, and I think it’s really important that, it’s slow and steady wins, and I usually will use the GI-MAP with clients. There’s a typical pattern I’ll see on the GI-MAP, which is a DNA-based stool test, and there’s a pattern that gives me some insight that someone might be headed in that direction or they probably have H. pylori, what I was always taught was, where H. pylori hides, parasites and SIBO reside. If I see H. pylori, and parasites, and some other nuances on that test, the clinical suspicion is always high. But I always tell people like, “Listen. I’m going to tell you what I think, but we have to address all these other things.”

One important thing that I was taught was that, digestion goes into North to South process, and so you have to address the H. pylori before you address the parasite, before you even think about addressing the SIBO if you suspect it. It’s never typically not the first test I will look at. Like you mentioned, food sensitivities, stress management, sleep quality, hydration, all things that people think are pretty small, but they do have a huge impact. We’ve touched on antibiotic therapy, antimicrobials, the elemental diet, which I’ve had a couple friends who’ve actually done it, and they said, it wasn’t as bad as they thought it would be.

Phoebe: Yeah. [laughs]

Cynthia: I think it’s the fastest way to have the greatest impact-

Phoebe: Yes.

Cynthia: -on SIBO, but for a lot of people, they’re freaked out about drinking shakes for two weeks.

Phoebe: I was one of those people for sure.

Cynthia: Yeah. [laughs] How bad was it?

Phoebe: Oh, I didn’t do it. [crosstalk] Yeah. I was like, “I’m a chef and food writer.” I was like, “I can’t, not eat food for two weeks.” [laughs]

Cynthia: Yeah, no. That would be hard for anyone. Let’s say someone has selected one of those modalities. Let’s say they’re doing microbials. There’s something called a Herxheimer reaction, and for anyone that’s listening, this is a reaction that clinicians and people will look out for, but it can be mitigated by a particular type of bacteria. But I’d love for you to touch on that, because I think sometimes people will say, “Oh, well, I tried to get treated for X, and it didn’t work.” Really, what they’re referring to is they developed a detox reaction or reaction to the die-off. So, let’s touch on that.

Phoebe: Yeah, I get messages from people all the time who have been on the herbals or the emetics for a week or two, and are saying, I feel worse. It’s not uncommon. Again, these are, even the herbs themselves are not benign. They’re super intense and broad spectrum. What can happen is, when the bacteria are being killed, they release a toxin that is really more harmful to the system than the bacteria themselves were. It is truly toxic. It’s just something to keep in mind. It usually manifests as more of a flu-like reaction rather than just an increase of maybe your GI symptoms, though that could certainly be part of it too. It’s something to keep in mind and talk to your practitioner about a lot of people recommend binders like activated charcoal or bentonite clay just to again, in between your doses of herbals or antibiotics, to lessen the reactivity of that toxin and usher it out.

Cynthia: Yeah, I think that’s important. Also, the biofilm disruptors, something that’s kind of gross, but it’s even goes down to thinking about like, for example, when we go to the dentist. The dentist clears plaque off our teeth. That is a biofilm.

Phoebe: Yeah.

Cynthia: All of these bacteria, fungi, etc., have biofilms. They’re trying to ensure that they survive. They don’t want to die. Biofilms are certainly a really important part to all of this. Do you use a lot of or were you when you’ve been interviewing a lot of these SIBO experts, and you mentioned one of my favorites, PHGG, a lot of the SIBO experts, are they using this in their protocols? I would imagine they probably are.

Phoebe: Yeah, and they’re some natural biofilm busters too, apple cider, vinegar, coconut oil. But often, you do need something like monolaurin, I think also works as a biofilm buster. But there are various complexes and a few that are popular in the SIBO community. I’m blanking on their exact names and labs, but I do have them on my website. If you’re curious in the shop section, you can look through [laughs] all the supplements for SIBO. There’s also a very robust medicine cabinet chart, which I [laughs] loved creating in the book that’ll give you a guide to all the possibilities for these various categories. But yeah, I think it’s something that’s worth adding.

Cynthia: Absolutely. PHGG is this prebiotic fiber. Obviously, we want to get food-based sources when we’re speaking in generalities but this is something that prebiotics are food for the probiotics in our gut, so it’s like fertilizer, and it’s a beneficial fertilizer. Don’t think of it as a nonbeneficial thing. Now, I had about five questions that I wanted to review with you. I was trying to be all encompassing from the milieu of questions I received. One woman asked, “What’s your favorite suggestion for pain, gas or bloating with SIBO?” Are there particular therapies that you have found based on the research that are most efficacious, most effective? Because this woman in particular said that is her biggest issue, is that even though she’s been getting treated properly, and she’s said, “I have ongoing discussions with my health care provider.” So, she’s doing all the right things but she said it hasn’t gotten a lot better. What would you suggest?

Phoebe: Yeah. For each one of those symptom prongs, they’re different recommendations, but I probably go with something called Iberogast, which is an herbal complex that’s specifically for gas bloating, nausea. It’s an all-purpose [laughs] formula that’s had a lot of success. They’re little drops in, you can take them before meals, and it can be helpful. For diarrhea, and constipation, and bloating, actually, activated charcoal does have some good data associated with it. Peppermint is always great panacea of digestive things as is ginger if you’re looking for natural things to incorporate, especially nausea, ginger chews, ginger tea, peppermint that’s either encapsulated to actually get to the gut or you can have tea as well can be helpful. But yeah, there’s some mega formulas like the Iberogast.

There’s another one that’s great for methane symptoms called Atrantil. I might not even be saying it correctly. But again, it’s another kind of herbal formula that was designed actually off the back of research in trying to reduce methane output in cattle. Yeah, it is specifically for the methane type, but can help with the gas associated with that tremendously, and some of the constipation,

Cynthia: Oh, goodness. What are the strategies that you use while you travel? Now, we’re going to think pre-COVID and coming out of the pandemic, what are your best strategies? What do you take with you, what do you think is important to have when you’re traveling?

Phoebe: I actually got back from my first trip in a year and a half yesterday. [crosstalk] it’s only four days, but I had to think about it again. I’m like, “Oh, my God, my travel kit.” [laughs] My gut travel kit. I always include digestive enzymes, which help get the stomach acid flowing, if you have one especially that has pepsin HCL built in. If you don’t like digestive enzymes, you can always just do a pepsin or HCL supplement. But I think that’s really important again to just make sure that our stomach acid, our first barrier of protection is running on all cylinders. I always pack charcoal with me in case of some sort of adverse reaction, so that I can just cut it off after I eat something.

If you have a sensitive stomach, and you’re traveling somewhere where you know that you’re not going to be terribly familiar with the cuisine, I just think even if it’s not actual food poisoning, the possibility for some indigestion [laughs] or IBS experience is high. So, pack that. Then, yeah, I take monolaurin. I like monolaurin a lot. It’s antiviral and antibacterial. It’s also a biofilm– it’s got a lot of different efficacies. I think it’s a good kind of all-purpose thing to take with you just again to ward off anything that you might come into contact with.

Then, yeah, I would just recommend taking your usual supplements. For me, vitamin D is really big. It’s great for gut health, and great for healing leaky gut, again tackles a lot of different elements. It’s also so important for thyroid health. So, I always pack that. I’m trying to think what else was in my bundle? Then, yeah, I just always take some multivitamin just again to cover your basis.

Cynthia: No, and I love that. I’m always a fan of bringing binders.

Phoebe: [laughs]

Cynthia: When I go out, there’s even a gluten dairy [unintelligible [00:48:16] that I’ll take with me if I’m eating at a restaurant, because I’m gluten and dairy free, and inevitably, I’m sure I’m consuming those things, even though I specify otherwise. I got this question multiple times. A lot of people who are concerned about SIBO, think they have SIBO, and the issue of FODMAP, so navigating that and it’s been my experience, and you may feel differently or feel the same, but bio-individuality really rules. I don’t necessarily say to everyone, you have to be on a low FODMAP diet. It’s really what works best for each individual person.

Phoebe: Yeah. The low FODMAP diet is very effective at reducing symptoms, because it removes a lot of prebiotic fibers that tend to be your bacteria’s favorite foods, or if not their favorite foods, the ones that produce the most gas. But again, on the other side of the coin is, they are the most important fibers to feed the overall health of the bacteria in your large intestine. There’s data that says, people who go on the low FODMAP diet and stay on it for too long for months on end are really damaging that foundation irrevocably. I think it’s often the hardest thing for people, because there are a lot of people who are just blanketly recommending the prescription of the low FODMAP diet. Even a lot of conventional GIs who maybe aren’t savvy on SIBO yet have read the data in terms of the low FODMAP diet and IBS, and we’ll just recommend that without any information on how to cut come off it or even any acknowledgement that you would come off of it.

But in reality, it is a therapeutic diet. It’s something that you’re going to want to try for a month or two, and then reintroduce, because the reintroduction for any therapeutic diet is how you actually get information. The low FODMAP diet is a really complicated, but also really interesting one, because it’s quantity specific. The acronym stands for various carbohydrates, and it’s really hard to generalize. There are certain categories that have fruits, but then also grains, but then also different types of things in them, includes lactose, includes various types of sugars. Essentially, you want to just reintroduce and see which categories tend to disrupt your system the most, because most people are not sensitive to every single one. Then, most people can do smaller quantities of their problem ingredients and work their way back up. Then also, once you get rid of the overgrowth, oftentimes, you can have an easier time with some of these ingredients.

I think there are different approaches in terms of whether you overlap that with treatment or not. I think it again, really depends on how severe your symptoms are. Of course, if your symptoms are super severe, your gut’s not going to be able to heal, you’re probably going to have worse die-off, if you’re letting that go on check. In which case, having some intense band-aid approach like that diet to bring things down is great. But always keep in mind the fact that point B is making sure that the health of our overall gut, especially our large intestine, is something that we’re supporting. Getting there, especially with SIBO as a starting point can be really difficult, because they’re basically opposites, and it can be a difficult gap to bridge. But you have to always strive for that diversity and for incorporating those important fibers as the end goal.

Cynthia: Oh, slow and steady wins.

Phoebe: Yep.

Cynthia: One person asked, “How long to try herbals before considering antibiotics or an elemental diet?” Again, I know this is bio individuality, but as a general theme, what should be the timeframe that they give the anti-microbials before considering other options?

Phoebe: Yeah, again, I’m not a practitioner myself, but from talking to others and how they approach choosing a treatment, it really comes down to how you’re responding as an individual. That’s where the testing comes in. Seeing how far you are able to reduce your gas levels with a course of herbals. If there was some improvement, maybe your doctor will say, “Okay, let’s try another round of them to bring them down another chunk,” because each of these treatments only has a certain capacity to reduce your gas numbers. The elemental diet has the largest capacity, which is why people– as you said, because it’s quick and has the most dramatic possibility for effectiveness. That’s why people look towards it. But if it didn’t move the needle, that’s when it’s time to try something else. You wouldn’t want to try it again if it didn’t make any difference. These things are supposed to work. So, if it didn’t work for you, that’s time to try another type of treatment.

Cynthia: Absolutely, and lastly, what are your favorite ways to heal and seal the gut?

Phoebe: Ooh, okay, well, yes. Leaky gut tactics. I’m huge on using diet as the main tool, doing a lot of broads. I think especially for those who have weaned themselves on to a more limited diet on SIBO just to reduce the symptoms, trying to reintroduce things in pureed form can be really helpful. Anything that’s cooked and of course broken down in any way prior to it reaching your gut just means less work that your entire digestive system is going to have to do. Not all of us are chewing [laughs] as well as we could be. If that’s you, no shame, but just think about ways that you can help your system, because it reaches your intestines, there’s no teeth.

So, I have a lot of really beautiful therapeutic soups in the book. Like, a pureed green soup, a pureed orange soup, any collagen that you get from bone broth or added via supplementation if that’s your thing, unless you have histamine issues in which case you have to be careful of that, but yeah, again, bio individuality. Fresh ginger, fresh lemon juice, drinking the brine of sauerkraut, so fermented cabbage juice is great. Cabbage actually has the highest level of L-glutamine of natural food. L-glutamine is the powerhouse amino acid for repairing your intestinal lining. Vitamin D, also very important. Turmeric, also incredible. So, just getting all these things in through diet as much as possible. I have a ton of turmeric in the recipes in the book and also a ton of fresh ginger. Yeah, those would be– I’m sure I’m forgetting something.

Cynthia: I love it. Very all encompassing, and certainly two years out for my long hospitalization, it has been a long process to heal that gut. I was on a modified carnivore diet for about nine months.

Phoebe: Wow.

Cynthia: Because when I came out, I couldn’t tolerate anything else. I was never so happy as when I was able to eat raw vegetable again.

Phoebe: I know. That’s the goal. [laughs]

Cynthia: Yeah, exactly. Now, I feel it’s going to take– I’m still healing, but I have multiple different kinds of fermented cabbage in my kitchen, in my refrigerator. My kids laugh, because they see the container seems to last forever. I’m like, “Well, two forkfuls is as much as I need with a meal,” and they have bananas, but– [crosstalk]

Phoebe: Yeah, the juice too, you just take a little swag throughout the day.

Cynthia: Well, anyway, it has been a pleasure. I want to be really respectful of your time. Share with the listeners, how to connect with you, how to purchase your book, which is really well done. SIBO Made Simple, I actually have it sitting on my floor, because my next forays to look for a recipe to create this week before we leave for Montana.

Phoebe: Yay.

Cynthia: Yeah.

Phoebe: Well, you can find me on my website which is feedmephoebe.com. I have tons of recipe archives in there with free dishes that are all gluten free, mostly dairy free, anti-inflammatory, and then there’s a lot of low FODMAP content on there too. You can also find my podcast there, SIBO Made Simple, and then for the book SIBO Made Simple, you can just go to sibomadesimple.com, and if you’re curious about Hashimoto’s and my last book, you can go to the wellnessproject.com.

Cynthia: Awesome. Well, it’s been such a pleasure to connect with you. I know this will be an incredibly popular episode based on the feedback that I got prior to us recording.

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