Welcome to the SIBO Success Plan.

I'm Dr. Nirala Jacobi, your host over the next eight episodes, and in today's lesson, we're going to be looking at what is SIBO? What is going on here?

If you're like many of my patients that have been referred to me, you may have been treated for SIBO before. You may have actually just been diagnosed, or you are doing research yourself on the internet as to why you cannot get on top of the bloating, or what's going on with your digestive tract, and you've stumbled across SIBO. This course is really for those that have been diagnosed with SIBO, and how to really help themselves. I'm really excited to be sharing this information with you. I've worked really hard at making it very digestible and deliverable so that you can learn how to really manage certain symptoms, and how to help yourself with certain home treatments, and also what kind of questions to ask your practitioner if you're under the care of a practitioner.

This course really is best done under the care of a SIBO treating practitioner, but because we get emails from all over the world asking for either referrals or patients saying they have no one that can help them, I really wanted to design a course where people can be as independent as possible within the confines of it making, really improving their symptoms and really helping their SIBO.

Of course, SIBO is a medical condition that will have its nuances. No two SIBO patients are alike, and that's a really important concept that not everything that somebody says on the internet in a support group will work for your particular symptoms. Really I've designed the course so that you fully understand what's going on, and how to really help yourself. Just a bit more about me, just so you feel confident that I truly can teach you a thing or two about SIBO. I have been a naturopathic doctor for the past 20 plus years of my life. I started out as a primary care physician in Montana, where I practiced in a multidisciplinary clinic, and really just treating just like a GP or medical doctor would do, and then I decided to move to Australia, and where I'm located now, and have been here for about 15 years. I still see patients. For the last eight years, I've been focusing mainly on SIBO, and my focus was also teaching other practitioners, and the photos you see of me speaking there is me giving lectures and conferences about SIBO, and different topics that come up around SIBO.

I've been doing that for the past eight years, and my passion really was about practitioner education. To that end, we have a SIBO doctor education platform that aims to educate practitioners, but this obviously is our first foray into educating you, the patient, about what to really ask your practitioner, how to help yourself if you're in a location that doesn't have any SIBO treating practitioners around you, so there's a lot that we've now put on offer for patients. We also have a breath testing company called SIBOTest.com that I formed about six, seven years ago, just in response to wanting to offer testing to practitioners and to patients that were along the guidelines of what I learned when I learned all about SIBO in 2011 in the US.

That's also my background, where I've had the opportunity to look at thousands of breath tests, and then finally the biome clinic is my naturopathic clinic where I practice and see patients, but also have other practitioners that I've trained, that are very, very good at treating SIBO.

Like I said, all the nuances, all the difficulties that come along with having SIBO. Gone are the days for me where I see very straightforward patients. Mostly my patients have been referred by other practitioners, and as of this recording, I've actually closed my books for new patients, just because it's just too overwhelming to do everything I do plus see patients. It's a lot, but we do have other practitioners here, and you may have heard about me, actually, in perhaps in a different support group on Facebook. I'm the creator of the SIBO biphasic diet that I've basically created in response to needing more structure for my patients, and we'll get into detail about the biphasic diet in lesson three. Hopefully you will learn a lot. Actually, not hopefully. I'm pretty certain you're going to learn a lot, just following along from the lessons. This is really what we believe in as naturopathic doctors, or functional medical practitioners, where gut health in general, if we don't think just about SIBO, but really gut health in general, has several different keystone areas that we must address for your gut to be totally healthy, and we'll talk about all of those, along with SIBO, and how to treat it, et cetera.

For example, the microbiome, very, very important obviously. The microbiome, you've heard a lot about it, is basically a separate organ in your digestive tract that's comprised of trillions of bacteria that do a number of things for you that we'll get into, but also of course stress management is something we have to talk about because the nervous system of the brain and the gut are intricately linked, and talking about mental and emotional health is also something that's of course linked with stress management. Of course your diet contribuets to how healthy your gut is. Sleep and exercise is important as well as immunity and genetics or nutrigenomics as we call it nowadays, of how our lifestyle really influences our gene expression. This you don't have to really memorize at all. This is basically just to give you an understanding of how naturopathic doctors approach a particular condition, whether that's SIBO, or menstrual disorders, or migraines, or you name it. Really, we look at this as our therapeutic order, meaning that the very first thing we do at the bottom of the pyramid is we establish conditions for health.

If you're somebody that drinks 10 cups of coffee a day and gets two hours of sleep a night, we will look at that and say, "This is not conducive to being healthy," and so we start to give you all kinds of advice as to how to actually reestablish the basics of health. The next level of the pyramid is something called stimulating the vis medicatrix naturae. It's a fancy way of saying, stimulating your own innate healing power, and we have certain exercises in this course that really addresses how to actually stimulate your own self-healing force, and this is well-demonstrated ... Let's say you cut your finger. It is still a miracle, to this day, how your body knows what to do in order to completely heal it, so that there's no scar even visible. That's the healing power of nature, that you don't have to really do anything but get out of the way, and we we call remove the obstacles of healing. Stress and anxiety, et cetera, are often a huge obstacle to healing when it comes to SIBO, and we'll talk a lot more about that in Lesson Seven.

Sometimes, we have to give very specific organ support, such as hydrochloric acid when it comes to low stomach acid, or we have to strengthen your immune system if you have an infection, a viral infection, or Lyme disease, or whatever that may be. We definitely have to decrease toxicity. We have to decrease inflammation, and we have to increase and optimize metabolic function, and balancing the whole system out, and enhancing regeneration, and harmonizing with your life force, whatever that may be for you. That is a very important level on the pyramid, after which correcting structure really is about getting a chiropractic adjustment, so that your nerves are functioning better as an example. It's not always that you have to do every level of this pyramid, but then really just to demonstrate how late in the system we actually start to give particular herbal or other naturopathic supplements to address the actual problem. It wouldn't be until all of this down below has been done and accomplished before we would think of giving you an equivalent of a painkiller for a headache, so that we really understand what's causing your SIBO, for example, or what's causing your relapsing SIBO.

We'll get into all of that a little bit later on. Of course as you go up the pyramid, it's more and more interventional, meaning that there's more damage that can be done when you actually rely on those levels, but sometimes they're very important. It's not that they shouldn't be on the pyramid. It's just that they shouldn't be first option, obviously, so it's a good way to orient ourselves in terms of how we want to approach really any illness. As I've mentioned before, it's always best to work with a SIBO treating practitioner, and it's really only because there are so many of you patients that are in need of help that I created this course. It was because we got desperate emails from people in very remote areas that say, "I really don't know of anyone here that can help me," and hopefully if you're one of those patients listening, we really had you in mind creating this course. Be advised that this course is, of course, for educational purposes only, and is not really intended as medical advice. This is a disclaimer, as with anything. If you have acute symptoms, you must seek medical care.

It's best to review this plan with your practitioner or your medical practitioner to see that you don't have a preexisting condition that where it would not be a good idea to use certain herbs, for example. You can understand that we don't know your individual condition or situation. We don't know your family history, so all of that would be partly considered before any practitioner would embark on a treatment plan. A lot of these treatments are very well known for SIBO, and will go a little bit more into it, and how to pick a good probiotic, et cetera. Those are fairly harmless, but still it's best to approach this in a very systematized fashion that involves your medical practitioner. If you don't have a medical practitioner, you can find a SIBO treating practitioner on sibotests.com. We're about to revise the entire database, and it'll be moved over to thesibodoctor.com very soon, so that is a resource that's coming, and will be updated very likely in 2019. What is the SIBO Success Plan? What are we actually going to learn?

This lesson, Lesson One, is what is SIBO, so that you understand what is actually going on in your digestive tract. The next lesson, Lesson Two, we're going to be talking about underlying causes, and this is a pet peeve of mine, where I get a patient referred to me that has relapsing SIBO, and the practitioner has not really looked at what caused the SIBO for this particular patient, because the treatment after you've cleared bacteria might be very different from the next person, because it's all dependent on what caused it to begin with. Lesson Three will be about the SIBO biphasic diet, but also the actual protocol, the actual antimicrobials and gut healing support that we typically utilize when we go through this program. Lesson Four is about food reaction, so if you're not somebody that has histamine reactions, or salicylates, or oxalates, or sulfur. They you might want to skip that lesson, but of course there's always a lot there to learn, because you may not know that you have actually a food reaction, that some of your symptoms may not be the SIBO, but may be due to histamine, for example.

Lesson Five will be about what do we do to actually heal the gut, because the gut in many cases is in such a disarray for many of you that just treating SIBO alone is sometimes not good enough. We need to do more in order for the inflammation to go down, and for some of these symptoms to resolve. For those of you that have very strong symptoms of bloating, constipation, reflux, and nausea, Lesson Six is all about that. What do you do at home to really help yourself get out of those really painful situations sometimes? All of those symptoms, bloating, constipation, reflux, and nausea will be alleviated by just treating SIBO, but some of you have other issues, and other conditions that are contributing to why you're bloated, or why you're constipated, or why you have reflux, so it's nice to know that there's very specific symptom relief you may need. Lesson Seven is about how to calm your nervous system. No, SIBO is not all in your head. That's not what we're saying, but what we are saying, or what I am saying, is that we cannot separate the brain from the gut.

It's actually the same neural tissue that developed the brain that also developed the digestive tract, so we know that there is great communication between the two, and if you're in a state where you're constantly stressed, and you have a lot going on in your life, it's very likely that that will influence either your speed of healing, or it might actually be very much contributing to all of your symptoms, so it's a very important lesson that I really encourage all of you to listen to. Lesson Eight is all about preventing relapse. How do we ensure that after we've cleared SIBO, and you're clear on a retest, that we, that you don't develop it again? This is very, very important, and it ties back to Lesson Two, what caused my SIBO, because preventing relapse is all about addressing the underlying condition. Lesson Two and Lesson Eight are somewhat linked, but you can review in your own time. One word about downloadable slides or PowerPoint, and also the dispensary guide that comes with your SIBO Success Plan.

The dispensary guide that I've devised basically is a guide where we list all of the antimicrobials, all of the probiotics, lots of different support that you can look at it, that is really customized to Australian patients, American patients, and we also have a distributor listed there for the UK and Europe. If you're elsewhere in the world, you might be able to get some of these products on Amazon shipped to you from America. That's possible. The reason why we are ... It was a very intentional reason to not have the presentations, and the dispensary guide downloadable as a PDF, and there's two reasons for that. The first reason is, because many people will just read the products, and will not do the plan correctly. They will actually just take the products for either too short, or it's not even the right product for them, so we really did not want to have this document shareable, because we want people to listen to the information, and then draw their own conclusion as to what is specific for their case. We do have downloadable transcripts that you can certainly review on your own time, but you can listen to this as often and as you want, until you really understand what's going on.

We hope that you understand our hesitation to not have the actual presentations downloaded, or the dispensary guide downloaded, because to be frank, I actually get a lot of patients that have just tried stuff on them, by themselves, or on themselves by listening to somebody's advice that had worked for them, and so they've gone through a year or more of just chasing symptoms, and they're not getting anywhere. We really are adamant that this is best taught in the context of actually listening to the lessons. I said there were two reasons didn't I, why we didn't want to do that. Oh, yes. The other reason why the dispensary guide is not downloadable is because we are keeping it up to date all the time, so whenever we come across another product that really works well, you can rest assured that this has been tried by us. SIBO treating practitioners. I have tried all the different products, and some with better results than others, and I'll talk about that as we go along, but yes, we do keep this up to date.

Of course you can download the handouts that we talk about. This is more relevant in Lesson Two, where you get the handout about what caused my SIBO. You can do a little questionnaire on yourself, and highlight the area that you may need to focus on when we're talking about relapse. In Lesson Three, we have more handouts about specific diets, as well as food reactions. You also get some more handouts, so we have a lot of stuff for you to download anyways.

Okay, so after all that introduction, let's finally get to Lesson One. What are we going to talk about here? We're going to talk about irritable bowel syndrome and SIBO. We're going to go deep into what is SIBO, and the damage that is caused by SIBO bacteria. Then we'll move into, how do we diagnose SIBO if you haven't really had a breath test. You will learn a lot in this section because we go through different interpretations as well. Some of this will be over your head, and we've made this lessons various levels, because some people are extremely educated about this condition because they have followed everything we've done, or they have been at this for a while.

They already know a lot, so we really made this whole course kind of like whether you just started out, or you're far advanced in your journey. There's going to be something in it for everyone, so if this is over your head, you can always review it. I'm going to go through a couple of simple breath tests, and you can see where you fit in if you've already had testing done by your practitioner, or you've ordered it yourself through SIBOTest.com. Then we'll end up with talking about small intestinal fungal overgrowth, which is actually really, really common in people with SIBO, so sometimes we have these two conditions and SIBO can clear, and people aren't, still not well, and that's because they still have fungal ... They have fungal overgrowth that's not completely resolved. That's what we'll talk about in this lesson, so let's get started with SIBO and IBS. SIBO is actually a subset of IBS. Not all IBS is SIBO, but irritable bowel syndrome is ... The prevalence is about 11.3%, so that's about one out of 10 people, little more than one out of 10 people will have some digestive disorder that actually is IBS.

Typically that means alternating bowel habits or diarrhea, pain after bowel movements, abdominal pain in general, so there's certain criteria that determines whether or not you actually have irritable bowel syndrome. Estimation is that SIBO is about 60 to 80% of all worldwide cases of IBS, so that's a huge number, so that's ... It's possible that we are looking at about 500 million SIBO cases worldwide, and of course the vast majority doesn't know that they have SIBO. In the past five years, every time I check PubMed, which is a research database, there's just hundreds and hundreds more research studies that are coming out, which is really exciting for you, the SIBO sufferer, to understand this condition more, and this is something that we are all sort of holding our breath as to what's the latest and greatest in SIBO research. There's a couple of, actually three types of SIBO, and arguably maybe even only two types of SIBO. IBSD is about 40% of it, and that's diarrhea dominant, so people that have loose stools predominantly.

40% of that is really a good number, so the majority of SIBO cases would be IBSD. IBSM, which is the mixed type, so this is sometimes you have constipation, and sometimes diarrhea. Together, they make up about 63%, so IBSM, or SIBOM and SIBOD, make up most of the SIBO cases. That's true SIBO. That is actually where we do see the typical rises in gases that you'll see about in a moment, on the breath test. What we are starting to kind of veer off a little bit is this IBSC, or the constipation dominant patient. That's only about 35%, although some cases, I've seen ... Sometimes I just feels like all I see is IBSC, constipation-dominant, and that's a harder to treat type of SIBO. I will tell you right now that not everyone that has high methane has SIBO, and we'll get into that in a moment. This is also something that you might want to discuss with your practitioner, is what am I really? Am I IBSD? Obviously if you have diarrhea, that's easy to diagnose, but if you're not sure, you might actually want to discuss this with your practitioner.

Mostly you'll know if you're constipated or diarrhea dominant, and as we'll see in a moment, there are different bacteria that determine what type you are. What actually is SIBO? SIBO is, if you look at normal digestion, and you go from the mouth, to the stomach, to the small intestine, the stomach is actually supposed to be a vat of acid. It's just supposed to be so acidic that anything kind of orally coming its way, if you're eating something that has bacteria in it, it's supposed to be killed by the stomach acid. There are certain mechanisms that we'll talk about in a moment that don't allow normally for bacteria to overgrow, or we would all have SIBO all the time. Generally speaking, SIBO is an abnormal number of bacteria that are present in in the small intestine. That's what the acronym stands for, small intestinal bacterial overgrowth. Typically the area from the stomach to where your small intestine connects to your large intestine is supposed to have some bacteria, but nowhere near the amount that we find in the large intestine.

The bacteria that are overgrown are typically normal bacteria, so these are not bacteria that cause food poisoning. They are also found in the large intestine, although there's some conflicting research that, where we're starting to see more what type of bacteria really comprised SIBO. Bacteria ferment starches and fibers into gases that damage the small intestine, and cause a lot of symptoms, as you know, and we will go through those in a bit more detail. If you look at your digestive tract, and this is one of the slides that I have from my practitioner course, so sometimes this happens where I do ... I hope that you can follow along, but this is basically a visual of your intestinal tract, or your digestive tract, where it starts with the stomach, and we move down, and this orange area is the small intestine here. That's divided into three sections, the duodenum, the jejunum, and the ilium. The ilium is connected to the large intestine here, and we see see a ... Basically this is the colon, and it goes around like this, and then it comes down, and then food passes out through the anus.

This is the typical path that food takes, where start with the stomach, go through the small intestine, and then go through here, the large intestine and out. In the small intestine, so if we look at here, duodenum is supposed to have zero bacteria. The duodenum is right below the stomach, and it's not supposed to have bacteria because the stomach is right here, and you are getting stomach acid, also bile from the gall bladder, and enzymes from the pancreas, all of which should hopefully kill any bacteria that have overgrown in this area, so this is what keeps it sterile. As we go down, so the jejunum that's right here. I know it all looks the same like a bowl of noodles, but these are segments that follow each other, so the jejunum is only supposed to have about 100, and CFU stands for colony forming units per milliliter, and a milliliter is about a fifth of a teaspoon, so that's about only 100 bacteria. That's nothing when it comes to bacteria. As we go down, we see ever-increasing amounts. You can see here that it's about 100 billion colony forming unit per mil in the colon, so you can see the huge difference of populations.

That's healthy. That's supposed to be all here, but in here it's supposed to be sterile. SIBO is considered, when there's greater than 10,000 colony forming units per mil, and so that's sort of more the official diagnosis of SIBO when they do what's called an aspirate, or where they actually go in with an endoscope and take some of the samples, some of the small intestinal juice, to determine how much overgrowth is there, but doing a breath test is a lot easier. SIBO, in essence, results in bacterial fermentation. Bacteria ferment the starches and fibers that you've just eaten in a meal, hopefully you eat a lot of fiber if you don't have SIBO. We want to get you to that point of where you eat more fiber, because it's very healthy for the normal microbiome, but you must first be clear of SIBO, but starches and fibers, it's part of a particular diet. If you eat a lot of vegetables, and breads, and cereals, et cetera, are usually starches, and people that eat that, and get a lot of bloating, very often end up having SIBO, and that's because bacteria just use that food for their own food, and fermented into gas.

Depending on if you have hydrogen producers, and we know this from a breath test that we'll get to in a minute, if your hydrogen is high, you have hydrogen producers. If your methane is high, you have methane producers. There isn't a test for hydrogen sulfide producers yet, so hang in there. We'll get to that a bit later, but you can create hydrogen gas, methane gas, and hydrogen sulfate gas. This would be normal if it occurred in the large intestine where all of this is meant to happen, but it's not normal because it's happening in the small intestine. If you have a lot of methane gas on a breath test, it's likely that you have constipation. Sometimes people with high methane gas also have nausea, or a lot of belching and burping, and that's because methane gas tends to, or can, cause the motility in your upper digestive tract to go backwards. Rather than forwards and down towards the colon, we see it actually bubbling back up. Sometimes when I have a patient that just says, "I'm constipated, and I burp a lot," I often think of, this must be a very high methane gas.

Then we do a breath test, and then I usually confirm my suspicion. Hydrogen gas on a breath test is usually more associated with diarrhea or alternating diarrhea constipation. Also abdominal cramping. In very, very high levels, it's often associated with fibromyalgia, which is a very painful condition of body aching and fatigue. Hydrogen sulfate gas is more associated with diarrhea if it's in the small intestine, but if you have an overgrowth of hydrogen sulfate in the large intestine, it can also lead to constipation, so hydrogen sulfate tends to be a little more confusing, but also foul gas, like a rotten egg smell gas, is what we typically, what patients are reporting. Also bladder pain can happen and joint pain, so if this kind of ... If you can sort of navigate around this, it's very helpful once we get into treatment as to what we will do for you. As I've mentioned, the normal antibacterial control of the small intestine includes the digestive juices that your body secretes when food is coming down the throat, into the stomach, then into the small intestine, and then is starts to break things down.

It really is meant to be what we call bacterio static, or actually killing bacteria with these juices, and that includes HCL, which is actually hydrochloric acid. That's an abbreviation for hydrochloric acid, which is made in your stomach. Pancreatic enzymes are there to break food down into ... If we go back to the stomach, hydrochloric acid initiates the protein digestion. Acid is there to unravel these long strands of protein and kind of cleave them up so that pancreatic enzymes, when food has moved out of the stomach into the first part of the small intestine, the pancreatic enzymes are really there to start acting on smaller starches, smaller proteins, and smaller fat globules. We do need bile to emulsify these fats, because just like with oil and ... Oil and water don't mix, so we need something that's more fat soluble, and that's bile. Bile will break the fats into tiny, tiny, tiny globules, so that your body and the enzymes can act upon it, and really start this process of absorption.

They really do kill bacteria really well, and sometimes when people have been stressed out for years, and tremendous amount of stress in their lives, that absolutely affects all of these digestive processes, and that's why addressing the nervous system is so important for comprehensive SIBO protocol. Let's briefly talk about something that's part of your nervous system in your small intestine called the migrating motor complex. The migrating motor complex is basically part of your nervous system that's in the wall of your digestive tract, especially in your small intestine. It's also known as the housekeeper wave, or the cleansing wave, and it basically is this wave of contraction that sweeps through the small intestine every 90 minutes, between meals, and its purpose is to sweep out any residual bacteria from the upper gut. If the HCL and the pancreatic enzymes and the bile didn't kill the bacteria, we also have this very strong wave that is more or less imperceptible to us. We don't really notice that's going on, and to ensure that everything is swept out.

It's very important for SIBO, as we'll see a little bit later on as well, in session, or Lesson Two. It's about a 40 centimeter section, which translations to roughly ... I think it's about 25 to ... This is always where my conversion gets a bit mixed up, but it's about 20 to 30 inches, and it basically moves food along at about four or five inches, or six to 12 centimeters, per minute along, so it's kind of like a toothpaste tube that is being squeezed from the top down, so this very sequential contraction to ensure everything is swept out, and it's generated by the nervous system in your gut called the enteric nervous system. In SIBO, this is very, very often impaired. Imagine of the main ways that the body ensures that we all don't walk around with SIBO is damaged. This is very often the reason why people have relapse as well, because as soon as bacteria are killed with the protocol, they're just allowed to regrow because this cleansing wave is damaged, and we'll talk about that a lot more in Lesson Two with nice graphics and stuff.

What are these bacteria actually causing in the small intestine? What are they doing? The picture on the left here that looks like a rolled up shaggy carpet is actually a cross section of the small intestine, and these finger like protrusions here are called villi. Each little shag is called a villi, or a villus, and it's better seen ... Actually, this is actually also micro villi, where we have ... What you can see is even smaller hairs on top of these hairs, and that's micro villi, so you have this incredible surface area in your small intestine that is really meant to optimize the proper digestion, and breakdown of food, and the proper absorption, so it really, all that real estate is needed for your body to extract as many nutrients as it can. It's an incredible system that is just one of those miracles of the body that we're actually can turn food, which is a foreign substance, into self, meaning into cells, into proteins that we use for neurotransmitters, and cognition, and glucose that we use in our muscles to run away.

All this amazing activity is required from your digestive tract, just so you can function. What you can also see here, it ... Because it is a cross section is that you can see blood vessels around, very, very innervated with nerves and lots of vessels. It's just a hotspot of activity in your gut, and that makes sense because if you're eating food, your body wants to absolutely optimize extracting as much of that as possible. Now imagine having tons of bacteria there, and creating gas, and damaging some of these processes, so you can see, and start to appreciate what a big deal SIBO can be for a lot of people. SIBO can actually cause micro villi damage, so these are the little hairlike protrusion that are on the villi, that if you can imagine Bart Simpson, his head is the individual villus, or the main little shaggy protrusion, and his hair is like the little micro villi, and these micro villi is where a lot of absorption actually happens. The gas from the bacteria can damage this quite severely, and it can lead to leaky gut, and food allergies, and it can lead to histamine intolerance.

It can damage what's known as the brush border enzymes, and brush border enzymes are released by these micro villi to really help with this last step of digestion. It also causes your bile acids to be destroyed, and we need bile, as I've already mentioned, for basically absorption of fat, right? Fat is very important in your diet. Your brain is mainly fat, so if you don't ... If you can't really properly absorb your fats, you can't absorb your essential fatty acids, which is omega three fatty acids. Also your fat soluble vitamins, like Vitamin A for your eyes, Vitamin E for your heart, Vitamin D for your immune system, Vitamin K for your bones, and your essential fatty acids for your brain. You can see that this is a problem if we're starting to see SIBO go on, and on, and on, and on. Also, it causes the impaired migrating motor complex, or the motility of the small intestine, allowing bacteria to stay in the small intestine, and again, we have just talked about that, but we will talk more about the underlying causes.

Specifically, it can cause B12, magnesium, and iron malabsorption, so we often see people that have a lot of fatigue. Often I start there, though you have to be quite cautious with supplementation in some cases because iron can also act as a food for bacteria, so I usually pick the time to be a little bit later after we've already cleared SIBO, unless this person really has very low iron levels, but B12 is pretty good to take if you are low, but those tend to be very targeted nutrients that are specifically destroyed. Often times if you've had SIBO for a long time and you can appreciate that your digestive surface area has just been compromised, it just means that you can't extract as many nutrients, and so sometimes taking a multivitamin is helpful or very targeted nutrients. That we'll get into in other lessons. What are the symptoms of SIBO? Here's a guy who can't button his pants, and a lot of women. I should have a gallery of photos that people send me of when they've just eaten, and it looks like they're nine months pregnant.

This is the classic SIBO symptom, but really, SIBO encompasses all sorts of symptoms, because IBS is not just bloating. It's also constipation, diarrhea alternating. A lot of abdominal pain. That can be due to the gas, but sometimes it's not due to the gas. Can cause a lot of belching and flatulence, or gas, and nausea, and acid reflux. It can cause all sort of leaky gut symptoms like rashes and food reactions, and also fat malabsorption as we've just learned, and a lot of sticky poos, and so forth. This is just ... The symptoms that I've just listed are just the symptoms that we see in the gut. We have a lot of other systemic symptoms, as we call them, meaning that you can get headaches. You can get fatigue. You can get insomnia. You can get rashes. You can get joint pain. You can get all sorts of problems that we've linked back to SIBO. These are the conditions that are very often associated with SIBO. IBS, we've already mentioned it. It's actually, SIBO's actually a subset of IBS, so it's not a surprise that IBS is very often seen with SIBO.

Another condition known as IBD, or inflammatory bowel disease, and this is Crohn's disease or ulcerative colitis, and these are much more serious, destructive bowel diseases, where we see very high levels of inflammation, but they often have SIBO as a component when they're flaring. That's another area where we can intervene with acute flares with these patients, and really bring a lot of relief there. Celiac disease is also often associated with SIBO, and celiac disease is a condition of severe gluten intolerance, allergic, immune-mediated response. Fibromyalgia, as I've mentioned, is very much associated. The underlying ones are very high up. If somebody comes in with any one of these conditions, I check for SIBO regardless of their digestive symptoms, but fibromyalgia is a condition that has a lot of pain, body pain, fatigue, immune dysfunction associated with it, and it's very ... You need a very comprehensive treatment approach, and certainly I'm not suggesting that all fibromyalgia patients have SIBO, and just treating SIBO will make that go away, because it's multi system dysfunction.

Interstitial cystitis is a very painful condition of the bladder. It's kind of like leaky bladder. When we think about leaky gut, interstitial cystitis is like a leaky gut of the bladder, and it's very much associated with SIBO. Restless leg syndrome, where you kind of jerk at night, and jerk yourself awake, and you can't keep still, and acne rosacea, which is more of an adult type of acne, and also very much associated with SIBO. Atherosclerosis or heart disease, reflux disease, diabetes is very common with SIBO, hypothyroidism deserves a special mention, and we'll talk about that more in lesson two. Scleroderma is a very specific autoimmune disease that causes thickening of skin, not just the external skin, but also the internal skin, and so these cleansing waves are very difficult to move through the intestinal tract. Nash is an increasing condition. We're seeing a lot more of it, where it's basically fatty liver very much linked to this, and then chronic prostatitis. If you yourself have prostatitis, or you have a male relative that has this, and it doesn't go away, you might want to think about SIBO for them.

Diverticulitis can also often be seen, which is little out pouches in the large intestine, and they just act as bacterial reservoirs, so this can also be a contributing factor to SIBO, and gallstones are all on the list of common conditions. Let's take a moment to talk about SIFO, or small intestine fungal overgrowth. This is very commonly seen together with SIBO, and if you're listening to the SIBO Doctor podcast, that I host, I interview Dr. [Satish Rao 00:45:47], who did a study. He's in a medical university, a researcher, and he actually did aspirates, meaning he took the juices out of the small intestines of these patients, and he looked at how many of them had SIBO, how many of them had SIFO, and how many had both, and what he found is that in about 25% of SIBO cases, these people also had SIFO, which is pretty big news, and that's why sometimes when you take antibiotics that don't really do anything for fungus, your symptoms don't get any better. That's when you really know that, or you really highly suspect that this person has fungal overgrowth.

That's why I also like herbs, because this is ... Herbs are very often both antifungal and antibacterial. One of the confusing things I will just mention is that I spent half my life in America, and I'm working on the other half of my life in Australia, so when I say things like herbs, and you're listening to America, and you're confused, that's how we say things down here, down under, so just bear with me then, please. Back to SIFO. It causes the same symptoms as SIBO, so it is understandable why it's so confusing, is this SIBO? Is this SIFO? There is no reliable test for it. You have to sort of rule this out based on history, meaning does this person have had tons of antibiotics? Do they have any other symptoms of SIFO that can mean fungal rashes, or really intense sugar cravings? Those are the things I look for when I suspect SIFO, and then I do specialty testing that is not ... You can't just order this directly from a lab, but it is something called an organic acids test that I sometimes specifically do if I suspect SIFO.

Even there, I can't rely on it 100%, just so you know. If your symptoms do not improve with antibiotics, you might want to switch over to a herbal antimicrobial that also is an antifungal, and see if you do better. For example, if you're listening to this and you've already tried to a few rounds of Rifaximin and Neomycin, and you're not getting anywhere, and your test is clear now, but you still have symptoms, that's a classic picture that we see for SIFO. Stay tuned for Lesson Three, where we really go into some of these antimicrobials. The most common organism with fungal overgrowth is candida species, so this could be candida albicans, candida parapsilosis. There's several different species of candida. You've probably heard of the word candida. It's just a fungal species that normally lives in our gut. Our gut is not sterile, as we've just discussed. Your large intestine is supposed to have bacteria that create the microbiome. It also is meant to have viruses called the virome, and it's also supposed to have fungi called the mycome.

These are all symbiotically working together, and nobody is bothering anybody if everything is healthy and right. Candida is one of those organisms that if it's in a warm, moist environment, and it gets fed, meaning lots of sugar and starches, it will grow. That's just no way around it, so some people have very minor candida overgrowth, and some people have pretty substantial candida overgrowth, so it depends on if you're mild or severe, where we really determine how long you have to do this, but again, this is just an intro to what SIBO is. We'll get into treatment a little bit later in the lessons. Herbs are often better for SIFO, if you have both SIBO and SIFO, because a lot of herbs actually have a dual action of bacteria and antifungal. You really want to suspect it if you get a lot of yeast infections, rashes, also histamine intolerance is something that we often see hand in hand with SIFO, and symptoms get worse with sugar, get a lot worse with sugar, and that's not always the case with SIBO.

Very, very typically for SIFO. You can have candida overgrowth in the colon, and this ... It's easier to test with stool tests, but then it's still not always positive, so you cannot rely on stool tests to give you definitive information about whether or not somebody has SIFO, or definitely not SIFO, because that's small intestine, but even in large intestinal fungal overgrowth. What we typically see is with candida, it's rarely just the small intestine, and in a way it doesn't really matter because when we treat for fungal overgrowth it's typically in both areas, and we treat both areas at the same time. Let's have a look at how do we actually diagnose whether or not we have SIBO? This is done with a breath test. Many of you will have done one of these breath tests, and if you don't know where to order it, and you ... If you're working with a practitioner that is trained in SIBO, they know exactly where to order it. Different continents have different labs. SIBO test is something, is a lab that we run here in Australia, a testing facility.

If you go to sibotest.com, you can ... You're somewhere where you can't have access to a lab, we can certainly send you a breath test kit, and that can be done, but certainly we recommend that if you're working with a practitioner that has a lab, there's no need to send it all the way to Australia, so work with somebody locally if possible. What we know is that breath tests are not with ... They're not foolproof, meaning that they are accurate, but they're not 100% accurate, certainly not, so we have to always bear that in mind, and there was a lot of conflicting sort of recommendations by practitioners for a long time, because some practitioners and some researcher thought that lactulose breath testing is very inaccurate, and we could only be doing glucose, but the glucose gets absorbed very quickly, so you can't really use that for somebody that has SIBO further down in the digestive tract, so we were always wondering, what's the best way of really testing for SIBO? The North American consensus has made a statement that breath test is a useful, inexpensive, simple and safe diagnostic test in the evaluation of common gastroenterology problems.

It definitely is a good place to start by any means, so what we know is that stool testing is absolutely not accurate for SIBO. You cannot rely on a stool test to tell you really anything about the small intestine. It tells you a lot about the large intestine, but nothing about the small intestine. The breath test is a test that assesses for bacterial fermentation over about 90 to 100 minutes. The test is performed over two to three hours, so that we can also see what's happening after that test's sugar that you drink before the test, what happens when it actually arrives in the colon. It's a good thing to have a three hour test. It measure methane and hydrogen gas, and neither of those are produced by humans. Hydrogen sulfide is also ... Can be suspected under certain circumstances, such as if both hydrogen and methane are near zero, and I'll show you an example of that. How do we test? If we start over here on the right, we go ingestion of the substrate, and the substrate is a little packet of either lactulose. That's not the same as lactose. It's a separate sugar.

We also have fructose, glucose, and something called D-zylose. Those are all different substrates, but most labs really just do the lactulose, glucose, and maybe fructose as a combo to send out to their patients. You then ingest one of these sugars after you have been fasting overnight. You get up in the morning, you drink the lactulose liquid, and what happens then is that bacteria in the small intestine then ferment this lactulose, glucose, or fructose, and whatever is there will turn it into hydrogen or methane, or hydrogen sulfide, and then these gases are actually absorbed into your circulatory system, and carried to the lungs, where they're exhaled, and we capture the gases on the exhaled breath, and in a sample collection device. We can tell quite cleverly what's there by measuring hydrogen and methane after people drink these sugars. The breath test sugars essentially are food for bacteria, so the primary test for SIBO is a lactulose breath test, and that's the standard.

Some practitioners, and some researchers, only prefer glucose, and that's also legit, but it's just two camps of who you go see. I usually, if I'm really in doubt, I do both lactulose and glucose, and those would be done sequentially. You start with lactulose, and the next day, you do glucose, but it's important to know that not every bacteria actually ferments lactulose equally. Sometimes a lactulose breath test can be negative, and if it's totally negative, and even though you have all the classic symptoms of SIBO, I would probably run a glucose after that, just to ensure that it's been captured, and if it's still negative, then I would highly suspect SIFO. Some practitioners opt for testing with both lactulose and glucose, so this is, again, done one after the other, and glucose is an excellent test substrate, or test sugar, but it does get absorbed very quickly in the first part of the small intestine, and this is the reason why sometimes SIBO is missed, because by the time glucose gets all absorbed and SIBO's much further down in the digestive tract, you would just not actually pick up any fermentation.

Some practitioners do lactulose, glucose, and fructose on all sequential days, so one after the other, so that we cast our net out quite far. How do we interpret the results? I don't expect you to really become totally proficient in reading a test just so, but I want you to understand the basics, so that you can really look at the results, especially if you're not working with a practitioner, and you have sent a test kit to SIBO Test, and we're sending you the results, and it says positive or negative. You need to know what we're really doing. There is a lot of writeup, but some labs are really poor with giving instructions or what to do or if this is actually positive or negative. Typically, the testing window is 90 to 100 minutes, right, so this is after you've actually consumed either the lactulose or the glucose, and every 20 minutes, you're actually blowing into a little tube. Some labs are still archaic in that they're breathing into plastic bags. We recommend more the closed collection system, which are little glass tubes.

Every 20 minutes, you're sampling your breath and labeling it sample one, two, three, et cetera. After about two hours, that sugar, the lactulose or the glucose, actually transitions into the large intestine. We typically see a rise in the gases, and that's perfectly normal. That's what we want to see, because that's where your microbiome is. If you see a rise in the third hour, that's not SIBO. Very unlikely that that's SIBO, or at least with the testing interpretation that we now have, at this point, we would consider that a negative test result, and that you have more fermentation in the large intestine. We look for hydrogen, we look for methane, and we look for a combined value of both hydrogen and methane. We cannot directly test for hydrogen sulfide yet. No lab can, using a breath test. It's just, the technology is not commercially available yet, so let's have a look at what a positive SIBO test looks like. This was a patient of mine, had classic bloating, had diarrhea, and he was in his forties, and he had been traveling overseas, and this all happened after he became sick with a case of food poisoning.

Then about six months later, the symptoms were better, but they were still there, and he came to see me, and I did a breath test on him. This was the result, but this is just a classic example of what a positive looks like. The red boxes, let's have a ... Let's orient ourselves a little bit, so here are the sample numbers, so this is the first sample he did, all the way to 10 samples. This is baseline, meaning he got up, he did his first sample. Then he drank the sugar, and then 20 minutes later, 40, 60, et cetera, he's taken another breath sample. This is hydrogen column. This is methane column, and this is the combined column, so what we're looking for is, before it ... By about 100 minutes, we want to see the hydrogen go up by 20 parts per million, and his did by 60 minutes, so right now he's positive for SIBO. Then it goes up way higher, up to the 100 minutes, so it was a huge amount of overgrowth here, but it's classic SIBO. He also happened to have a combination of hydrogen and methane. Methane as we'll see in a moment, is a little bit of a different animal, in that it does utilize hydrogen to make methane.

But just for diagnostic purposes, what we want to see is a rise of 12 parts per million in the methane column. We did see that by 80 minutes. He went from 18, the lowest reading, to the highest reading and had a rise of 30, so the combined value, of course, was very high. You can look at this, and maybe review your own breath test, and see where you fall. I will say that I know this was a great sample, because his hydrogen was very low. If hydrogen starts out in the teens, or twenties, that was not a good sample, and it's not going to be as accurate as if you start out very, very low, and that's done with a really strict prep diet. That's something else that's important to prep before you actually test. Methane, very, very often has a higher baseline, because there's also large intestinal fermentation with methane that sticks around a lot longer past the prep times, and so what we see is that's very often not a low point, unless it's low in general. This is a classic case, and I've treated him and he is all better.

He does need some pro kinetics, but other than that, he was not a relapsing type of SIBO, so very good result. This one is an example of what it might look like if you have bloating, a gas that smells really like rotten eggs, severe diarrhea, rashes, headaches, that kind of thing, and you can see here that hydrogen, again, here are the samples, hydrogen at three, and it never really goes anywhere. It just stays the same, or it goes down even. Methane is, there's just nothing there at all, so rather than saying, "Oh, there's nothing there," it's interesting that by 120 minutes, which again, is where we actually transition into the large intestine. Still, nothing happened. There was no fermentation, and everything is what we call flat lining, so on this graph, it's very flat lining. If this patient did not have diarrhea, and had sort of more of a mixed pattern, it's unlikely to be hydrogen sulfide, because usually you want to see a bit more action with hydrogen sulfide when it comes to SIBO, so it's always very ... As I've mentioned before, there's no two SIBO patients that are exactly alike.

There's always unique situations, but this is ... As of now, we are thinking of this that's suggestive of hydrogen sulfide, because we have no other way of really assessing hydrogen sulfide in the small intestine. This is actually a methane positive for SIBO, so classic SIBO positive. If we actually see by 100 minutes a rise of 12 parts per million, so very often what we see is a higher baseline, as you can see here. This is the methane column, and it starts with 39, and then it goes up to 68, so that's a rise of almost 30 parts per million, so we already know this is a positive SIBO test result for methane. Methane positive IBSC, but negative for SIBO. I know this is so confusing, especially for all of you methane people, but it's important to understand that methane itself is not a pathogen. This is just a normal organism that tends to slow the digestive tract down, and we'll get into that in other lessons, but it is a normal organism that in some people is naturally high, and even in those that are not constipated.

Just the presence of methane doesn't mean you have to be constipated. We get plenty of test results where the patient is not constipated, and they have high levels of methane, so it's important distinction. When we see a test result where there was no rise, you can see here where we have a 32, 32, 31, 33, and it never really goes maybe up to 36, but not until the large intestine do we see it go up. We think of this more as IBSC methane positive, and that has really important connotations for SIBO, because theoretically this is not a SIBO. This is where we see a bloom of methane in the large intestine, and it's just there throughout the entire time. It never really rises. There's no definitive fermentation present in the small intestine, so the important thing here is if the patient is not constipated, they may not need treatment at all for this, right? Very important to understand this, and let's kind of look at it a little bit closer. Just to recap, if high methane throughout your breath test is high, and it stays high, it's likely to be a large intestinal overgrowth, or bloom of this organism called methanobrevibacter smithii, which is the main methane producer in humans.

Methane actually is produced wherever hydrogen producing bacteria are located, so there is a relationship for sure. Methanogens, like methanobrevibacter smithii, require hydrogen to produce methane. The presence of hydrogen producing bacteria in the upper gut is SIBO, but hydrogen producers are also common in the colon, so the timing of the test is really important. Making sure you've had a very strict prep diet, which is usually for 24 hours before the test is important, and the numbers are important in terms of where they occur, how high is the fermentation, so all of that determines whether or not you are methane positive, or you have SIBO methane, so it really is a fine line for me, and I've spent a lot of time teaching other practitioners, because why I'm spending so much time explaining it, is because I find that a lot of patients are over-treated and over-diagnosed with methane SIBO, when in fact it's sort of like a combination of an overgrowth in the small and the large intestine, and why is it important?

If you have more large intestinal overgrowth, I'm not going to give you a low fod map diet or a low fermentation diet, because you don't need that. It's very unlikely that you need that. You're probably going to need a lot more fiber, and a lot more ... You can still use low fermentation foods, but you don't have to be as strict, certainly not as strict if you have more of a large intestinal methane overgrowth. I hope I've made that sort of clear enough. It is something that I've lectured at numerous SIBO conferences about, and it's something that really needs to be addressed by a lot of practitioners, I find. Let's talk about retesting. This is the famous chart by Drs. Allison C. Becker and Steven Sandburg Lewis. Some of you may have already seen this before. This was a chart that was presented and is available online, and it really is the flow chart of treatment. Let's say that a patient comes to me, and I suspect SIBO. We start here at the top, and they have bloating. They have maybe acne rosacea, and I'm really thinking, wow. They really fit the picture for somebody with SIBO.

I run a lactulose and/or glucose breath test, and then if they're positive, I will prescribe one of three things. Either the antibiotics, or refer them to somebody that can prescribe antibiotics, like Rifaximin and Neomycin, and I'll put them on a biphasic diet as well, or I prescribe herbal antimicrobials, and put them on the biphasic diet, or they start the elemental diet, which is a whole separate treatment, antimicrobial treatment that we'll talk about in Lesson Three. Let's say they come, after their treatment, so elemental diet usually is about two weeks. Herbal antimicrobials tend to be six weeks or longer, and antibiotics are about two to three weeks, so they come back, and they say, "Um, Doc. You're amazing. I'm 90% better," and in that case, we're not going to retest necessarily. We're going to just use some preventative measures, and we're going to start healing their gut, and do all these other bits, so really nothing more needs to be done when there is a 90% improvement, or at least no retesting needs to be done.

If we see a partial improvement, like, well, I'm maybe 40%, 50% better, it's important to actually retest, because we need to know whether or not the treatment was actually effective. Let's say we retest, and the test is positive, so it's as positive as it was before, in which case I would totally change antimicrobials to a different kind, or maybe go to Rifaximin, or maybe use the elemental diet. All depends on how high the levels are, but that means that the treatment did not work, or worked sort of inefficiently. If the test is negative, that means we beat SIBO, but we need to now consider a whole nother diagnosis because this is actually a chart I use also for private practitioners, so pardon me for the abbreviation of diagnosis, which is DX. Consider another diagnosis, so yes, you may have had SIBO, and we beat SIBO, but that was not the underlying cause to your symptoms, so you can see how retesting is really, really important in the context of a really comprehensive SIBO treatment plan.

That concludes Lesson One. Lesson One really focused on SIBO, what is SIBO, and discussing the bacteria, and what they do in your small intestine, and the symptoms of SIBO, and why they are caused by bacteria, and the damage that they cause to the small intestine. We looked at breath tests, and how they are a useful way to diagnose SIBO, and to monitor progress, and then we moved on to SIFO, or small intestine fungal overgrowth, and that it's also often present, and also often needs treatment. We know that methane, from just looking at test results, is definitely more complicated, and we concluded by retesting is recommended if you still suffer symptoms after your treatment round, so that we understand whether or not we're still dealing with SIBO, or there's something else going on underneath. Well done. You've completed Lesson One. Now you know what SIBO is. Now let's move on to Lesson Two and learn about what caused SIBO for you. See you in Lesson Two.