OneMedicine Podcast

Rob Lutz 00:03
Hello and welcome to the OneMedicine Podcast from Today's Practitioner. In each episode, we share the expertise of a respected thought leader. Some you'll know and others you'll probably meet for the first time. We cover topics important to you always with a focus on improving the health outcomes of the patients you treat, while expanding your understanding of the many healing modalities being used today. Welcome to the one medicine podcast. I'm your host Rob Lutz and with me today is our guest Angela Pifer, the SIBO Guru. Why is SIBO challenging to treat? Might the issue lie in hasty diagnosis and repetitive treatments without deeply exploring the root cause of SIBO? Could its persistent nature be attributed to the common approach of using antibiotics or herbal equivalents and restrictive diets aimed at starving gut bacteria? Join us today for an honest discussion with Angela Pifer, the renowned SIBO Guru. Welcome, Angela. I appreciate you coming on today. I'm gonna go through your bio in just a second. But I do appreciate it. I know we've tried to get this organized in the past. And so I'm really excited to have you on; it's a great topic, lots of interest from our readers and subscribers and you're the expert. You're the perfect person to have on the show.

Angela Pifer 01:14
Oh, I love that. Thank you. Yeah, happy to be here.

Rob Lutz 01:17
So I'm going to just go quickly go through your bio and then I've got a couple of questions we'll ask before we really get into the topic. Okay, a quick bio on Angela. Angela Pifer has been in clinical practice as a functional medicine nutritionist for two decades. She holds a master's degree in Nutritional Science, graduating at the top of her class from Bastyr University in 2005. Angela's an authority on everything gut, specializing and functional gut disorders from the beginning of her career. The focus of her practice is to find the root cause of chronic GI symptoms. She is a GI health researcher, functional medicine educator, licensed certified nutritionist, and focuses all her continuing education on GI conditions. Angela sits on the Scientific Advisory Board for Physicians Choice, who sells the number one ordered probiotic on Amazon. She is known affectionately to her patients as SIBO Guru for her focus and success in treating SIBO (small intestine bowel overgrowth) for over the past 12 years. She is also the creator of Simply SIBO FODMAP recipe site to help people dealing with IBS and SIBO expand their diet, Gut RX Gurus Bone Broth and Functional Medicine Shop founder. Welcome, Angela. Again, really appreciate you being on here today. And before I stop talking and give you a chance to really share your knowledge with the audience, I have a couple of questions that I'd like to ask before we get started just to kind of get a little bit more background in general about you and how you look at things. So I'm just curious, how did you become a functional medicine nutritionist focused on SIBO and gut health? And what was your path to get here? Anything happened to you personally, or what brought you there? What was so interesting about it?

Angela Pifer 02:56
Yeah, absolutely. So I have an undergrad in psychology, and my goal was to get a PhD in psychology. And I took a course in nutrition at the University of Washington. I didn't...I'm not saying I knew more than they did. It just seems strange to me how it was presenting; I learned that that's probably the only class that doctors get. And it just, I just flipped on a dime. Luckily, Bastyr University was nearby. I live in Seattle, Washington, and it just happened that that's the school I chose. I didn't have any health issues prior. I know a lot of people who get into this field; they found their healing in alternative medicine or functional medicine, and it really drove them to get into it. But it was just the luck of the draw, honestly, in where I went. And I have such a fascination with the human body and figuring out puzzles, so it just seemed like the perfect fit.

Rob Lutz 03:53
It does seem like a perfect fit and Bastyr--not a better place to do that. Right?

Angela Pifer 04:01
Yes, it was great.

Rob Lutz 04:04
Yeah. And top of your class, too. That's impressive. So what type of medicine or school of medicine do you practice or do you feel most aligned with and why?

Angela Pifer 04:10
Yeah, team approach with the patient and root cause. I say functional, integrative--it's kind of all of the above, it's all of the above. How do we treat the patient? What other approaches will help them? How can we team up with the patient and other practitioners to get somebody better? So I think sometimes it takes a group.

Rob Lutz 04:30
Yeah, it makes sense. And really involving the patient in that process and understanding it's personalized. Everyone is a little bit different in taking that approach. It really sounds like getting to know the patient, too.

Angela Pifer 04:41
Yeah, working with them. And we obviously we've got to trust their experience and do a really deep dive into their health history to get them better. Right? I think that's just missed. We'll look at a little bit of lab history and all, but it's having a really in-depth conversation with the patient is what really tells you everything.

Rob Lutz 05:01
Yeah. And that's so different than a lot of conventional practitioners where you've got your three minutes with the doctor and four minutes with the nurse practitioner. So I think solving this kind of a complicated condition probably takes that approach. So it's great that you do it.

Angela Pifer 05:16
Correct.

Rob Lutz 05:17
Okay, so the last question before we get started is: Do you think there's a unifying principle that runs through all the types of medicine, regardless of what name it goes by? What would you say all types of medicine have in common?

Angela Pifer 05:29
We just all want to see results with our patients. It's common. I think we're all going about it a little differently. I'm sure, unfortunately, I think we we can see some positive and negatives in all modalities. But we need to get back to patient-centered care. And for that, we need more time with our patients.

Rob Lutz 05:51
Makes sense.

Angela Pifer 05:52
We just have to.

Rob Lutz 05:52
Right. Well, thanks for sharing that with us. And I think now we can jump in. We're talking about SIBO, and you're the SIBO Guru. So where would you like to get started? What do you want to make sure the practitioners that are listening today walk away with? Where do you want to start?

Angela Pifer 05:57
I think just topically, it's if SIBO is a recurrent condition, why? We have to keep asking ourselves that question. SIBO is being treated on an algorithm when SIBO is a secondary condition. It's not a primary condition. And we're all constantly complaining at how recurrent SIBO is. So could it be the way it's being treated?

Rob Lutz 06:37
That makes sense.

Angela Pifer 06:38
It's really driving that.

Rob Lutz 06:40
You see a lot of patients, and do they come to you saying: I think I've got SIBO? Or do you diagnose them based on...how do you do that? I mean, how do you determine that "Hey, this patient has SIBO"?

Angela Pifer 06:53
So SIBO should be a diagnosis of exclusion. And then you should run a lactulose breath test to confirm it. A lot of times, I don't think the testing is done. There are some concerns with the testing, but it is what we have, and it is what is recommended as standard of care. And so that's how we would diagnose it. So, I've worked with SIBO, for the last 12 years. Initially, I was getting brand new SIBO cases. "I just tested positive; help me." And so I could approach it a little different. But now I'm usually the seventh or eighth practitioner in line, they've been through multiple rounds of treatment, they have four or five positive SIBO tests. So we know SIBO is there. But I really set all those aside and do a full onboarding and look at things from a systemic perspective before I would ever jump in and look at treating SIBO. I mean, we look at SIBO as an epidemic at this point. That's what everyone's talking about it as. But yes, SIBO exists, definitely, but I don't think at the numbers suggested and absolutely not at the numbers that would warrant overuse of the treatment with antibiotics as we see it. SIBO is kind of this catch-all for anyone complaining about GI issues and bloating at this point. And, you know, it could be anything else. It could be anything else, but SIBO is just immediately what a lot of practitioners are jumping to and then people are just getting on the conveyor belt of treatment, treatment, treatment.

Rob Lutz 08:21
Just kind of like the cookie cutter approach with antibiotics and changing your diet. Is that usually something that most practitioners recommend to alter the diet?

Angela Pifer 08:31
Yeah, I think they do, a lot of them. Maybe around five years ago, we started to see a lot more GI doctors and primary care doctors accepting SIBO as a diagnosis. And so they're handing out a low FODMAP diet, and they are giving antibiotics. But we know from the antibiotics SIBO is going to continue to recur most of the time. So eventually, are those antibiotics doing more harm than good? What are we missing? What's the underlying root cause? Because there's always going to be. SIBO is a secondary condition, so we always have to look for that and treat it.

Rob Lutz 09:05
What about that, the secondary condition--the antibiotics that are being used to treat the patient? Why isn't that working? If you could share with us what your thoughts are?

Angela Pifer 09:15
That's a fantastic question. That's the golden ticket question. Why aren't they working? I think SIBO to me is being treated like an infection when it's an overgrowth, it's an imbalance. And so they're already likely dysbiotic when they come into your practice, they're complaining of GI issues, and then antibiotics are being used. Yeah, they definitely are going to knock down symptoms because they're knocking down everything. But then it's going to come back healthier? Where's the momentum? Have we corrected motility? What's affecting motility? Have we corrected immune dysregulation and what's triggering immune dysregulation? We have to get more to root cause for people to make this really work and stick. I've seen people on a low FODMAP diet for five years that have come to me, they still have SIBO. It doesn't work. The studies have shown across the board that it does not treat SIBO. And how could dropping polyphenols, antioxidants, and fiber be a good thing? Right? We know all the benefits of those, but for whatever reason with SIBO, everything else goes out the window. We're going to restrict all of those. We're going to tell people this is recurrent, which to me makes it more recurrent. The placebo effect. They're going down the road of antibiotic, antibiotic antibiotic, and everyone's beating their head against the wall that this is a reoccurring issue. But I think a lot of people are part of the problem. And I don't mean that with any disrespect. I say that respectfully. We have to step back and rethink how we're treating SIBO.

Rob Lutz 10:48
Yeah, well, you have to believe practitioners have the best intentions.

Angela Pifer 10:52
Absolutely. 100%.

Rob Lutz 10:53
They have the best knowledge. So, you've mentioned root cause a couple of times. Is there any specific common root cause for most people's SIBO?

Angela Pifer 11:05
Yeah, the two main ones that we see are post-infectious IBS, so you get a food poisoning event. And the common denominator with that is the cytolethal distending toxin. So the CDTB toxin and your immune system will mount an antibody response to that, and in some people you'll get crossover where that antibody will start and immune system will start attacking vinculin. And vinculin is involved in motility with the migrating motor complex and the intestinal tract. So about three months after a food poisoning event, you'll get a slowdown and motility SIBO will be set up and you'll start getting symptoms. So kind of unmask at that point. So that's one. Second I would say is parasites. Parasites reside in the upper GI. They will stall gastric emptying, stomach acid production, bile flow, and motility. So those two are really common. It's hard to test for parasites. My favorite test is Parawellness Research. It is hands-down the most sensitive test, hands-down. Real quick: I had a patient I worked with last year. She came back to me a couple of months back and said: "A colleague of mine and I went to an event. Within 24 hours, we had loose watery stool just dumping nonstop." They go to their doctor and they're trying to do everything they can, obviously. They ran over the course of three to four months for both of them, they ran three standard path screens, negative every single time. And she calls me and I'm like, "Why didn't you call me sooner? Let's work on some things here." But I said: "Go get this test, Parawellness Research"...and they found cryptosporidium and giardia in both of them. It's a very, very sensitive test, and oftentimes the the main tests are being missed.

Rob Lutz 12:52
We'll certainly link to that company.

Angela Pifer 12:55
I'd love to. Yeah, they're really, really great. And there's a lot of other reasons people can get SIBO: scleroderma, pseudo-obstruction, adhesives, Crohn's disease, active inflammation can really drive a lot of this. Celiac radiation, iteritis, small bowel diverticuli disease where you can get pockets, and to me that would be more of an infection that should be treated probably a little bit more with antibiotics if we have pockets that are that are getting infected. Diabetic enteropathy, Ehlers-Danlos Syndrome, where it's a genetic predisposition to loose ligaments, and then the intestines drop a little bit creating pockets, surgical resectioning of the intestinal tract. There's a lot of reasons why this could be set up. I'd say from from a functional perspective, most often, those are probably more the smaller percent of people for root cause, most often it's post-infectious IBS or parasites.

Rob Lutz 13:54
Got it. And so in your intake, you're obviously asking lots of questions to the patient to get some of this stuff to top of mind so you have a better direction to go.

Angela Pifer 14:04
Yeah, so when I onboard somebody that I'm going to work with, I like to see labs for last five to 10 years, 10 years if they can get them. I have them send those over, and I fill out my paperwork, of course. I sit down prior to the onboarding session with them and put everything into a flow chart. So I am so primed and ready. Sometimes it takes me half an hour, sometimes it takes me an hour, it's all worked into my fees on how I work with somebody. So, I'm primed. And then we have a 90-minute onboarding session. And we do a deep, deep dive into history. And part of that includes looking at prior practitioners, and what was diagnosed, what was treated. And what I see from that and history is time and time again, we've got SIBO as the target when they've got multiple diagnoses. And oftentimes out of the gate, it's just antibiotic without even testing. Let's see if an antibiotic works. Where are we? This seems like such a bizarro world. We all know that there's bacterial resistance happening. Why are we just throwing these things out like candy for SIBO patients? It's so strange to me.

Rob Lutz 15:09
Or really for most patients, you know. It's too common.

Angela Pifer 15:14
Yeah, I agree. I think when I see all that it results in a lot of doctor-hopping or practitioner-hopping, and they're going kill phase to kill phase to kill phase. And I don't think a lot of practitioners look at that. They'll onboard, they're doing the best they can, just full respect there. But they'll onboard, they'll look at symptoms, they'll look at labs, and they're like: "Oh, SIBO. You have gut symptoms; let's treat SIBO. Here's my protocol." But they don't know that six other prior doctors just did the same thing you did. Maybe a little different in the protocol. So why is yours going to work?

Rob Lutz 15:47
The patient doesn't say that to the doctor. "Hey, I've already tried this route." Typically, they're like: "You're the doctor, so I'm gonna listen to what you say."

Angela Pifer 15:53
Yeah, correct. And that's when people come to me after being through six or seven different practitioners. And a lot of us have this; this isn't just me getting these people. Again, SIBO is recurrent. They do a protocol with somebody, it doesn't work, they move on. So, they're coming to me, I'm the seventh in row or 12th in row and they're like, "Ah, you're the one! You're gonna give me the protocol that's going to kill this." But I'm seeing the six fairly robust treatments, and they either aren't getting better or they're getting worse. So we need to step back and rethink the diagnosis. Is the diagnosis even correct? Has root cause ever been identified? And 90% of the time it has not. It hasn't. They're just not looking at it?

Rob Lutz 16:38
You've mentioned a few that are common from what you've seen: the parasite and infection. So you're doing some testing to determine which one of those it might be?

Angela Pifer 16:46
Yeah, and that really comes into play again, that's a health history intake. When I'm having the conversation, that's where that conversation is so important, because you can lay out across their life, what burdens did they bring in? When did things change? Where were they living? Think back on stress state, you kind of look back and go, Okay, 15 years ago, things changed drastically for you; what was going on the year prior? So it's that kind of thing. And then, based on their symptoms, and what happened, and how consistent they were, I start thinking about different root causes that make sense to me, and then we can start testing for that.

Rob Lutz 17:22
Okay. So one thing we talked about earlier that we wanted to touch on, you and I, before we started the podcast: Can a stool test diagnose SIBO? What are your thoughts?

Angela Pifer 17:32
The resounding answer is absolutely no. And it's ridiculous that it's being listed on any of the digestive stool tests. What we were taught up to three years ago were really two things. One, the small intestine and large intestine were on different planets when it comes to terrain and makeup of microbes. Stool testing represents the large intestine only. Right? That's what we were told forever. So now we've got all these stool tests coming out with companies labeling SIBO on these and they shouldn't be. I've seen it when talking to other doctors: "Oh, yeah, they have SIBO. I just treated off the stool tests." Which again is--what are we doing? That's not the way that we diagnose SIBO. Let's stop just throwing antibiotics at people. Again, we just have to rethink that. So I appreciate it stool--easy to access. You can extract the DNA, you can amplify it easier. I get that, but it's only representing four to five feet of large intestine and not the small intestine. From a small intestine perspective, basically, we had biopsies and we had aspirate cultures any time we're looking at the microbes there. The drawback being that the aspirate cultures weren't sterile. They'd get contaminated when they came up through the mouth. But we still noticed drastically different microbes present. Those tests versus stool testing, right? We have 20 feet of small intestine, it's a highly active absorptive surface. Nutrition assimilation, detox, this is where bile gastric contents of food, pancreatic secretions...they all converge. So much going on. And it's different than the large intestine. So what's interesting is in the last five, I believe five years ago is when these studies started to be done, but Cedars Sinai basically invented a new aspirate catheter that allows you to go down into the small intestine, bring out fluid in a sterile way, so it's not going to contaminate it as it's coming back up. And so they've done a series of studies called the REIMAGINE studies, and REIMAGINE is a mouthful, but it's "Revealing the Entire Intestinal Microbiota and its Associations with the Genetic, Immunologic, and Neuroendocrine Ecosystem." It's a mouthful, so REIMAGINE is so much easier. So, two studies I want to look at with this and kind of talk about in relation to this because again, if if this is the only thing I can get other practitioners to take home is we have to start pushing back on the stool testing companies for even adding this and we can't use any reference to the stool test to treat SIBO.

Rob Lutz 20:16
Okay, one question before you go into this other piece. Why did they think stool was the way to test for it? And quickly, just in a nutshell, why shouldn't we be looking at stool as an indicator for SIBO?

Angela Pifer 20:31
Stool is only representative of the large intestine, not the small intestine. That's it. And I think it was just out of sheer convenience that we've always looked at stool. Easy to collect, all of that. To go in and do an aspirate that far down in the small intestine is incredibly invasive. To have somebody poop in a container, non-invasive. Gross, but non-invasive. That's mainly why; you could do a lot larger studies, less expensive, all of it. Until this aspirate catheter was invented by Cedars Sinai, we didn't know what we were really getting on a lot of the tests.

Rob Lutz 21:17
How frequently do you have your patients use that test?

Angela Pifer 21:21
Which test?

Rob Lutz 21:22
The one with the catheter.

Angela Pifer 21:25
This isn't available for outpatient; this is only being used in studies. So basically, what they're doing with the REIMAGINE studies, they're saying the entire intestinal microbiota, but they're really looking at the comparison of the small intestine to the large intestine as a whole. So the first study mapping the segmental microbiomes in the human small bowel in comparison with stool, and quoting from their study, tremendous differences between the small bowel and stool microbiomes. "Our findings demonstrate that the small bowel microbiome is unique, and that stool is not a surrogate for the entire gut microbiome." So basically what they did as they use that catheter, and they brought up fluid from the duodenum, the jejunum, and then the furthest point that they could reach in the small intestine. And what they found was that the alpha and beta diversity were similar for all three collections within the small intestine. What they found were differences when we start to look at small intestine, the large intestine, we're pretty drastic. In the small intestine 90% of the phyla were firmicutes, proteobacteria and actinobacteria. And then in this study that they did, firmicutes were dominant, representing about 50% of the phyla, and of that phyla, 68% were the order of lactobacilliaes. When they looked at stool, 90% of the phyla were firmicutes and bacteroides. And then in the stool, the firmicutes were 93% clostridials. So very drastic difference in presentation. So if we're looking at stool and are like: "Oh my gosh, look at all that clostridial that's present," that could be SIBO. You're looking back up in the small intestine...well, almost 70% of the firmicutes were lactobacilliae. It's that you're looking at the large intestine and then treating the small intestine.

Rob Lutz 23:23
Interesting. So basically you're saying the stool test just doesn't work. And this, this proves that essentially.

Angela Pifer 23:30
Yeah, it just doesn't work. In the stool, they found that proteobacteria that were present in the stool two classes were more abundant, one of them being the delta proteobacteria, and those are our hydrogen sulfide producers. So desulfovibrio and belaphilia, those are more present in the large intestine. And if we think about the three subtypes with SIBO, we have hydrogen producers, methane producers, and hydrogen sulfide producers. And so if you run a trio smart test, which is the only breath test that looks at hydrogen sulfide, basically, there's a much, much, much more likelihood that that's from the large intestine. And on the test, they'll say that they can't distinguish between the small intestine and large intestine with the test. But then those people are being told they have SIBO and then they're going down the rabbit hole of treating SIBO. And I'm not saying that they don't need to treat hydrogen sulfide. It's not good to have that in the large intestine, but do you need to change your diet to a SIBO diet? If it's large intestine, it gets to be interesting as we're looking at all of it.

Rob Lutz 24:39
It sounds really complicated, actually.

Angela Pifer 24:42
Yeah, I would agree with that.

Rob Lutz 24:44
Breath test isn't giving you everything that they say it does, stool test isn't giving you much of what they say it is. So where are you going? How are you moving through this process with your patient?

Angela Pifer 24:56
If I had a patient come to me without SIBO diagnosed, and I suspect SIBO, I'm still setting it aside and saying what else is going on? SIBO is not my first thing that I go to, because if SIBO is present, once we get to it, what else is going on? It's a starting point for investigation. It's not an endpoint for treatment. Right? So the testing that I do if I am going to test for SIBO, it's through Aerodiagnostics. That's my go-to breath test company and they are absolutely phenomenal and amazing. Gary Stapleton is the owner, a wealth of information. Just reach out, get a test and run it, just walk through a conversation with him, and it'll really make sense. They're using Quintron machines, they're very reliable, and I have good results when I see that on what I'm treating.

Rob Lutz 25:47
I'll make sure we put the link to that as well.

Angela Pifer 25:49
Yeah, I'd love to. Yeah, Gary's amazing. So, I'd love to look at another study that was also done by the REIMAGINE group. This one is titled "The duodenal microbiome is altered in small intestinal bacterial overgrowth." So this one compared duodenal aspirates for bacterial composition, and also compared this to a SIBO breath test. And when they do the aspirate and pull up the fluid, and test it, they're looking for SIBO diagnosis is a greater than 10^3 of bacteria. Okay? So there has to be a larger presence of bacteria present to be identified as a SIBO positive on the aspirate. And so of those SIBO positive with the aspirate, they had less diversity, proteobacteria and classes of proteobacteria, gamma proteobacteria and delta proteobacteria were higher. And then part of that phyla, a family underneath that, is the NRO bactericeae family under, and those were higher, and that was really linked with bloating. So we have a lot more proteobacteria, different classes than we see elsewhere. So what they also found when proteobacteria and then enterobacteriaceae were higher, that firmicutes was lower. When I see that, my question is: Should antibiotics be the first step here? If we back up, we know that proteobacteria is very prevalent in the oral microbiome, averaging maybe around 34%. We know that firmicutes is like an acidic environment. We know that the upper duodenum is around six on the pH scale and the pH scale becomes a little bit more basic, I think until about 7.3 as it goes down the small intestine, if I remember correctly. So what's the common denominator in all of that? Could it be low stomach acid, allowing the proteobacteria to migrate through the stomach, and more basic pH and the upper duodenum, that could account for less firmicutes in that area. So we can correct stomach acid for sure. That can be done fairly easily with supplements, but we can also look for root cause. Is it hypothyroid driving down metabolic rate? Sympathetic dominance driving blood flow away from the digestive tract and organs, which could be caused by a myriad of issues? But so many of our patients are so stressed out. They're just so stressed out and with the political crap--there's no other way to say it--political crap, COVID crap, all of it crap. We were already stressed as a nation, and now made worse. Could it be caused by an autoimmune condition like AIG? Atrophic gastritis, PPI use, excessive alcohol consumption, pancreatic insufficiency, H. Pylori, age related. Is it parasites? But they don't look at that. It's antibiotics, antibiotics, antibiotics.

Rob Lutz 28:51
That's why it doesn't work.

Angela Pifer 28:52
It seems after all this time, and that's been the treatment and SIBO has just continued to be recurrent. It seems like that's the common denominator. And I'm not saying that there aren't some cases that might need to be treated with antibiotics, they can be very severe, they might need them. We definitely see an improvement in symptoms going on antibiotics. But that's not necessarily treating root cause.

Rob Lutz 29:17
Right, especially if it comes back and and you're not solving the issue.

Angela Pifer 29:23
So I'd say just to wrap up the conversation on stool testing for SIBO, it's causing practitioners and patients to go down a rabbit hole, oftentimes skipping a breath test, oftentimes skipping root cause and going straight to antibiotics, and it's just leading to more and more overtreatment.

Rob Lutz 29:41
I mean, what my takeaway so far is, this is such a complicated thing to really figure out what's causing it. Using that I-wish-this-was-the-magic-bullet antibiotic because it DOES work may limit some symptoms at times. That's the temptation for a practitioner that's not really skilled and getting down to the root cause and truly solving this for patients, which it sounds like you've done for a long time, by taking the approach that you're doing--lots of research tons of questions, and really looking at some different testing that other practitioners might not be using.

Angela Pifer 30:17
All of us were, honestly, at the start of this, every practitioner that was working within the SIBO realm was putting people on a starvation diet and doing kill phases. All of us were; I'm not going to stand here and say I wasn't at all; it was just standard care at that time. And I know it's standard of care right now, but it's not working. That's the whole point. It took me about two to three years to start to see enough people recur and be stuck on a diet to say: "Wait a second, this isn't even making sense." It's just not making sense. We have to look outside the box with this.

Rob Lutz 30:52
This happens, I think, with a lot of conditions. This is what we've been doing, whether it's conventional or even some integrative, so that's what we're going to do. But there are some practitioners out there that are really diving a little bit deeper. And that's kind of what we're talking about here is you're sharing what you've learned over the years, what's worked and what to look for, what questions to ask, and you are getting better results. So hopefully this becomes more of the standard of care, things that you've learned and other practitioners have learned, that really solve the issue for these patients, because--personally, I don't have it, and I don't know anyone that does, but just from what I've heard, it just sounds terrible.

Angela Pifer 31:32
It really can be. I would say it can be anywhere from symptoms of a 2 to 3 on a scale of 0 to 10, and it can be all the way up to 15 for some people. And again if, depending on how far it is up in the small intestine, it depends on what the root cause is, how long it's been there, all of that, other cofactors, they have an autoimmune that's just getting really flared. And then they're really sensitive to supplements, it just can be very hard to treat sometimes. You've just got to keep peeling the onion as you get down to root cause and treating and stabilizing people.

Rob Lutz 32:08
So those are the studies, you've talked a little bit about why is SIBO recurrent. Is there anything else that you want to share about that, go a little bit deeper on it?

Angela Pifer 32:17
I'd love to look at the algorithms for how this is being treated. Because I think, again, as we look at recurrence, my thesis here is that it's recurrent because we're not getting to root cause, and we're overtreating it with antibiotics. But that's all that's being presented in the treatment algorithms. And so there's two algorithms--there's one for alternative medicine, and there's one for mainstream medicine. And if we look at...we'll look at the alternative medicine first. And I'll say, too, both algorithms' standard of care is to test, to do a lactulose breath test. That is the standard of care. And there are so many practitioners out there that just: "I'm just going to give an antibiotic and see if it sticks to the wall." Please don't do that. Please don't do that, please. And I appreciate sometimes if it just is completely cost-prohibitive for getting a SIBO test. I appreciate sometimes we have to do other things, but for the most part standard of care should not be: "I suspect it; here's an antibiotic." So, alternative medicine: For the algorithm, basically if SIBO is suspected, you confirm with a breath test. There are four choices here: You can put them on I'll just call it a SIBO diet, because there are three out there: There's the FODMAP diet, the SIBO-specific diet, and there's a biphasic diet. But you put them on a diet for a year and a half. There is absolutely no research for that whatsoever. I'll just say that. I did a huge write-up for you all, for Today's Practitioner on the pervasive misunderstanding of the FODMAP diet, very well researched, if I do say so myself, I worked a lot on that.

Rob Lutz 33:53
It was a very impressive piece. I mean, I read through it again today before our talk. You pick apart these studies, and what's wrong with these studies? So you can't take their conclusions, because they were flawed in many cases.

Angela Pifer 34:06
Correct. Thank you. You can put someone on an elemental diet, you can put someone on herbal antibiotics, or you can put them on antibiotics. And after they go through whatever you're going to put them on of those four, if they feel better, then you keep them on the diet, which is a band-aid approach, and you add a prokinetic. That's the algorithm. If they relapse or if they don't feel better after treatment, you retest and you retreat. So I don't understand why we're going off of symptoms to assess if someone is better or worse. We're supposed to go off of testing. There was a study done in 2016 by Rezaie, Pimentel, and Dr. Rao. The study was called "How to test and treat SIBO: an evidence based approach", and I'll quote here because I think this is great: "Symptomatic response to antibiotics has been proposed as a clinical tool for the diagnosis of SIBO. However, given the nonspecific nature of symptoms, the inability to predict which antibiotic may be effective against which constellation of symptoms or organisms, the potential for misuse of antibiotics and the development of drug resistance, and the recent increase in the incidence of C Diff, empiric treatment with antibiotics may pose unjustified risk to the patients." So this is standard of care; we're supposed to test first and then give an antibiotic. I love that they said it and yet I see a lot of patients that come out of Cedars Sinai working with the group over there and Pimentel and Rezaie, and five rounds of antibiotics, seven rounds of antibiotics, I had one person that was put through 12 rounds of antibiotics. 12. So I kind of I kind of do this: All right, maybe I can forgive the first round, maybe the second. We do have some studies showing Rifaximin, if you do it a second time, which is one of the antibiotics for SIBO, you can get better clearance with normalization of the breath test. It still has a pretty high percentage for recurring. So maybe one or two. But three, four, five? And it's the most ridiculous approach to me.

Rob Lutz 34:08
You did a great job on that. It sounds irresponsible.

Angela Pifer 35:34
To me, it's very irresponsible. And I think, too, with all the antibiotic use, we rely on the bacteria to help us break down fiber. Collectively, we make amylase, maltase, lactase, lipase, sucrase, and proteases. The bacteria collectively produce 50,000 to 70,000 different digestive enzymes. And we're just knocking down the variety, knocking them down, knocking them down, knocking them down, and then people get more and more stuck on the diet because they're altering fibers, they're knocking down fibers in the diet, and then they're having a hard time after all that treatment expanding their diet. Well, you're not relying as much on the bacteria to help you with your food digestion.

Rob Lutz 37:04
And that's because you're narrowing the diet and what you're feeding the gut?

Angela Pifer 37:11
Correct.

Rob Lutz 37:12
So just curious about that real quickly: Is there anything that you feel like your patients should be eating, just in general? If you're like: "This person, I think they have SIBO." Based on your diagnosis, are there things they should eat to feed the good bacteria or help the cause?

Angela Pifer 37:29
The idea that we can feed the good bacteria or starve the bad bacteria, I don't think is really founded anywhere at all. Obviously, I want people to eat whole foods, I want people to eat a variety. Most people are going to need to alter their diet in some way because there are big triggers coming in. I'd say for SIBO, it's usually onions and garlic or the fructans in the groups. Those are usually the main offenders. Lactose, I think people usually know that they have a reaction to that. So usually, we're just kind of adjusting things. I don't want people to have to deal with symptoms of 6 or 7 out of 10 while we're trying to treat. So, there might be some alteration there just to settle things down a little bit so it's manageable while we're working through treatment and root cause and everything. But the more the better. The more the better. Oftentimes, people are handed this handout that says: You've got to go on this diet. And it's a long laundry list like a FODMAP diet, a long laundry list of what could cause osmotic shift in people who have IBS. That's what it was used for. And people are taking it at face value of: These foods trigger SIBO; I must pull these foods. And then they're just they're pulling everything and it should never be used that way. It just should not be used that way. Alright, so the second algorithm was the conventional algorithm. So again, SIBO is tested. If they find methane, the recommendations are broad spectrum antibiotics. If they find hydrogen, it's broad spectrum antibiotics. And for the hydrogen, if it's hydrogen alone, the recommendation for the broad spectrum antibiotics are amoxicillin, rifaximin, or cipro. And cipro just pisses me off.

Rob Lutz 39:20
Yeah, that's terrible.

Angela Pifer 39:21
It is such a bad antibiotic. It has so many side effects. It ruptures tendons, it has a blackbox warning, and we're gonna use it for hydrogen production in the small intestine that is an overgrowth and not an infection? I had a patient I onboarded last month, and she was just newly diagnosed with SIBO. I'd say her symptoms are probably just collectively a 2-3 out of 10. Cipro out of the gate, out of the gate. I don't understand that. So, I think the part of this again, we've got this algorithm, it's being presented in studies as how we treat this, it's being presented by Pimentel's group who I have great respect for, and all the studies that they've done and what they've added to the field, great respect for insights that they're seeing. But this is what's being offered; it's just so antibiotic-heavy. So, doctors are happy to pick up: Okay, here's the plan, here's the algorithm, this is how we're treating. And so if they get a clinical response, they're supposed to add strategies to help with keeping people in remission, basically. They're not mentioning cure here, just remission. And then if they get a recurrence, it's kind of a rinse and repeat with treatment. Alongside the chart in the paper--and I'll link all the studies over, I'll get you copies of all those--but alongside the chart printed vertically is, "Consider elimination or modification of the underlying cause of SIBO." "Consider." "Consider." But that's kind of just there, it looks like a nice border thing. For the most part, most of it is just antibiotics. And in that same paper, I'll quote one sentence here. They say: "SIBO is a relapsing disease, especially when there are predisposing factors." There are always predisposing factors. Always, always, always. So, that does just doesn't make sense to me. I almost feel like if somebody walks in and says: "I feel like I have SIBO," and the doctor gives them rifaximin, and they walk away and they're cured I don't really think they had SIBO. SIBO is not a topical condition. There are a lot of factors leading to it and setting it up. And that just doesn't make too much sense.

Rob Lutz 41:45
The antibiotics aren't going to fix that root cause that you talked about earlier on.

Angela Pifer 41:49
They're not. So, going back to kind of the stool testing vs. what we see in the small intestine, so rifaximin is used a lot. They say it's completely safe. It's a non absorbing antibiotic, so it doesn't go systemic. It's active in the small intestine because bile is present. 98% gets reabsorbed...bile gets reabsorbed before the large intestine, so it's only acting on the small intestine, but they're claiming that it's safe because they've only looked at stool tests for it. Right? We're not seeing negative effects in the large intestine, and sometimes we even see bifidobacterium go up. We've never seen a study with the REIMAGINE group with rifaximin and the effects on the small intestine. We just haven't. And it'll be interesting because Dr. Pimentel is on the board with Salix, which makes rifaximin. So it would be interesting if they ever would do a study like that or if they wouldn't. I think it's interesting that I've not seen--because I kind of watch their studies--and I've not seen it done in a study. I'd love anyone to correct me if they know this has been done. I haven't seen it done in a study and I haven't seen a study proposal for that published. So it's just interesting. It's just interesting.

Rob Lutz 43:07
So, we talked a little bit about root cause of SIBO. Is there anything else you want to say about that?

Angela Pifer 43:14
I think I think that was covered enough. I just think, again, post-infectious IBS, you can test. Vibrant Labs, there's the candida and IBS profile, and that will look for antibodies to the CDTB toxin, and then also vinculin, and then IBSSure, and the IBS Check Test. All of those will look for root cause for that, and then parasite would be Parawellness Research. That's really the best one.

Rob Lutz 43:39
Okay. And then you've talked a little bit: Does diet help SIBO? Anything else you want to mention about that?

Angela Pifer 43:45
So the diet doesn't help SIBO in the way that it's going to starve any organisms. It causes a lot of fear and isolation. It causes disordered eating patterns. It creates so much fear around food. When you have chronic GI symptoms, and even identified as having SIBO, every hiccup is the fear of SIBO getting worse in your system.

Rob Lutz 44:11
Anxiety, and that's not helping either.

Angela Pifer 44:13
Correct. And so, people are being told they can control this with food, then they start to feel like they're eating something that's wrong that's causing this. We do not need to set up fear around food, ever, for a human being. We need healthy food, we need a variety coming in. We need a good relationship with food always, because the more stressed out they are around eating, the worse everything is going to be. It's going to be hard to get in front of it.

Rob Lutz 44:42
So, how do you talk to your patient about that kind of thing? Your patients come in, they're presenting, you're trying to get to the root cause, and you're doing that stuff. How are you--probably using your psychology background--I think so many patients probably need that support and guidance in that area. So tell me how you would approach that with a patient.

Angela Pifer 45:01
Yeah, they really do. For the most part, again, I get people that have been on the gravy train with SIBO for quite some time, usually years. And so most of them have been on one of the restricted diets for a very long time, and I just let them know out of the gate, we are going to work to expand your diet. You do not need to be on this; you should have never been put on it. It's not helping to treat SIBO. And there's usually a collective sigh of: "Oh, thank God," because they always feel like they're starting up with somebody new, we're going to restrict everything again.

Rob Lutz 45:33
"What else am I not going to be able to eat now?"

Angela Pifer 45:34
Yeah, exactly. So, I spend my days expanding people's diets nonstop.

Rob Lutz 45:41
And then you talk to them about stress relief, or how to deal with their anxiety? I mean, you give them some lifestyle changes or recommendation?

Angela Pifer 45:49
Yeah, I do. I treat top-down, so I'm always looking at stress and what that's doing to the system, what's driving it. We do see that there are specific traits for people who get post-infectious IBS and also go on to develop SIBO, and anxiety is a trait that's very common with that group. So kind of a chicken-and-the-egg thing. Don't know: Have they been anxious throughout their life for other reasons? And now this kind of setup, them being more at risk for getting that food poisoning event. It's kind of funny, my husband and I went out on a date years ago, and we went to a new restaurant that had the tiniest little bar. We just had one plate that we both ate off of, and I got deathly sick and he did not. It was the same food! How did I get sick and not him? But certain traits will set that up for people, not having good robust bacteria in your intestinal tract, and a healthy balanced immune system, and just good immune endurance overall, you're going to be more susceptible. Having low stomach acid, you're going to be more susceptible. Having anxiety and keeping someone in that sympathetic dominance is. Unfortunately, we don't have a middle ground; it's an on/off switch. Rest and digest, sympathetic dominance. I think we all know that. But when you're in rest and digest, you have 50% blood flow going to your digestive tract and organs. And when you're in stress state you have 5%. It's 5%. It is a choking off of fluid coming into those areas, chemicals coming into those areas that help us digest the whole way down.

Rob Lutz 47:32
So, do you recommend that patients get exercise, try to meditate, stress relief? Vagus nerve stimulation is something I'm hearing a lot about now that I wonder how that might impact this?

Angela Pifer 47:43
Yeah, some people definitely might need that. Again, I like to treat top-down, correcting oral microbiome, looking at stomach acid issues, gastric emptying issues, and just kind of going down.

Rob Lutz 47:57
To just get the whole system firing on all cylinders and really working properly.

Angela Pifer 48:00
Correct. To fix the gut, we need to get them out of sympathetic dominance and we have to support and open up all the digestive pathways. People chewing until the food is liquid, people taking stomach support if they need it, digestive enzymes if they need it, making sure that we can have good bile and bioflow coming through. We have to correct all of those to start rebalancing everything, to me.

Rob Lutz 48:24
It's the whole system that you work on. And I think that's really interesting. You spend a lot of time with your patients. You're not looking for one thing to fix this complicated issue. And you're really probably helping them bring their whole system back into proper functioning, which is going to help everything.

Angela Pifer 48:44
Correct.

Rob Lutz 48:45
Anything else that you feel like you want to share with the group here?

Angela Pifer 48:51
One other thing on Rifaximin if we can look at a study real quick?

Rob Lutz 48:54
Sure. Absolutely.

Angela Pifer 48:56
So this study is titled, "Small Intestinal Bacterial Overgrowth and Irritable Bowel Syndrome - An Update" and it's by Takakura and Pimentel. I like Pimentel very much; I love his studies. So, he's great. They looked at a metaanalysis, and the normalization of breath test in response to antibiotics. So, 8 of 10 studies used rifaximin. What they found was that 49.5% of people had normalization of breath test using rifaximin. So, more than half the time they didn't, at least for the first round, so I think that's important to point out. I will say if you go and listen, if you go to conferences and listen to Rezaie or Pimentel, oftentimes--there's one other gentleman I'm thinking of, I can't remember his name--but oftentimes they're claiming it's 80+% effective and that's because they give people a second round. When the study design is one round, what happens is they're like: "Oh, we'll just give them a second round. Look...it's 80+%." You just have to look at that first round of the study design as it was laid out. We do see rifaximin improving symptoms, but transiently, maybe for just weeks or months, that's from the study. But I think what's interesting is that 10% of people who were placed on placebo, for the studies that did that, had a normalization of breath test. 10% I love the power of placebo. I just love it. Rifaximin was compared to placebo in three of the studies; it had a favorable response, but it was not statistically significant. That was fun. And again, they just continue to state--I feel like it's rifaximin, this is standard of care, safe and effective. But they've only tested it through stool. So I'm very interested to see what it actually does in the small intestine, in terms of the bacteria and all.

Rob Lutz 50:46
And how would we find that out?

Angela Pifer 50:48
Through REIMAGINE study. They're the only ones that can really look concisely at the makeup of the microbes in the small intestine.

Rob Lutz 50:59
Makes sense. All right. Well, I think we've covered a lot. And is there a pearl, something you really want to make sure that if there's one thing the listeners walk away with, is there one thing to just kind of summarize, a real pearl for them to walk away with?

Angela Pifer 51:17
SIBO is a starting point for the investigation, not the endpoint for treatment.

Rob Lutz 51:23
Love it. That's great. Well, thank you so much for coming on the show. This was really fantastic. I knew it would be. You went through a lot of studies, I'd love to be having your write-ups on those studies. I'd love to share those with the audience as well. In the show notes, we'll have all the links and different resources that you mentioned in there for them to go a little bit deeper. Your contact information will be in there as well. And, again, thank you so much.

Angela Pifer 51:52
Absolutely. It's a pleasure, Rob.

Rob Lutz 51:56
Thanks for listening to the OneMedicine Podcast. I hope you found today's episode interesting and came away with a few insights you can apply to your practice. If you're looking for the show notes, they can be found in the link below. If you want to go deeper on this topic or anything else, please visit TodaysPractitioner.com and consider registering for our weekly newsletter as well. Thanks again. And I hope you'll join us next time.