(VIDEO) Advanced Gut Health - IBS, SIBO, Candida, Dysbiosis
IBS (Irritable Bowel Syndrome) is a very common condition plaguing many Americans which may alternatively include bouts of constipation, diarrhea or cramping. What many do not know is that the CAUSE of this condition may be SIBO (Small Intestinal Bacterial Overgrowth). When SIBO is present you don't want to "miss it" otherwise most of your efforts to resolve your IBS symptoms will be a waste of time, money and effort. It is relatively simple to test for SIBO but understanding how to interpret the test results and selecting the appropriate protocol can be more involved. Plus, the science and research into SIBO is constantly evolving as is our understanding of gut bacteria as a whole. During this class, Dr. Zachary will teach you the "what, why, & how" of SIBO from the basics to advanced treatment protocols. This will truly be a detailed and informative class that will get ALL of your questions answered about SIBO and gut health! Check out the video below!
below you'll find the outline and handouts referenced in the class
SIBO - Small Intestinal Bacterial Overgrowth CLASS OUTLINE
Slow Motility (hypochlorhydria, hypothyroidism, TBI)
Ileocecal valve disorder
Diverticulosis/Scar tissue bowel infiltration
Medications (Ab, PPI, immunosuppressant)
Diet high in sugar, carbs, alcohol
Upper GI disorders - (low HCL)
Essential nutrients (protein, carb, fats) do not get absorbed/assimilated (starving - nut def)
It hurts and seriously impacts your life
Small Bowel Aspiration/Culture
Breath Test - 3 hour
OAT, Cyrex Array 22 (indicative, not diagnostic)
If unable to test consider SIBO if meet these criteria:
Consistent bloating that worsens throughout the day
Test Low FODMAP/SCD and feel better
Feel worse when take Probiotics
⇒ TESTING NOTES
Breath Test Instructions
Breath Test Interpretation
Breath Test Examples
Treatment SIBO tx flow⇒ SIBO TX FLOWCHART
SIBO Treatment Protocol handout (Pimental/Siebecker/Sandberg-Lewis)
Role of Diet⇒ DIET NOTES
Gut Health Diet (modified Siebecker SIBO low FODMAP/SCD with Dr. B clinical experience & notes for SIFO considerations)
Bi-Phasic Diet (Dr. Jacobi)
3 Treatment Options
Medical - Rifaximin - high cost, high recurrence (see best rec by Dr. Pimental in Tx Notes)
Herbal Anti-Microbials - low FODMAP diet, herbs (oregano oil, berberine, GSE, etc), longer
ProkineticsWhen to add/use probiotics or prebiotics
Concomitant conditions (SIFO, LIBO)
⇒ TREATMENT NOTES
List of possible Supplements
Prescription protocols & considerations
Elemental Diet Instructions
ED Food Reintroduction
The patient experience
Bloating, good then why bad?
LBP & other symptoms
getting rid of SIBO seems the big deal - but if handled well that’s the easier part - dealing with life after more important to not relapse, address food issues
The practitioner experience
addressing root cause
cost of treatment
troubleshooting problems plus LIBO, CDiff, IBD, Intestinal Hyperpermeability (“Leaky Gut”), etc
when to order OATs, GI-MAP, Dunwoody labs, Cyrex labs, MRT or other tests
Additional therapies that may help
Abdominal massage, alignment, movement, pelvic floor, weight normalization
Hormone balancing (thyroid & adrenal issues)
Lifestyle changes and practices
Global transformation to a life well-lived
Root Cause - Avoid Releapse
Why NOT Getting Better?
Didn’t treat long enough
Didn’t post-test to confirm gone
Didn’t identify root cause & resolve (including hormonal or structural issues, scar tissue, etc)
Didn’t use a variety of tx - some patients need 2 or all 3 or even multiple rounds
Didn’t vary herbal anti-microbials
Didn’t test for other infections
Didn’t take probiotics to benefit beneficial bacteria or didn’t do it at the right time or with the right strains
Didn’t resolve upper digestion issue (ex. hypochlorhydria) or continue digestive aids if needed
Didn’t address MMC
Didn’t want to address the impact of stress, decreased vagal tone
Didn’t want to continue a life so mindful of health, diet & self-care (“gave up”, too hard, food is entertainment, family pressure, budget pressure, etc)
Didn’t want to face reality if there were underlying causes that could NOT be resolved (ex. Primary immunodeficiency, scar tissue needing surgical removal, etc) and therefore permanent lifestyle changes needed to manage SIBO vs eradicate
Resolved SIBO but relapsed due to the return of poor habits (bingeing, etc)
SIBO - BREATH TEST INFORMATION
Genova 3-hr SIBO Breath Test Instructions & Helpful Tips Eight fasting breath samples, taken at Baseline, 20 minutes, 40 minutes, 60 minutes, 90 minutes, 120 minutes, 150 minutes & 180 minutes. This test is extremely time sensitive- important to follow instructions exactly as they are written.
Patients find the best day to complete this test is Sunday morning, an uninterrupted 3 hours is ideal.
8:00 am - 8: 00 pm Saturday- Specific diet 24 hours: Baked or broiled chicken, fish or turkey (salt and pepper only), plain steamed white rice, eggs, clear chicken or beef broth with no vegetable pieces, water, plain coffee or tea (no sugar/ artificial sweeteners or cream). Vegetarians may have tofu with salt and pepper. Do not take probiotics. Stop all nutrients.
8:00 pm-11: 00 am Sunday- FAST: Do not eat or drink anything other than water for 12 hours prior and during the test. Do not take non-essential medications or supplements until the test is completed. Do not chew gum, eat candy, or use mouthwash until the test is completed.1 hour before the test- No smoking, No sleeping or vigorous exercise, no toothpaste.
Use the Breath Collection Schedule Table on the front of the Requisition to help you schedule your collection times. Pre-write each label and have ready to affix to the tube as you collect. Write first/lame name, date of birth, gender and date of collection as well as the tube number (1-8 in order of collection).
Use a timer on your phone to alert you to the next collection time. Use the below sample time schedule as a guide.
7:00 am Wake 1 hour before the test. Brush your teeth and tongue (including the back of your tongue) without toothpaste or mouthwash. Rinse your mouth with water.==>Stir the Lactulose solution into 8 oz of water to dissolve completely. Set aside until after you have completed your first breath test. Set timer for 1 hour
8:00 am Baseline Sample 1 Instructions for Collection:
Pickup mouthpiece/plastic bag in one hand and Tube 1 in your other hand Breath normally, inhale and hold for 5 seconds. Then close your mouth tightly around the mouthpiece and exhale normally into the bag until it fills completely. Do not blow hard.
Continue to exhale normally, with the bag expanded, and press the specimen tube into the side part of the mouthpiece. The needle will puncture the tube’s self-sealing membrane, allowing air into the tube. Do not inhale at any point.
Remove the tube within 2 seconds of puncturing. Do not unscrew the cap of the collection tube.
Affix label to the tube. Record the time and date of collection on the tube label and Breath Collection Table located on the requisition.
Place tube in bubble wrap bag.Immediately drink the Lactulose solution before continuing with the rest of the test, finish within 5 minutes. DO NOT DRINK WATER for 1 hour after you drink the solution. Set timer for 20 minutes
8:20 am Sample 2 Continue instructions (Steps 1-5) for collection, affixing each label as you go. Set timer for 20 minutes
8:40 am Sample 3 Continue instructions (Steps 1-5) for collection, affixing each label as you go. Set timer for 20 minutes
9:00 am Sample 4 Continue instructions (Steps 1-5) for collection, affixing each label as you go. Set timer for 30 minutes
9:30 am Sample 5 Continue instructions (Steps 1-5) for collection, affixing each label as you go. Set timer for 30 minutes
10:00 am Sample 6 Continue instructions (Steps 1-5) for collection, affixing each label as you go. Set timer for 30 minutes
10:30 am Sample 7 Continue instructions (Steps 1-5) for collection, affixing each label as you go. Set timer for 30 minutes
11:00 am Sample 8 Continue instructions (Steps 1-5) for collection, affixing each label as you go.
Ensure test requisition form is complete and the date of collection is recorded.Specimen(s) do not need to be refrigerated. Be sure to return the specimen within the original package and place that inside the included mailing materials. Schedule a pickup from FedEx or drop at the nearest FedEx first thing Monday morning.
SIBO - TREATMENT FLOW
per Siebecker/Sandberg-Lewis (modified from Pimentel)
SIBO - Diet (Dr. Z modified)
SIBO - Rx, Anti-Microbial & Elemental Diet Treatment Options
3 Tx Options - Supplement/Rx Details with SIBO with SIBO (& SIFO when noted)
Medical - Rx Rifaximin
Pros: may be covered by health insurance, may be “atomic bomb” and done (possibly 14 days and over?), stays mostly in the gut (not systemic), may be needed along with other treatment options
Cons: high reoccurrence rate (some estimates up to 85%, some reports “worse”), if not covered by ins can be $1,000 for a treatment and a severe case might need up to 4 rounds
Notes: According to Dr. Pimental Rifaximin effective for both H2 & H2S dominant SIBO. If CH4 dominant SIBO best to also ADD Neomycin (or Flagyl) with PHGG (partially hydrolyzed guar gum to feed bacteria - do NOT eat low FODMAP in this situation) and often need an anti-fungal at the same time. Many docs recommend Diflucan with can be a heavy hitter so may be better to use a supplemental anti-fungal in this situation.
Fungal notes: Some docs treat SIBO first, others SIFO first and some simultaneously. Must be considered on a case-by-case basis including the stamina and full clinical picture of the patient. Dr. B highly recommends testing to see the severity of any concomitant fungal overgrowth. (SIFO is typically longer/harder to resolve!)
low FODMAP diet, herbs (oregano oil, berberine, GSE, etc), longer A typical cycling treatment Dr. Zachary may use for 20 days (repeat 2-4x as needed)
Days 1-4 Gut Flora Complex 3/2x (Mediherb) Myrrh 4/2x (Mediherb)ADP 1-3/2x (Biotics)
Days 5-10 Gut Flora Complex 3/2x (Mediherb)ADP 1-3/2x (Biotics)
Days 10-20 Garlic Forte 1/2x (Mediherb) - low FODMAP Vitanox (Mediherb) 1/2x or Goldenseal 1/2x
Typically add a biofilm buster through all days
Interfase 1-4/day (Klaire Labs) - not the Plus version
Kirkman Biofilm Defense 1-3/day (Kirkman)
Often eating low FODMAP (see Gut Disorders Meal Plan handout) with digestive support as needed in form of betaine hcl (not with H2S SIBO), enzymes &/or fat metabolism support
Typically include a prokinetic
Motilpro 1-3/day (Pure Encapsulations)
Motility Activator (Integrative Therapeutics)
Rx options - LDN (low dose Naltrexone) - pain, Crohn’s, autoimmune, low motility
May need an antifungal, some options include:
Grapefruit Seed Extract (GSE) 10 drops in H20/3x for 10 days (Nutribiotic)
Advanced Candida Care (Horopito) 1-2/day (Kolorex)
Oil of Oregano (overlap with SIBO herbal treatment)
Undecylex 1-2/day (ProThera) - undecylenic acid
Probiotics for SIBO when appropriate (Dr. B typically use toward end)
MegaSporeBiotic 1-2/day (Microbiome Labs) - soil based probiotic
Terraflora 1-2/day (Environmedica) - soil based probiotic with prebiotic
Ideal Bowel Support - Lactobacillus Plantarum 299v 1-2/day (Jarrow) helpful with Candida
Lactic Acid Yeast (Standard Process) helpful with Candida
New Earth Superfoods Coconut Probiotic yogurt (some SIBO pts tolerate)
GI Microb-X (Designs for Health)
Echinachea Premium (Mediherb)
Cat’s Claw (Quicksilver Scientific or DFH)
Saccharomyces Boulardii (Ortho Molecular or DFH)
Heavy Metal/Parasite support if warranted
H2S SIBO (often sulfur gas, nausea, diarrhea, bladder pain) - treatment considerably different including diet (short term Vegan/low sulfur/high fiber - avoid dairy & high fat)
Herbal recommendations per Jacobi’s research efforts & Dr. B can verify they’ve been highly effective in clinical practice:
Berberine (use mostly for H2 producing SIFO) mixed results with H2S-WATCH FOR BERBERINE SULFATE
Artemisia - well tolerated, indicated
High dose Oregano oil (250 mg TID x 10 days, then 150 mg TID x20days)
Molybdenum (activates enzyme that breaks down sulfites)
CAREFUL with garlic, cholagogues and ox bile supplements (SRB love bile: SRB reduce sulfur into H2S)
Probiotic Considerations in H2S SIBO:
Lactobacillus Plantarum (Lp-8) - no access yet (research only) - showed positive benefits
Use Lactobacillus Plantarum 299v for now...it’s what’s available (great for IBS)
Post SIBO or SIFO tx repair for Intestinal Hyperpermeability “Leaky Gut” warranted.
GI Revive 7 capsules or 1 scoop (Designs for Health)
Colixen (Ecological Formulas)
SBI Protect Powder - IgG (Ortho Molecular Products)
Collagen (Designs for Health or OTC)
GALT Immune (Energetix)
Gotu Kola (Mediherb)
15 days ~ 80% effective
21 days ~ 85% effective
28 days ~ not shown more effective but some severe case may not report relief until last week
See ED notes, typically no other supplements during this time, occasionally an anti-fungal and rarely a prokinetic. May use herbal anti-microbials when coming off ED if needed. Patient must be closely monitored in Dr. B’s opinion (she requires email check-ins 2x weekly) and be aware of yeast flare and impact on LI flora
SIBO - Elemental Diet Instructions
STARTING THE PHYSICIANS ELEMENTAL DIET
Details: $130.00 & 36 servings/bag. 150 calories/serving. Sip each drink slowly (over 15-60 minutes). No limit to the number of drinks (“shakes”) you can have/ day, especially when you start. Typically, patients have between 4-7 drinks/day. Stay hydrated and drink water in between drinks. Okay to blend with ice to make a “slushie” drink or with warm water.
This is a 15-21 (sometimes 28) day reset. Dr. Zachary requires her patients check-in 2x/week with daily journal updates including the number of drinks/day, bowel movements, symptoms, feelings, activities, etc. - so stay in close contact with your doctor! Initial constipation- use MCT oil (1tsp- 1T). Normal to not have a bowel movement every day after the initial clearing of bowels.
Stress Management & Rest Very important to manage stress and allow yourself to rest and heal. Limit exercise during the next month.
Supportive/ Use as needed:
Epsom salt baths
Charcoal brushing (1-x/week)
Grapefruit Seed Extract (GSE) rinse (10 drops in water)
Castor Oil Belly Pack
See Sheet for reintroducing foods coming off the Elemental Diet, and refer to SIBO meal plan: tinyurl.com/badgut Genova SIBO Breath Test- Perform 10-14 days after reintroducing foods, confer with BLC staff and see specific instructions for completing.
Nutrient Tools: Do ED for 5-7 days first without any nutrient support. Check in with Dr. Zachary who will advise if anything additional is needed (such as an anti-fungal) Toward the end of ED or immediately following be prepared to possibly need the following:
Prokinetics Iberogast (Order on Amazon) - 10-15 drops 3x/day plus evening MotilPro - 3/day (1-1-1) - Start with 1 at night. It is normal to feel a "flushing"/ warming sensation from the ginger. Work up to having 3/ day in between meals.
Herbal Microbials (at end of ED tx or as an alternative to ED, rarely during ED tx)A.D.P - (Oil of Oregano tablet - Biotics) Start with 1 at night. Can add more (Max 6-8) but Dr. B would like you to try one and see how you feel. Let her know how you are doing on 1 before increasing higher.Gut Flora Complex - (Oil of Oregano enteric coated capsule - Mediherb) Start with 1 at night. Can add more (max 6) but Dr. Zachary would like you to try one and see how you feel. Let her know how you are doing on 1 before increasing higher Grapefruit Seed Extract (GSE) - (liquid drops - Nutribiotic) have on hand but only use if added by Dr. B (max 10 days)Garlic Forte - (tablets - Mediherb, not high FODMAP) - have on hand if CH4 + SIBO Gut Health/ Other Myrrh Forte Goldenseal (Berberine) Interfase (Biofilm buster)
SIBO - Reintroducing Foods After Being on the Elemental Diet
REINTRODUCING FOODS COMING OFF THE ELEMENTAL DIET BROTH
-Start with broth made from meat (Crock-pot, add water, add chicken breasts and thighs (no bones, no vegetables). Okay to add sea salt. (Might want to freeze some of the chicken for eating later in the next couple weeks.)
-An alternative is to buy short simmer broth (This is the best bone broth Dr.Brandy can find and specifically the short simmer beef bone marrow blend...definitely cheaper to make your own!)
Start with small amounts. Normal for body to re-adjust. May be some bloating and indigestion. Should go away in a couple of days.
Space meals 4 hours apart. Keep doing ED drinks to keep calories up.
COOKED VEGGIES After broth for 1 day (if feeling OK and tolerating broth OK), add in cooked and pureed vegetables (think baby food) Carrots, Zucchini. Can add in some chicken (cut up very small or puree in broth). Try each individually and then mix in all together in a soup. DIGESTIVE AIDS - once Protein added
Use Zypan (Standard Process) or Digest Forte (Mediherb - cut tablets in half for the smaller meals as protein is added back in)
Use MCT oil (very small amounts) ½- 1 t then build up to ½ T
Soft, easy and simple. Add sea salt to broth and soups as the only seasoning.
WHITE RICE, EGGS & EXPANDING DIET
Next, add in a little white rice. Try scrambled eggs. 3 - 7 days. Less and less ED as real food gets put in.
After about 7 days, see gut health disorders meal plan(tinyurl.com/badgut). Stay in the Highly Sensitive column. Slowly move across to next column once all foods from 1st column are tolerated.
Some patients move quickly through food introduction (3 days) and some take longer (2 weeks) so pace yourself & listen to your body.
All foods should be cooked (no raw) in the reintroduction initial weeks.
Continue using Iberogast and/or Motilpro as Dr. B has recommended.
SIBO BREATH RETEST
SIBO Breath Test 10-14 days after introducing foods.
If not feeling good after reintroducing foods, talk to Dr. B as she will advise on nutrients such as Gut Flora Complex, Goldenseal, ADP or other items.
If the test still positive consider repeating ED or utilizing another tx option such as anti-microbials or Rx
If test negative and you do not feel better, consider concomitant issues such as SIFO, LIBO, etc
If test negative and you do feel better, make sure cause of SIBO is addressed so as to not relapse (SIBO has a HIGH relapse rate) & continue using digestive aids, prokinetics as needed.
Body Love Cafe - Dr. Brandy Zachary, DC, ACN - 3093 Citrus Cir Ste. #125, Walnut Creek, CA 94598 - 925-788-6300 - Team@BodyLoveCafe.com(c)2019 Body Love Cafe by Dr. Brandy Zachary, DC. Statements not evaluated by FDA, not intended to diagnose, treat, cure or prevent any disease.
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