Episode 4: How is SIBO different from IBS?
Phoebe Lapine is the author of “The Wellness Project” and the woman behind the popular blog, Feed Me Phoebe. Having been diagnosed with Hashimoto’s in her early 20s, she’s spent the last half decade trying to reconcile her love for hedonistic foods with her new, healthier lifestyle.
Still, despite all she knows about gut health and diet, she recently found herself staring down a SIBO (small intestine bacterial overgrowth) diagnosis that threw her for a loop. When she came up mostly empty-handed in her search for reliable information on SIBO, she took matters into her own hands, launched a blog series detailing the whats, whens, and hows of her treatment, and even started a SIBO-centered podcast.
On today’s show, she walks Andrea through how she discovered she had SIBO and how others who suspect an issue can find out for sure. She also discusses the most common risk factors for SIBO (food poisoning, we’re looking at you!) and some different remedies on how to control it if you’ve got it.
Andrea Wien: Welcome to the Microbiome Report powered by BIOHM Health. I'm Andrea Wien and on today's episode, we're talking about SIBO, what it is, why it happens, and most importantly, how to get rid of it? SIBO stands for small intestine bacterial overgrowth. While there's still plenty we don't know about it, we do know that SIBO is caused by bacteria that's in the wrong place. Most of the bacteria and fungi in our guts actually lives in our large intestine. It's kept in place by our ileocecal valve that connects our small intestine to our colon. This valve is critical for keeping bacteria where they're meant to be, but sometimes it can get stuck open, allowing those critters to migrate back into the small intestine. My guest today knows this struggle all too well. Her name is Phoebe Lapine and she's the author of The Wellness Project and the woman behind the popular blog, Feed Me Phoebe.
Last year, Phoebe was diagnosed with SIBO. She detailed her journey to recovery in a three-part series on her blog and is now launching her own SIBO-centered podcast to help others with this difficult-to-treat diagnosis. On this show, we talk about how she discovered her SIBO, common risk factors and the tools she used to heal. One more thing before we get started; make sure to stick around after the show for a special offer only for podcast members. Now let's get to it.
Phoebe. Thank you so much for coming on the show. How's it going?
Phoebe Lapine: It's going so well. Thanks for having me.
Andrea Wien: SIBO. It's this big topic suddenly that is everywhere and a lot of people have no idea what it is. Let's just start with what is SIBO.
Phoebe Lapine: SIBO is an acronym that stands for small intestine bacterial overgrowth. It's kind of this tricky disorder condition because it presents as IBS symptoms. A lot of doctors who treat many SIBO patients and do a lot of research that's SIBO-related actually think that something like 60% of all IBS cases are actually SIBO. What happens is I feel like we've learned a lot over the last five plus years about the microbiome and gut health. It's certainly something that's very much top of the conversation in the wellness world, but small intestine bacterial overgrowth is not an issue of bad versus good bacteria.
It's when your good bacteria or whatever type of bacteria are simply in the wrong place. That's something that I didn't really know before I started really digging into this topic and having to deal with it personally is that our small intestine doesn't actually have very much bacteria in it naturally because it's where we absorb our nutrients.
When they're there, they compete for our food resources and don't really have so much of a function and because they're eating your dinner, they can have a whole host of adverse reactions, cause a whole host of adverse reactions. One big one and it's pretty much the most obvious symptom of SIBO is intense bloating because when they eat your food, they release gases. Those gases being in this intermediary area of your alimentary canal have nowhere to go. They can't be easily pushed out through the bottom. Oftentimes you'll burp them up, but really that distension, pregnancy style bloat is a signature trait of SIBO.
Andrea Wien: Such a sexy thing to talk about, bacteria in the wrong places-
Phoebe Lapine: I know.
Andrea Wien:...and crazy bloating. I love it. IBS for so long has just been this catch-all of like, "We don't really know what's going on. We don't quite know what's wrong with you, so we'll call it IBS."
Phoebe Lapine: Exactly.
Andrea Wien: I think it's very exciting that 60% of those cases could potentially be something that we could give a name to.
Phoebe Lapine: Exactly. Even though it's not the best news ever for a lot of people who, and especially a lot of women... IBS diagnosis, those are 75% women, similar demographics, gender breakdown for SIBO. So many women just get bounced around between different doctors, gastroenterologists, functional medicine doctors, what have you. Hopefully a functional medicine doctor will be the one to dig a little deeper and maybe do some extra testing and get to the root cause. But for a lot of people, any answer is good news. Then of course they get to the phase of actually treating SIBO and once they learn all the different steps and various complicated solutions.
Andrea Wien: Yeah, it's definitely one of the more difficult things I think to eradicate, which we'll get to in a minute. But you brought up that women are more susceptible or more likely to be diagnosed with SIBO. Is it also common in other types of populations? Maybe I've heard in the past people who've had food poisoning or maybe have certain autoimmune diseases.
Phoebe Lapine: For sure. You hit the nail on the head. Yes, there's a lot of comorbidity. Risk factors overlap between the auto-immune community. Certainly the digestive-related auto-immune diseases like Crohn's and colitis, but also celiac, I guess that's a digestive-related one as well. Celiac, there's a really high degree of correlation and then hypothyroidism and Hashimoto's, there's another high degree of correlation. This is something that I've been dealing with for the last 10 years and wasn't something that my doctor told me when he diagnosed with SIBO, but since I've, again, done a deep dive on it and started interviewing some of the bigwigs of the SIBO world in terms of research and their medical practices, I've learned how the complicated dance circles back to hypothyroidism. It's interesting in general with autoimmune diseases, it's a chicken or the egg because SIBO can cause leaky gut; leaky gut can cause autoimmune diseases.
And then again, having a risk factor for these autoimmune diseases, some of them not entirely sure of the exact relationship, but can cause SIBO in its way and specifically for thyroid, people with low stomach acid, that is a major root cause. When you're hypothyroid, you tend to not produce a lot of stomach acid. You are usually lacking in some of the minerals and vitamins that are necessary to produce it. There's a lot of pieces of the puzzle that are interrelated and it's been super-interesting to learn more. I don't have to completely eek out here.
Andrea Wien: No, I like it. I like it. I think you brought up such an interesting point is about low stomach acid. It's not just people who have thyroid issues that have low stomach acid. It's really across the board. In fact, 90% of people are walking around thinking they may have too much stomach acid and maybe they're taking PPIs and doing all these things to suppress their acid when actually it's too low. I think we're starting to see a shift in how people are thinking and yet conventional doctors are still prescribing antacids like they're candy. I think is that why we're starting to see maybe more higher rates of SIBO and IBS and some of these other conditions because we're degrading our digestive systems by suppressing them?
Phoebe Lapine: Totally. This has been something that has been a pet peeve of mine since I wrote my book, The Wellness Project and went on this year-long health trial-and-error journey in which I tried on a lot of different practices on [inaudible 00:07:58] to heal my Hashimoto's pre-SIBO. But I did a whole month dedicated to gut health. Again, didn't really know anything about SIBO at the time, but a lot of people talk about low stomach acid as a reason why our microbiomes in general, our good gut bacteria in our large intestine is slightly off and can potentially lead to various invasions. Because if you think about it, that stomach acid is the first leg of the labyrinth. The majority of our germs are coming in through our nose and mouth and they have to make it past your stomach acid in order to survive.
When you're depleting that essential well to neutralize the bad guys, then they can more easily make it down into your system. There's many other factors that degrade the existing troops of good bacteria that are fighting those battles for you. It's just like a slippery slope there. Specifically for SIBO, there are multiple factors in play again. But if you think about it, of course, if the bacteria is not getting killed during that leg and makes it to your small intestine and then usually a layering factor is that you have slow motility, meaning the street sweeper of your intestines, that's supposed to be moving food through your system is slightly slower. By the way, that's another factor associated with Hashimoto's is slow motility and anyone who is hypothyroid, Hashimoto's and is quite constipated or has that as a main symptom probably knows what I'm talking about there. Once I learned that connection, I was like, "Oh yeah, makes sense."
Andrea Wien: "Yeah, I had that. I'm not taking the trash out every day. Got it."
Phoebe Lapine: Exactly. Yeah. Again, it's like compounding factors, but I'm really glad you brought up the low stomach acid. And then another interesting thing is a symptom that's associated with IBS and SIBO and one more of this medication that's prescribed is reflex. That's actually often time caused by too little stomach acid and so your body unable to get the signal to shut the front door and therefore is leaking into your esophagus because your body doesn't realize that it's time to digest.
Andrea Wien: Absolutely. I think our lives where we're running around and eating a granola bar in the car before we pick up the kids from school and stuck in subway traffic and whatever else we might be dealing with, people don't realize rest and digest is called that for a reason. We can't actually digest, create the good stomach acid that we need unless we're in a parasympathetic, relaxed state. There's a whole another topic on that, but I'm curious. Do you think that you were walking around with SIBO this whole time throughout your experiences and writing The Wellness Project and it just kind of cropped up or is it something that you feel like came after the fact?
Phoebe Lapine: It was after the fact, for sure. I was feeling really good for a year and I was feeling progressively better over the course of my "year-long project." It was all incremental, low and slow, but spoiler alert, at one point, I found out I had a parasite, eradicated that, brought me up to a whole another plateau. Going on that intense medication did make me more prone to food poisoning and such. Sorry. Oh! I guess that was one that we didn't cover from your question before. But food poisoning, I can't remember the statistic, but people think that it's a huge contributing factor to SIBO because perpetuated by low stomach acid, when something pathogenic makes its way into your system, it releases its own toxins. What happens is you get nerve damage that causes the migrating motor complex, that street sweeper to not function as well.
Eventually, I'd say it was probably like the year my book came out that I don't know, just some of those digestive symptoms, IBS-C symptoms started to crop back up and it wasn't major, major. I think it got a little bit, again, progressively worse as I went, but there were so many other factors. My book was coming out. I was super-stressed out about that. I was traveling like a maniac. It was just so easy to chalk it up to constantly changing environments and not having my mental game completely under control. So it took me a while. I'd say for most of that year, I was feeling a little off and then once my book tour calmed down in the fall, I was like, "Oh, I guess it's actually been a while since I've had a full workup at a functional medicine doctor."
I decided to go see someone new and he did a bunch of tests. But SIBO is one of the first ones that he pointed me towards. For those who don't know, it's a breath test. You do it at home two to three hours, take a sample of your breath every 15 minutes or so. What begins the process is you drink a sugar solution and your bacteria's favorite food are carbohydrates, so it very much exacerbates your symptoms and again, gets them eating and off-gassing and then you're testing for those gases in the breath test. It's interesting, I talked to another doctor recently who had the same experience. But I'd say after the tests, it wasn't just the psychological blow of getting the diagnosis, but actually feeding the bugs in that way, taking the test definitely exacerbated my symptoms.
Andrea Wien: It's very much like when people have to take a gluten challenge, maybe they've cut gluten out of their lives and their doctor wants them to go back on it for six weeks and the symptoms are so much worse than when they were just eating gluten regularly. So it's a similar, similar thing.
Phoebe Lapine: Totally.
Andrea Wien: Let's say that you find out you have SIBO, is it easy to get rid of? What are some of the options to kick it?
Phoebe Lapine: Yeah, unfortunately it's a chronic condition mainly because some of those root causes that we talked about, the motility, sometimes you have a structural issue. One of the populations we didn't talk about is women with endometriosis, especially those who have gotten repeat surgeries, that scar tissue can really limit just your movement down there in that part of the body, prevent your intestines from doing their job.
There's an interesting prong of the treatment of doing body work to kind of work on some of those structural issues, but essentially it becomes chronic when you haven't dealt with that root cause. The bummer part is that not all the root causes can always be completely eradicated. But the treatment types, you can either take a conventional antibiotic and there's actually some good options for SIBO that don't affect the large intestine, so don't blow out all your gut bacteria and the way that we think of antibiotics and the way that we think of the antiparasitics that I took, that screwed me up.
It's not a bad option and it's one that holistic doctors and functional medicine doctors also prescribe. It's one thing in the toolbox and it's pretty effective for SIBO and targeted. And then there are these herbal antimicrobials, which either come... there are a few different star herbs that practitioners will turn to and then there are a few companies that make these compounds herbs that are a bunch of different things in one pill. There've been tests on one particular type of these and they've been proven to be just as effective as the regular antibiotics.
If you're someone that feels strongly one way or the other, going the natural route, there are certainly drawbacks either way and depends on what your system can ultimately tolerate. But that's just another great option and then I think it's a little bit harder when you're going your own way.
But if you have a practitioner who's a little bit more savvy on the diagnosis and wants to try you on just one or two singular herbs at a time, oil of oregano is a big one, neem is a big one, then depending on what type... this is another complicating factor. Your treatment plan depends on what type of SIBO you have and the different types are hydrogen-dominance, methane dominance and then there's a new type called hydrogen sulfide that we don't really know as much about, but those different types of gas that are being produced respond to different types of therapies better.
Methane is historically more difficult to treat, it's a little bit trickier; extracts that is particularly effective with methane is allicin. It comes from garlic. That's a very interesting thing because then there's this whole prong of the treatment that's diet-related. One of the main diets that people recommend is a low FODMAP diet. The number one thing in a low FODMAP diet that you'll eliminate is garlic, many contradictions in the world of SIBO treatment, which is yet another thing that makes it quite complicated to wrap your head around.
Andrea Wien: It seems like, that's part of what's so frustrating about it is that you could do something that works very well for someone else and it doesn't work for you.
Phoebe Lapine: Totally. It can be very frustrating, but there's a bright side to that. There are a lot of options. Especially for something that is chronic, I think most practitioners will rotate through methods so that you don't build up resistance to anyone. The nice thing is, again, there's a lot of things in the toolkit.
Andrea Wien: You mentioned it a little bit in terms of diet, you touched on it a little bit with manual therapies. But once you get rid of it and you're free and clear for all intents and purposes for a moment, what can you really do to mitigate the risk of reoccurrence?
Phoebe Lapine: Yeah. One big one is to take a prokinetic, which basically just addresses the motility issue. There are a few prescription drugs that are good for that. I'm personally on something called low-dose naltrexone which... it's interesting. It's like, I don't want to say like a huge blanket statement, but I'm like, "Ah, maybe if I'd been on this preemptively, just as someone who is prone to constipation with Hashimoto's, that might have helped me. There's no real risk to being on that long term. It was actually funny. I was just in... My acupuncturist is like a big mentor for me. I was just in to see her and she was like, "Hey, do you know about this low-dose naltrexone stuff? I think it could be a really good idea for you." I'm like, "Yup. Already on it."
Andrea Wien: "Where were you a few years ago?"
Phoebe Lapine: Yeah, I don't know. I think it's something that I only learned about because of SIBO, but just personally wondering if it's something that more doctors should be talking about with their Hashimoto's patients. Because it's also... it's said to be slightly antiinflammatory. There's a bunch of good stuff going on there. Then there's natural prokinetics and some other supplements that get the job done in a similar way. I have a whole list on my site. There's a post on SIBO, natural treatments and otherwise and I have a list of prokinetic options and then yeah, an interesting part is people will talk a lot about diet, but it's just as much how you're eating as what you're eating specifically with SIBO, for sure because it's about your ability to digest your food, chewing food super-thoroughly, giving yourself, as you mentioned, time to digest. Your migrating motor complex only kicks in, in a fasting state of 90 minutes or more.
There's a ton of conflicting information I find with my readers about whether or not you should be eating like three big meals a day versus lots of smaller meals or snacking. This alone would be my argument for not snap hacking. I think people who sit at their desk, even if it's the healthiest option, with a bag of almonds and eats one every 10 minutes, you're never getting that time to let the street sweeper do its job. There's lifestyle things to look at there too. I have a list of those as well, but I think it's an essential part of retraining yourself during treatment and then the same rules apply for afterwards and prevention.
Andrea Wien: Sure. For someone who might not know what prokinetic means, can you just explain that?
Phoebe Lapine: To be honest, I'm not a practitioner, so I don't know the official definition, but it's just something that improves motility, it improves the ability... the natural... the system in your intestines that moves food through. Fat that's considered by some people a natural prokinetic, lubes up the system in its way. Yeah, I don't know if like people would consider them officially prokinetics, but like one of my tactics, things I use when I'm really backed up is like a tea called Smooth Move. I find it very effective. That's my own little prokinetic right there.
Andrea Wien: Perfect. Great. You have an interesting podcast coming out all about this topic. Can you tell us a little bit about that in case people want to hear even more?
Phoebe Lapine: For sure. It's called SIBO Made Simple. As you've probably gleaned from this conversation, SIBO is anything but simple, but it's my goal to give the newly diagnosed and really patients who are laymen the A-to-Z guide to healing. I've been interviewing a ton of experts on everything from the diet piece to root causes. I have a whole episode dedicated to thyroid and the women's health connection and the hormone connection and then yeah, in terms of other subsets of diet, how to go about choosing one, because there are several different approaches and then re-introducing items, which is a big stumbling block for people when it comes to prevention because people will get really freaked out that it's their diet that was causing the SIBO in the first place, whereas really it's just the diet that can spark symptoms because it's again, when you're a bacteria [inaudible 00:23:14] reintroduced to carbohydrates.
Even if there's still some lingering or perhaps it's just your body, readjusting after a period of a really restrictive diet, there's going to be like a little bit of discomfort. Yeah, I'm really excited about it. If you want to nerd out on SIBO and dig a little bit deeper, I hope that you'll come and give it a listen.
Andrea Wien: How can people find it?
Phoebe Lapine: They can go to iTunes, it'll be available on iTunes and wherever podcasts are broadcast in the new year. So in early 2019, fingers crossed.
Andrea Wien: Fantastic. We will update our show notes for sure once you have all the links and the information for people to come find you. Phoebe, thank you so much. We're so happy that you were on the show to talk about this. It's such an important topic that's not getting a lot of airtime. Really appreciate it and we hope to have you back soon.
Phoebe Lapine: Thanks for having me.
Andrea Wien: Thanks so much for listening to the show. To read more about Phoebe and to check out the show notes, visit the BIOHM blog at biohmhealth.com/blogs/podcast. We're also excited to announce that podcast listeners are eligible for 10% off any BIOHM purchase. Simply use BIOHM 10, B-I-O-H-M 10 at checkout to save. See you next time.
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