I have seen so many patients when they finally like to click into that practice that works for them. Oh, so much of that staff just lightened the load. Lightens. Right. Especially with, you know, anxiety around store urgency and just anxiety around bowel function in general. Bloating. Cramping. Unpredictable digestion. If you've been dealing with gut issues and you still don't have answers, you are not alone.
IBS or irritable bowel syndrome and SIBO are notoriously hard to diagnose. They leave so many women feeling frustrated, dismissed, gaslit, or stuck with Band-Aid solutions that don't actually work. In this episode, I'm sitting down with a gastroenterologist who actually gets it not just from a conventional medical perspective, but with a functional approach that actually helps patients get better. We're covering why IBS and SIBO are so tricky to pinpoint. How to really know if you have them, and most importantly, what you can do about it. If you've ever been told it's just stress or try more fiber, or worst of all, good luck, then you need to hear this episode. Doctor Steinberg spent four years at Parsley Health as a functional medicine physician and research advisor, and she's now based out of Brooklyn, New York, where she runs her own online private practice called Gut Instinct Health. She specializes in treating conditions such as SIBO, Crohn's disease, Gerd, mixed pots, autoimmune disease, hormonal imbalance like PCOS, and menopause. Let's dive in. I can't wait to explore this.
This is a lifelong relationship between you and your body, and it's a lifelong conversation. And you're going to keep going back and forth trying different things. And that's true about everything that you put into your body and that everything that you do with your body and it's, you know, it's your relationship with yourself and how you nourish yourself.
Dr. Steinberg, Sarah, thank you so much for coming on today. I think this is such an important topic and I cannot wait to dive in. So thank you for being here.
Thank you for having me. I'm thrilled to be here.
Sarah, you are a gastroenterologist. I'd love to start just by talking about your transition from the world of conventional medicine. And what brought about it. We'll just kind of cover this briefly is what brought about this transition to functional medicine.
Really great question. The seeds were planted a really long time ago before I went to medical school. I started practicing yoga, and that was really life saving. And I remember I had throughout medical school, I always, you know, a lot of people are like, well, what would be my fantasy career if I wasn't a doctor? And I was always go back to being a yoga teacher. So during medical school and really more during fellowship, I started to dig into the research on proton pump inhibitors, and I knew I was going into GI and I really started to dig into like, what are the downsides of proton pump inhibitors and what are the downsides of, you know, permanently blocking your ability to produce stomach acid?
And you're talking because people know these medications as a member of Nexium. Yeah. And that was really interesting to me. And because, you know, there's an impact on bone health, on kidney health. But from the God perspective, there's also quite a detrimental effect for your gut microbiome. And just the simple fact you covered this on your last podcast so beautifully, but the effect of blocking stomach acid on how we digest food is devastating.
Yeah. Quite honestly. It's a real problem when people stay on those medications long term, except for the situations like Barrett's esophagus or eosinophilic esophagitis, where you might have to. And the benefits outweigh the cons. But later, when I had my kids, that was when I started getting really interested in the gut microbiome. And, you know, that was around the time when people were just starting to do research about how the gut microbiome is passed from the mom to the baby and ways that we can try and fix that problem if there is a C-section.
So I was literally like, there wasn't a protocol out there yet. And when I had my first kid and I was like, if this ends up being a C-section, like, we're going to do swabs. And I began handing me the swab, she was like, go for it. Like, I'm not touching this with a ten foot or so.
I was that crazy lady. And yeah, as luck would have it, both my kids were C-sections. I tried to swab both of them, you know. Yeah, that happened. And one of them has no allergies. The other has allergies. But maybe they would be there. Maybe they're better off than they would have been if I hadn't stopped them.
So that was the beginning of my journey. And then after I had my kids, I took some time off and I was considering how to go back to work. Did I want to go back to scoping? It had been a while. Did I want to just try and do outpatient work? And I had been reading a lot about functional medicine, and I had read I had done, you know, the introductory AFM course and I, I, I happened to cross a practice that was a great fit for me.
I worked at Personal Health for four years. It was fantastic. So it was really and, you know, in part these like deep interests that I really like. When I thought about what I wanted to be doing all day, I really did not want to be sitting around prescribing puppies all day and I wanted to be working on people's gut microbiome.
So that was when I was most interested in. And that, combined with just the pressures of motherhood and not wanting to be like, you know, running back and forth from connect to endoscopy suites. And that was a hard one for me because I love endoscopy. It's like, I love working with my hands. It's something I'm good at. It's like it's very satisfying.
But I thought, you know, I have a lot of friends who do this really well too. And I can send them there. Yeah. And, you know, and that worked out great. I actually that was November 2019. And then Covid hit and I was very happy to be on the other side of the zoom screen. Yeah for sure. So yeah.
How has your practice changed then as you've started practicing from a more functional perspective? Oh, it's totally different. I mean, functional medicine works for me and patients. I think, on so many levels. But one of the biggest ways is that, you know, all that time that you lose in conventional medicine because you have to fit people into 50 minute slots, because you have to, you know, get to do procedures.
I got all that time back. Yeah. And I it's almost like you get to go back to being a medical student and doing that really thorough intake and really getting to know that person and understanding, like, what are the what, what were the hairpin turns that like that really changed the course of their health? You know, where where are the inflection points where things really changed for them.
And there are times when I feel like just just telling that story back to a patient and letting them see how their life has changed is so therapeutically powerful in and of itself. I love that I have time to do that. But it also, I would say the major way that it's changed is that I don't I don't practice in this formula away.
Now, don't get me wrong, there are times that I wish that there were better treatment algorithms out there for Sibo and for other things, but I'm always been, you know, I have a PhD in epidemiology. I've always been a research based person and my outlook. So I, you know, I use all the research that's out there that exists.
But it this type of approach really has allowed me to lean into my medical intuition about what is going to work for someone and rather than like, oh, you know, we try this and then we try this and we check this, and I, I love this algorithm. I still go back to them, you know, like they're and they're incredibly helpful.
The other day I had someone who I had to put on, pancreatic replacement therapy because they had no pancreatic enzymes and they were low enough that I was like, we're going to use Xn, not just the stuff from PostScript. And I went back to the algorithms. I was like, oh, yeah, that's right. We have to block the stomach acid if we want the Xn to work.
Which is a really interesting point about digestive enzymes when you get digestive enzymes, if they have if they have between HCR and pancreatic enzymes in them, the pancreatic enzymes aren't going to work. If you are getting it with stomach acid, because you need to block stomach acid to allow additional pancreatic enzymes to really do their thing. So that was and so I like treatment when it comes to I, you know, whether it's treatment or it's like diagnostic stuff I keep the the boxes like the tool boxes, but I keep both of them open at all times, conventional and, you know, and functional.
Like I'm always pulling from both of those. So it's been a it's been a great change. I've really it's been fantastic. And I love the community of functional medicine doctors. It's like I love the pace that people go at. It's really it's been terrific for me. I love hearing that and I love what you said at the end about having both toolboxes open.
I really think it's an advantage of working with a functional medicine physician as opposed to there's there's lots of people practicing functional medicine. And I think there's I'm glad people out there are doing the work and helping patients feel better and teaching them foundational health. But there's something really special about seeing a physician who can know when to draw from this toolbox.
Because as much as we want to avoid conventional medicine and prescription medications that have negative side effects when possible, there are times when we get to draw from both toolboxes to get the patient better, and really keeping that as the goal. I think some people think the goal is to avoid medicine and like that. That's a great superficial goal.
Like that's a great aim. But at the end of the day, we want people to be healthy and to feel their best. And I would say my practice is like 90%, 80% functional medicine and sprinkled with, you know, five, ten, 15, 20% conventional medicine when people need it to get better. And I'm sure glad when we get to that point that that we have it.
So it's both and and it's, it's a wonderful relationship. Well it tell us. So we're, we want to really dive into particularly talking about a really stubborn, aspect of the gut and diagnosis that we see in the gut. And then we'll, we'll talk about a couple extra things at the end if we have time, but especially this diagnosis that we all know and love called IBS or irritable bowel syndrome.
Yeah. And then you know how that intersects. And maybe the same thing as Sibo. So will you give us just an overview of what we're talking about today? What is IBS? What do. Absolutely I think a lot of patients have had that diagnosis and yeah, transitioned that into this idea of Sibo. Yeah. So IBS is irritable bowel syndrome.
It's really it's an umbrella term right. It's I don't know what else you have. Yeah I don't have these. Right. So it must be IBS. It means it it's in medicine. There is something called a diagnosis of exclusion. Right. Which means that we've determined that you don't have any of the big bad things. Yeah. So this is the bucket that you fall into now.
And just to be clear, IBS covers so many things. It covers constipation. It covers diarrhea. It covers people who go back and forth between constipation and diarrhea. It includes bloating. It includes abdominal pain, which is also referred to sometimes as visceral hypersensitivity. And it you know it urgency. There are all sorts of like if anything's going wrong here.
Like it could be IBS. So what is that really? So for the first step is, what? Isn't it? But before I even get to that, I just, I want to call out that when someone comes into my office with IBS, one of the things we talked about before is like, how is that frustrating for someone? Yeah. How are they?
What's happening? Why are they not finding answers? And one of the interesting parts about sitting on this side of the of the bench is you get to hear what people are hearing from their doctors and, and not only hear that, but hear how it lands with them. So what I hear people saying is like they go to their doctor is listening to them, or that they're being told that it's, you know, just IBS.
But don't worry about it. It's fine. It's like this is a chronic thing. Just don't worry about it. And then there's the like, it's all in your head kind of message. That's a hard one for me to unpack sometimes, because for me it is definitely in your head and it's in your body and in your head and they're working together.
And we have connected. As it turns out, those things are totally connected. So when you try to approach with like mind body approaches, in addition, you have to clarify that you're not minimizing or gaslighting them about about their symptoms, that they are very real. So the other really serious thing that happens is when IBS is not taken seriously, and there isn't enough of a workup done to rule out other causes, the very first thing that has to be done is to make sure that it's not inflammatory bowel disease.
This is confusing even for physicians who are gastroenterologists, IBS, and IBD. Like those. One letter is different, right? IBS is, you know, as we mentioned, a big umbrella, irregularity, some irregularity. Something's not right. IBD is inflammatory bowel disease that encapsulates three different diseases Crohn's disease, ulcerative colitis and microscopic colitis. And those diseases are really about your, immune system being over vigilant, right.
So seeing more things as foreign than they should and then attack your body if they're autoimmune diseases. So one of the first things that I want to assess with someone who has IBS is have they been properly evaluated for inflammatory bowel disease. Right. Maybe they've had a colonoscopy. And obviously that would be great if they had another simple test as a fecal cow protecting.
It's not 100%, but it does a really good job of differentiating the classic question that we have as doctors, which is sick or not sick. Right. And if that fecal cow protection, which measures like degree of inflammation in the intestinal wall, if that people cow protection is really low, I'm like, we can move on and we can try and differentiate what kind of IBS you have.
If that fecal protect is really high, we're going to get a scope pretty quickly, but continue with our workup. And if it's in the middle, then I usually I had a patient just the other day, I was like, look, I don't want to freak you out. This is just me trying to rule out the bad things. I think what's going to happen is we're going to treat your parasite, treat your Sibo, and this number is going to come down, but you have enough stuff going on.
Why don't we just go ahead and scheduled a colonoscopy? An endoscopy. You have all of these risk factors that bite, you know, make you eligible to get a colonoscopy that will be covered by insurance. And let's just get it on the books, because you're not going to get an appointment for three months anyway. So then in three months we'll know.
And and the appointment will be waiting there for you. So that's the first thing is make sure it's not inflammatory bowel disease. Then there are a bunch of different options. Right? I just want to recap for a second. I love how you introduce it and really emphasizing that this is a really frustrating diagnosis for people. And I just want to kind of second that of, you know, we kind of everyone has heard the term IBS, right?
Everyone knows someone who has IBS. And I think it's easy to say like, oh yeah, you have a little tummy troubles, but this can be incredibly disruptive. I mean, I have patients all the time, every single day who come in and they're not pooping for a week at a time. And we think like, well, you know, so what?
But like, if nothing else, that's incredibly uncomfortable. Not to mention the downstream negative side effects. But I just want to give voice to like IBS is a really big deal. I think some people know how bad they feel, and some people don't know how bad they feel until it's fixed and they realize, oh gosh, that was yeah, like I have been I had a patient who we treated for IBS and Sibo and she'd been chronically constipated and she said, oh, it doesn't bother me.
And I said, I'm pretty sure it does bother you. And she goes, no, I've been, I've, I poop once a week my whole life. Like, that's normal for me. We fixed it and she said, I can't believe how much flatter and how much softer and less uncomfortable my belly is, so I just want to draw attention to that.
On the flip side, some of these people will have bowel movements 510 times a day. Do we realize as a population how disruptive that is to your life, to have to be by a bathroom that readily, and to have to disrupt your work that frequently and sometimes with urgency, where where people will say like, I can't leave the house or I can't, you know, do x, y, z, because I have to be I have to have ready access to a to a bathroom and I don't go out to eat, because if I eat something weird, then it's embarrassing for me socially.
If I get gas or distension or I have to run to the bathroom and then I'm in the bathroom for 20 minutes and they don't know what's going on, like, I just my heart just goes out to people who deal with this because it's so easy to say, like, oh, I've got some bloating or I've got a little gas, but like, this can be severely disrupt to people's lives even if they're not going to die from it.
You know, even if it's so disruptive in disease, it's it's really bothersome. So I just want to kind of recap I love that you brought that up that that the first thing you're doing is kind of understanding their experience and giving voice to that. Because I do think that's one of the things that is so frustrating to them is conventional gastroenterology ists bless their hearts, but very frequently do not give voice to it because they're saying, hey, good news, you're not dying.
This is great. I've just ruled out these terrible things. We actually don't have any treatments for IBS, so go ahead and live your life. But I ruled out the scary stuff, and that's just I think that's unacceptable as a physician, as a healer, like that's unacceptable. If nothing else, you have to say I don't have a great treatment, but I'm really sorry.
This is rough. Like, this is really a hard go for you. So I just wanted to before we get too far into the treatment with this initial presentation. That is totally true. And I have to say on your point about how much better people feel when they poop every day. Yeah. That's actually one of the reasons that I went into gastroenterology, because if you think about all the body systems, and maybe this just is just my need for gratification.
I know, but there are so many things that you can fix. And once you fix, some people move on with their lives and, like, that's great. Like, now I, you know, but people appreciate having a good time with me every day. Yeah. Everyone now like, no, no one takes that for granted. Like, yeah, everyone appreciates it. Appreciates it every time that it happens.
And some people are very proud of it. Like I very proudly. Yeah. Good pooper. People will say like I have a bowel movement every morning. Yes. Then again, after lunch. And and for good reason, because you really do feel better not just in your belly, but like you really do feel better mentally. Right? Because it's also that stool stays there.
You're no doubt going to be reabsorbed toxins that you were supposed to be. Toxins, hormones, so many things that your body is trying to get rid of. So agreed like that is, you know, that's that's why we do this. Yes, exactly. We kind of just restated sort of the diverse array of symptoms. I think also bloating and stomach aches are really a big deal.
You get a lot of people who will say, like, I look thin in the beginning of the day, and by the end of the day I literally look 20 weeks pregnant. Those are some of the things that I that jump out to me with Sibo and IBS. Are there any other symptoms that you want to recap and then go back to where you were headed with sort of next phases in the evaluation and treatment?
Yeah, sure. So in a in that big umbrella that IBS covers, there are a whole bunch of things that could be going on there. Sibo is a really big one. The other ones that I think of, especially with diarrhea, are, bile acid diarrhea. That's a tough one because there isn't a great, like, widely available clinical test.
But you can, like, try some Callister. I mean, if you think that the stool looks particularly yellow and watery and could be worth a try, and that just means that you have too much bile acids and that's causing diarrhea. Other things under the IBS umbrella there could be a mechanical issue, right? So if there's any problem with how the, rectal sphincter is working, if there is a motility problem, those are other issues that are important to think about, like sort of at the beginning of your of your diagnostic journey in terms of like how I would approach this patient step by step.
The first step is, is I take a really good history. I want to know everything from about like how they were born and what's happened since then to get them to this point. Then testing. We talked about fecal cow protection and stratifying risk for IBD. And then there are some clinical signs. And this is where I think it's is really important for people to know if there is bladder mucus in the stool.
That's a red flag for me. The other one that's a really big red flag is if they are getting up in the middle of the night to have about movement, particularly diarrhea, that's another red flag. Those two things are things that, along with fecal count protection, are going to make me more likely to think maybe we should get you scoped earlier or later.
And the other thing that I more and more now do earlier in my evaluation is I check for a clinical history consistent with mast cell activation syndrome, because this is one of the things that gets in the way of treatment of other things. So I, I have a whole questionnaire that I go through. The big ones are hives flushing rosacea, which is like a red nose and face, spontaneous bloating, heartburn, mouth sores, restless leg tinnitus, all bunch of things that seem like a random collection of symptoms.
But if I have a high suspicion for MCs, I want to know that going in earlier rather than coming back around to it. And in terms of my like initial approach, Sibo is definitely the most common thing that I'm thinking about. And I'll talk a little bit about what Sibo is in a minute. But in my initial treatment and testing, there are a few things that I do pretty regularly in the beginning.
The first one is very simple. Anyone listening to this podcast can do it on their own. I take people off of dairy for a month. If they can't do it, I mean a month, 3 to 4 weeks is ideal for like, for, any kind of allergic response. It can only do it for a week. Try it for a week.
But that is a very common cause of both diarrhea, constipation and boiling. And it's one of the most confusing things for people because different types of dairy have different amounts of lactose in it. And it's that is wildly confusing. And the brain likes dairy and likes ice cream and likes butter. So it sort of convinces you that it's fine even when it's not.
And when I do that, I make really sure to like, point out that at some point they're going to come off of this dairy free time, whether intentionally or unintentionally, and that's fine. Just pay attention to your symptoms, because it's when you reintroduce that, you'll really notice that something is different. Some people may be like, oh my God, I have no gas coming from anywhere.
And that's great. But other people may not notice until they put it back in. So the first three things I do would be dairy free diet, do a Sibo test and lab testing, looking for not just fecal cow protection, but for GI pathogens and mass testing if that's appropriate. So that's that's where I start. The thing that is a little hard for people to understand sometimes is what is this Sibo thing that we're talking about, you know, small intestinal bacterial overgrowth.
Like, I thought we're supposed to have good bacteria in our guts, so we are supposed to have good bacteria in our gut, in our colon or large belt. So in our large bowel are supposed to have like ten to the 12 bacterial species, just a ton in our small bowel. It's actually supposed to be relatively cleaner, right? So ten to the third, ten to the fourth bacteria.
And if bacteria to find their way into the small bowel, that's when they can cause problems, especially if they can set up a home there and like, you know, find a an ecosystem where they can flourish. And when that happens, that's when you get that bloating after meals that get worse, gets worse. At the end of the day, that bloating where, you know, people send me pictures are like, I'm I look nine months pregnant.
Why is this happening every night? And it can be with constipation, with diarrhea, with both. Often there's some brain fog. There can be other symptoms. Rosacea is common with Sibo as well. So the two issues with seed oil are one the bacteria gets into the small bowel inappropriately, and two, that your body's defenses are know the the type of movement, the type of peristalsis that goes through your small bowel to clean it out may not be happening properly.
There's a specific type of movement called the migrating motor complex mic, and it goes to your small bowel. I like to think of it like a street sweeper or for the small bowel, and it goes through and it cleans it out. And if bacteria got in there, it cleans them out. How does that happen? Well, that happens in between meals when you're resting at night when you're not eating.
So periods when you're not eating. Also it happens when you are moving. So if you think about what's happened since Covid and since a lot of us started working from home, we sit in front of our computers all day long. We are don't necessarily have as clear demarcations for eating right. Eating may happen throughout the day. Those two things together really support poor small bowel function, so that's important.
The other the other issue is how the bacteria gets into the small bowel. And that can happen on a multiplicity of ways. One if you have low stomach acid that can that's one of your that's your body's second defense against pathogens. And if that stomach acid is low, if you're on a PPI, if you're on, you know, if you're on Zantac, which is an issue blocker, or Nexium, which is a PPI, then you may not kill those pathogens when they get to your stomach and then they get to your small bowel.
Also, if you have a bad bacterial or viral infection that can sort of stun your small bowel and slow things down, and you and bacteria can get in that way. The other way, which is so common, is just chronic constipation. If you're chronically constipated for years, there's a little bowel between the small bowel and a large balance called the ilio cycle valve.
And in chronic constipation, sometimes that valve just stays open and bacteria can just float right up. So there are a lot of ways for bacteria to get into the small bowel. There are a lot of ways for our defenses against that to be broken down, but the end result is going to be bloating, diarrhea and or constipation, usually some brain fog and maybe some rosacea.
And there can be there can be other symptoms too. But that's Sibo in a nutshell. Yeah, yeah. Thank you for going over all of that. I just want to recap a couple things because it's this is so common, I think in, in my perfect world, because I'm not a gastroenterologist. I really love it when a patient has already seen their gastroenterologist.
Their gastroenterologist has ruled out the Big Skerries, tells them, you know, I have nothing more to do with you. Good luck with your bloating and diarrhea and constipation. And then they come see me. In your case, you'll you'll do more of that workup upfront. But like you said, really considering diet and then doing some initial testing to see what is going on in the gut, both with the Sibo and with small intestine, and also the rest of the gut microbiome and any other inflammatory markers, etc. like you mentioned.
Will you tell us when you say dairy? I want to go back there a little bit, because I think a lot of people, by the time they've come to see us, have already done some sort of elimination trial. So will you comment on, food sensitivities, food sensitivity testing, celiac testing? Yeah, sure. Endless elimination trials of if you still have an upset gut, it's probably because you haven't found the right magical food to eliminate yet.
So narrow it down, narrow it down, narrow it down. And then also, I'm giving you, like eight things to talk about. That's also low Fodmap, right. So if you'll yeah kind of guide us through food and how that fits in. Yeah. So I'm going to start at the end with low Fodmap. I low FODMAPs are fructose oligosaccharide disaccharide monosaccharide I'm forget the a and polysaccharides.
They're the ones that are the different. Yeah. Yeah they're and if you look at the list of FODMAPs there are different categories. And then it is just like the most overwhelming list in the world. It has so many foods and it feels completely random. And the reason I bring it up is because often when people go to their GI and they're diagnosed with IBS, that is the one thing they're told is maybe try a low Fodmap diet forever.
And those those FODMAPs then are foods, not good foods, not bad foods. They're just foods like processed foods is a high Fodmap, and they're foods that create these fermentable products that often, create a lot of gas. So the GI says maybe eat fewer of these foods for the rest of your life, and you might have less production of this uncomfortable bloating.
So as you can see, I'm not a huge fan of low Fodmap diet, especially in the long run. But tell us. Tell us more about the like so many other things, a low Fodmap diet was never intended to be a long term solution, right? It was. I view it as a diagnostic tool, and I, I don't really use a low Fodmap diet at all.
In my practice. I if someone has been on a low Fodmap diet and they felt better, I find that to be a helpful diagnostic indicator that they may have Sibo, but there have actually been studies that should have shown that staying on low Fodmap diet long term results in nutritional deficiencies. So it's not. And it's something I have patients come in, they don't feel like they can't eat.
They don't feel good. Right. And it's also it doesn't cure Sibo right. Doesn't do anything to kill those bugs in your small bacteria or help restore your small bowel motility.
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I'm like, do you like beans? Do you like garlic? Do you like onions? Do you like brussel sprouts? Kale. You know, cabbage? Like, do you eat those things? And a lot of times they'll be like, I used to love them, but I don't go anywhere. I can't tolerate it. Yeah, right. And not everyone is reacts to everything on the list as the other issue.
So I use that as part of my intake process to see like do you do better on a low low ish Fodmap diet? If so, great, we still need a Sibo test. Now you may ask, why do you need a Sibo test? If they have, if you they've demonstrated that they, that they don't do well. And that's the reason is, is that when you do a Sego test, there are three different types of Sibo that we can test for through, like at home or in the office tests.
Hydrogen and methane are the most common. If you do a trio smart test, you can also test for hydrogen sulfide, which is rarer than the other two, but does happen. There's also, small intestinal fungal overgrowth, which you can really only test for through, and just, sampling of fluid in the duodenum. And even then, it's pretty hard to find a bike run of the mill gastroenterologist who's willing to do that because you know, there aren't really clear guidelines on how to do that.
There are some very amazing Sibo specialists like Satish Rao in Augusta, Georgia, who will do that. But for the most part, I that's not something that's done frequently. So the point is, is that if I don't know what kind of Sibo you have and how bad the scores are, I, I need that information to guide my treatment plan, to figure out whether, I need to start with antibiotics or herbal antimicrobials.
And if I'm struggling with antibiotics, if you have just hydrogen, we can do rifaximin only. But if you have nothing as well, you're going to need an additional antibiotic like fragile or neomycin. Otherwise it's not going to work. And I can't tell you how many times I've seen someone who goes to see a conventional gastroenterologist and they, like either don't test them at all and just give them rifaximin or they test them.
Find the methane and still just give you more facts. Yeah. So, you know, so that that is critical information. And what I tell people during Sibo treatment and after Sibo treatment is to stick with what I call just FODMAPs as tolerated. Yeah, most likely people have already figured out which FODMAPs they can and can't eat, and they've already like without even thinking about it.
They've like like they've navigated their way through a diet that will not make them feel awful. So that's why Sibo testing is really important and why, you know, a low Fodmap diet is a great diagnostic tool, but is, you know, it's not a really hard. It's it's a really hard one to do. And elimination alone is hard.
Yeah, yeah, yeah. So I've already forgotten all the other questions. Yeah. So the idea because I gave you time, the other ones that, that I wanted to ask about were the idea of the endless elimination trial and then sensitivity testing and celiac testing. Where in your workup are you considering any of, a further elimination trial other than dairy foods and b testing celiac testing?
Okay, so food sensitivity testing, I don't really bother with I, I don't find it to be that clinically useful. You know, there's IG food testing, which is a true allergy. And there's IgG for testing, which is food sensitivity. And my experience when I do food sensitivity testing, it often reflects very much of what that person eats. And they're like, you know, in the very rare situation, do I see something where they're like, oh, look, I have like a lactose.
And, you know, I have an IgG sensitivity in milk and I only eat it like in this particular part of my day. And it's no big deal to eliminate. So I'll me know if that happens. Great. But what usually happens is that they're like, wow. Because these are a lot of foods. I'm really overwhelmed and I have no idea what else to eat.
So I don't I don't find it to be that clinically helpful. And even IgG food testing, which I use sometimes, in certain situations, but I take it with a grain of salt because you really have to correlate it with. And so IgG food testing is like just for reference, if someone's like has taken like a CBM or food sensitivity test, those are specialty tests that a functional medicine practitioner may or may not order.
IG food testing is a type of food testing. You could use request Labs and you can like their house. Yeah, and an allergist or the allergist honestly are much more likely to do like they'll do some IgG testing, but I'll also just do skin testing. So the ag food testing is interesting because the number of stories correlate to what someone is, is experiencing, you know, symptomatically.
Right. And I've seen this, like with my own kid who has a whole bunch of food allergies. You know, watching the changes in his IgG testing, which I use to monitor their, are sometimes wildly different from what he's actually allergic to. Like actually has an anaphylactic reaction to. So I even IgG food testing I take with a grain of salt when it comes to food elimination that it's actually the gold standard.
And if you look at the and they've demonstrated this in research multiple times, but specifically in the case of eosinophilic esophagitis, which is sort of like an allergic reaction at the base of your esophagus, they they looked at IgG food testing versus food elimination. And food elimination wildly outperforms IgG food testing. There's like no point in doing IgG for testing in that situation.
So the food elimination testing is sometimes I do use the IgG food testing ahead of time to make sure I'm not going up against any really big allergies, right? If someone has, like if there are numbers or like through the roof for a particular allergen, I don't want to take them off of that and then ask them to reintroduce it.
That's asking for trouble. That person's going to have a bad experience. They're not going to be trustful of the process. So I like to have a little bit of information ahead of time about food allergies in some situations. So an elimination diet is a great thing. It's also really hard for people to do one big pitfall that people fall into a lot of times, especially with gluten, is stopping gluten before doing celiac testing.
So when I start with people, the reason I start with dairy free is because I want to keep them on gluten until I can test them. For celiac disease. So for like allergy to wheat, gluten, cultivated wheat. You don't have to take someone off of wheat or gluten for that. But for celiac disease, if you want to get a reliable test, that person has to.
Whether you're scoping or testing TTG IGA antibodies, which is the very specific antibody in the blood. Either way, they have to be on the equivalent of two slices of bread a day for two weeks. Minimum. Some people will say longer before you do that test. Otherwise it's not a reliable answer. So that's why I start with dairy free.
Also, because it's the most common one that causes problems in, you know, with GI issues, there are situations where I would do like a, like a bigger elimination diet. Sometimes I would do like dairy free, gluten free and very low sugar. Beyond that, in a significant autoimmune disease, I might do an autoimmune protocol diet, which, you know, adds a few more things in there, and that is really pretty tough.
But for the most part, I like to keep it as simple as possible. And I also like to really focus on two things. Number one, you're not doing this for any longer than one month, right? Any elimination diet except for IPI, which you may do for three months. But elimination diets should you have to understand it's a short period of time.
And also reminding them that that reintroduction phase that that is the most important part. And that's when they need the most support in terms of being able to, like, know how to reintroduce, but also to just like, calm down, not get upset with yourself. You messed up your elimination diet. That's okay. Just observe what happened to you when you eliminated that thing, when you reintroduce that thing.
So that's the general approach that I take to elimination diets. That's perfect. Eight so the thing I love about some of this is when we talk about this functional approach, it can leave patients feeling really frustrated because they're like, well, great. Where where do I go? Because you're telling me my conventional GI may not help me. So like, what do I do?
These are the things that are really doable. Like try it. I mimic the Whole30 is the the best. Well, then, it's easy to find on Pinterest and recipes and, you know, there are full meal plans for Whole30. So I basically stay with with Whole30 because it's so well known. So some things that you can do on your own, definitely a dairy free trial alone and then paying attention to when you bring it back.
A 30 day elimination trial akin to Whole30, partially because it's anti-inflammatory, partially because it's cutting out some most common bad guys and see, and then what I would do and like I just reiterate what you're saying is if that does absolutely nothing for you, then then leave it for a minute, then it's not your food or there's something else going on.
And I think that if you're working with a functional medicine practitioner whose answer is always like, well, cut this out now, now cut this out. Now do this test for this food like you're missing the point. If it's not resolving pretty quickly with a food, then you've got to look somewhere else. So the things you can do on your own.
Those two big dietary changes I think most primary care doctors are pretty open to doing celiac testing, especially if you say, I'm worried, I'm reacting to gluten. Would you mind testing me? I've got terrible diarrhea every time I eat wheat. Most of them will be okay with that. I also think some of them would be okay with a fecal cal protect in a lot of conventional doctors, I think yes, I don't like to order things they don't know what to do with, and I don't want to put anyone down.
But if you went to them and said, you know what, I have really bad bowel irregularity. Would you mind running a fecal cow protect in? And if it's elevated, I'd like to go see a gastroenterologist. Or can you get that going for me and then go see the gastroenterologist? You'll get pushback from some of them, but I think some of them would do it.
It's available through LabCorp, and it's easy to do, and it really does kind of tip the scale of like big bad guy versus no bad guy. And that's going to really help you then understand the urgency that you see a conventional gastroenterologist versus seeking out functional medicine support to then take the next steps, which is where I want to go next, and I'll just join you.
I rarely do the food sensitivity testing, usually only if pushed by a patient, and I've rarely found it to be the thing like, gosh, I don't know what to do with you. Oh, now I know. Like it just isn't. I don't think it's the end all be all. No, I think it's very accessible to people. And they feel so hopeless and so frustrated that they'll do anything.
Don't spend your money on that. Like do an elimination trial for a month. Get the help you need, but don't spend your money on that. It's just not not usually going to be the thing. Okay, so now they've come to see you or someone like you and they've done Sibo testing and it's positive. Will you kind of run through a couple?
I know it's extensive and maybe even before we get the treatment, why don't conventional why is this not bread and butter for conventional Gynecol it a gynecologist? I'm the gynecologist. You're a gastroenterologist. Why is this not bread and butter for gastroenterologists? Yeah. And then also tell us about why this is such a frustrating thing to treat. Why isn't there just do this and then it goes away forever.
Yeah. So I will say there are gastroenterologists who do this, and you do it all the time. Yep. And there are some who are real experts on it. And who have published papers, but it doesn't. It's not a disease or a condition that lends itself to the pace of conventional gastroenterology. Right. We're requires more for the listening.
Hearing it requires more hand-holding. And it, you know, over 65% of people who have small intestinal bacterial overgrowth require more than one course of treatment. Why is that? There are a couple of reasons. One, if this cause if you have enough bacterial load in there, enough bacterial density, there's a good chance that the first round of treatment just isn't going to get all of it.
And you feel better enough after the first round of treatment. But you're like, great. I feel like so much better than before. And like we were talking about with constipation. If you don't really remember what life is like before Cibo, any like a massive improvement in your symptoms, it's like it's a win. Like why would you why would you ask for more for life?
Right. So that's one reason. The other reason is that the underlying motility issues have not been either diagnosed or addressed, through lifestyle, through, through medications, through or through anything. Right? All that's happened is, you know, you've gotten a prescription for rifaximin. He felt a little better and you moved on with your life. Nobody wants to hear that.
This is going to take a while, right? This is probably going to take more than one course. And it's going to take more than one round of testing. It's not. It requires patience on both sides. That's the other thing is a lot of people don't retest afterwards to make sure that it's gone. A some I have to push myself to do it.
Sometimes I'm like, I'm really sorry. I don't want to make you take this test again, but let's just make sure it's really gone. And very often if the score is high enough, I will do a more extended course of treatment to start with before retesting them. I'll often start with antibiotics, especially if the score is high enough or if it's something Sibo.
And then I'll follow up with herbals because I can do herbals for a longer period of time without the downsides of antibiotics, which is, you know, risk of bacterial overgrowth, risk of C give diarrhea for a lot of things in there. You know, you can't drink while you're on antibiotics, which is, you know, not great when you're on herbals either.
But at least it's not like a firm contraindication if you're going into like Christmas party season, like it's you know, it doesn't mean that you have to put off the whole treatment. I try to approach it with like, a thoughtful approach to what type of antimicrobials I'm using. I also try to make sure I have some stuff in there to support gut healing.
I use a lot of, bovine immunoglobulins or make IgG or SBI protect because those also work as a mild binder. If there's, and die off at the same time. I always use a squirty if I'm using an antibiotic, because that's a new space probiotic that won't be killed by the antibiotic and will serve as like a placeholder in the gut.
And then I'll often follow that course of antibiotics with herbals sometimes before retesting. And I have the patient really keep an eye on how they physically respond to the antibiotics versus the rebels. Which ones do they tolerate better? Which ones make them feel better? And then after you treat Sibo, you need to repopulate the guy right? When it's all gone, then you have to really get in there and get back to rebuilding the microbiome.
Not the other face. I find I get patients who have seen a gastroenterologist, they're diagnosed, they're treated with for whatever regimen, and then they're sent out and they say, I kind of felt better for a while and then just not. And they're not given any instructions for that rebuild actual population. Reed. Yeah. Making it sturdy. Yeah. I mean, the first thing is like, is there something you see about us?
Right. Yeah. And then the other thing is like, what are we doing to address that small bowel motility? So getting people to get up and move more throughout the day, like, you know, I, I go to yoga or do something religiously every day and, you know, almost every day and I that's an hour. Right? That just not there.
There are two columns in life. There's like your your exercise that you do I to me that's like that's for fun. Right. And then there is the sedentary behavior. Yeah. And that's where like getting up and moving throughout the day is really important. Moving after you eat is really important. That is really important for keeping that small ball moving.
The meal spacing that we talked about I actually I have I, I call it the forms. So movement meal spacing, meditation and mastication I apologize. As for the last one, there's no way to say it starting with an Am. And I really was attached to four and I love it. So those four ends, the first two movement and meal spacing are for helping that the MNC move along.
Right. And then the meditation and mastication are both really address vagal nerve support. Right. Really getting into rest and digest. And that part I can't even begin to emphasize how important that is. I find getting my patients to find a meditation practice that works for them is like, that is the longest project that we have. I kind of, I sort of imagine it like, I don't know if you have these in Salt Lake City, but in New York we have these, like these pop up tennis bubbles.
Like where, like it's like, the restaurants know, like it's a, you know, it's like an inflated thing, like it's a big bubble where. Yeah. So and I imagine my patients are sort of like little ducks, like going around the this big bubble and like, trying to find the door. Right. And, and that's it's hard to find a meditation that practice meditation practice that works for you.
But when you find it and it may be a walking meditation, it may be a moving meditation, it may be a breathing practice. It may be chewing your food. But when you find it, it is I mean, it is so helpful for gut health. I, I have seen so many patients when they finally like click in to that practice that works for them.
Oh, so much of that stuff just lighten the load. Lightens. Right? Especially with, you know, anxiety around store urgency and just anxiety around bowel function in general. It gets so much better with the right meditation practice. So, putting those forms into place is really important. And I also often use low dose nail tech soon to support small bowel to motility.
Low dose naltrexone is an amazing drug. It doesn't work for everyone for small motility, but when it works, it works great. It's also a big key player in treating, muscle activation syndrome. So sometimes my folks do really well in LDN and like they need to circle back to your, cast questionnaire. Yeah. So we were talking before about, you know, when super treatment isn't working.
What what's going on. Right. Like there are some people where like, my Sibo is so stubborn. Why is it what's happening? There are a few things that could be going on in that situation. It could be small and it could be hydrogen sulfide, Sibo, it could be small intestinal fungal overgrowth, especially if you have had someone who's been on a ton of antibiotics, they could have fungal overgrowth.
Now, you could have a mechanical problem if this is a constipated patient, I want to make sure that they've had like an interactome, an almond tree evaluation to make sure that they're not doing that paradoxical clenching of their of their rectum, where they're clenching when they're supposed to be relaxing. For some of those people, I'll tell them to approach pooping, sort of like giving birth.
Like you just take like Instagram or Mars breaths and you try and exhale on pooping. And sometimes that works. Sometimes that's all you need. But sometimes they need, they need pelvic floor therapy because you can't if there is that kind of if there's a mechanical constipation issue. Basically the way I think of it is like the end of the the end of the tube is blocked.
Doesn't matter how many antibiotics or supplements I give you up here or how well you're chewing, if you're blocked at the end, we're not going to make progress because that constipation is going to continue. So those are the, you know, hydrogen sulfide, fungal Sibo, mechanical constipation, mast cell activation syndrome. And or like mold or Lyme is another thing.
It can really get in the way of Sibo treatment. So mast cell activation syndrome cells are a type of cell in your immune system. And in mass cell activation syndrome, they tend to get like overexcited. And they're just releasing histamine all over the place in any appropriate times and places they have, like Tourette's of the immune system. And, they just can't help spewing histamine all over the place.
And it can present in all kinds of ways. Like the classic thing is someone has facial flushing, they have hives, they may have some migraines, they can have diarrhea, they can have constipation. Fatigue is a really big part of this. You see a lot of mast cell activation syndrome in post-Covid as well. And I think that's part of why I'm seeing a lot more of it because of the immune cell during, you know, the immune system derangement that happens with Covid.
But if that's part of what's going on and if that is what is affecting your motility, but just affecting your system in general. Another big hallmark of empaths is when I have patients who tell me that they're very sensitive to medications and they can only take a little like a little tiny, like, you know, chip of a pill.
That's a clear to me that my cast may be going on, because a lot of these folks are very medication sensitive. So the way I like to approach em, CAS is in my patient population. They probably already done some elimination diets. And in fact, elimination diets can mask mass. Often I have to do my mass questionnaire and be like, okay, did did you feel worse?
Did you have these symptoms before you went dairy free and gluten free? Because starting the dairy free, gluten free, maybe yeast free is really important for me, at least for 3 or 4 weeks, to calm everything down. The next step is you need to address the hydrogen receptors. So H1 and H2 because this is for histamine right. And you need H1 receptors are like those blockers of H1 receptors are just antihistamines proteins.
Or check if I have someone who tells me they feel much more clear headed on Claritin. That's a clue, right? H2 receptors this is a tricky one. I like Pepcid Zantac and those can be very helpful. And I do want to try those to make sure to see if we need to have those in our back pocket.
But I don't, especially with Sibo. I don't like to keep people on, acid blockers. So H1 and H2 blockers. And then the other category of treatment as mast cell stabilizers. And there are a whole bunch of things that fall into this category. My favorites are quercetin and Libby Olson, LDN is a super star in this regard.
LDN helps to treat me in a variety of ways, but muscle stabilization is one of them. Now, Tonin is actually a muscle stabilizer as well. They're whole bunch of different masshealth stabilizers, but as long as I have h1, h2 blocking covered and meso stabilization covered, you know I can try those things like a discrete number of things, like four pronged attack or three prong pronged attack, and see if they get better.
And cast is a really tough one because like Sibo, the testing isn't easy. You have to catch them in the middle of a flare, and then you have to do blood testing, but also a 24 hour urine testing, which is not fun. And they have to be off of the antihistamines for five days and off of mast cell stabilizers for two days.
So very often, if I suspect am cast, I will do some baseline testing in the beginning, even if I know they're not in the middle of a flare just to see where they're at. But it is part of the reason the mcats is, well, there are a lot of papers out there in my cast, and there are a lot of experts on my cast.
Part of the reason that it hasn't really made its way into mainstream medicine is because the testing is so difficult, and it's so difficult to keep following them, but when you hit the right combination of medications for someone, it can make a world of difference. And it can really open your world up. In terms of treating Sibo. Sibo is very common in CAS, and treating Sibo is part of the.
It's an important part of the whole and cancer treatment approach. But you probably have to stabilize those muscles first. Well, I love that you take that to m CAS. I think, I wish we could spend more time on it because it is so important. I think the biggest takeaway I would want people to have is to have hope that, you know, if you have significant gut abnormalities, and then with m cas, that would be gut abnormalities plus other multiple system involvements, whatever those systems are, reproductive or mental health or, fatigue or cognitive etc..
But with either of them, we're we're doing okay at treating these. We get a lot of patients better. And especially with Sibo and with the gut in general. The gut is treatable. It can get better. You can have really regular bowel movements. And I think the biggest take home towards the end of that is if you're being treated for Sibo and you got better and then relapsed.
Number one, Sibo recurrence is common. And if you are not getting better, then there's something else going on. And you do want to find an astute provider who can kind of take those next layers. But by setting expectations, it can be annoying. It can be a long road, and it can be a lot of supplements and various medications like, LDN or naltrexone, like antihistamines, like, quercetin is a supplement like these herbal antimicrobials or prescription antibiotics.
It's one of my least favorite parts about treating the gut is they do end up on a bucket of stuff for a little while, while you're rebuilding and rehabbing and restructuring and doing. We got weeding right, like getting rid of some of the bad guys and then re, inviting the gut to, to to behave as it should.
And so setting expectations of this can be involved and it can be a lot of supplements and it can be some time but not a year. I mean for me sometimes, but the gut is it makes progress when you get to the right point. I think the annoying part is when you have to unlearn your stuff. So yeah, you collect some data, you try a couple initial things and then you get started.
And so many people, after years of feeling terrible and having gut symptoms, so many people will start feeling better within a month to two months and really do quite well from there. And then there's some that you kind of tried something and it didn't work. So now you have to go try something else and those will take a couple extra months, but even they will start feeling better pretty quickly.
And then if you're still not feeling better, it's usually because we haven't uncovered that layer yet. There's something else like, cast like mold like like fungal overgrowth or, you know, there's something else there, but it's doable. It's doable. And it's not 18,000 other options. It's like 3 to 5 more options that we need to explore. And I think that it takes a while to find the practitioner who can guide you down that.
But I really appreciate everything you've shared about how you approach this with our patients. Just as as closing. If you have any final words that you want to say about IBS or gut health or Sibo, to our listeners, I'd love to hear you, share that. Any any final advice or thoughts that you have? What I would say, first of all, if you're trying to figure this out on your own, a dairy free diet is a great way to start.
And don't be hard on yourself. Just focus on what happens when it comes back in. Totally easy right? Not easy. I don't know my mindset, but it's straightforward. Yeah. And the other thing is, is that, you know, there is this phrase and functional medicine that am a lot of people use it where they say it's about the terrain, right?
And what they mean, or it's about the soil. And while there are a lot of very great short term gains that we make when we start this journey, it is about the soil of, you know, the that like the, like the underlying health of our gut and our immune system and when people are wrestling with these things, I like to try and present the analogy of like, this is a lifelong relationship between you and your body, and it's a lifelong conversation, and you're going to keep going back and forth trying different things.
And that's true about everything that you put into your body and everything that you do with your body. And it's, you know, it's your relationship with yourself and, and how you nourish yourself. And if we take away dairy for a month, it doesn't mean you're going to take away dairy forever. But it might mean that you feel great off of dairy and you don't ever really want to eat dairy again.
And until you do, and then you're reminded of why you don't. Right. And there is no rush. Right? It's it's the journey that you're taking with yourself. And you'll learn a lot of interesting lessons along the way. And, you know, as practitioners, we're just here to, like, guide and support. But this is this is a, a lifelong conversation.
So it's just the beginning. Thank you for sharing that. I really appreciate everything you've said. Will you tell our listeners where they can find you, how they can work with. Yes, yes. So I have a practice called Gut Instinct Health and located in New York, in Brooklyn, actually. But all of my videos, I'll make a video visits online.
So anyone who is in New York State at the time of the visit can I can meet with me. And, I do 15 minute free consultations. If anyone wants to come and chat and see if I'm the right person for them. And quite honestly, if they just, like, want to know about functional medicine, I'm more of a chat, like, I'll make an appointment.
I'd love to chat with you. Well, I'm sure anyone who gets to work with you is so fortunate. You are such a kindhearted and thorough and you've advised me on some of my patients who have been struggling with that. And I'm so grateful for your willingness to share and to teach and the the energy that you bring to what you do.
It's it's really it's really lovely. And we're we're fortunate to have people like you helping in this functional world, in this, this health world. So thank you for all that you do. Oh, thank you. It's my absolute pleasure. Thank you so much for tuning into today's episode. A huge thank you to our guests for sharing their insights and time with us.
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