Hello, and welcome to Zoe Shorts, the bite-size podcast where we discuss one topic around science and nutrition. I'm Jonathan Wolf, and as always, I'm joined by Dr. Will Bulsowitch. And today's subject is SIBO.

Yes, SIBO, or small Intestinal Bacteria Overgrowth. Interest in research into this condition has been growing year-on-year, Jonathan. There's still a lot we don't know about Ceebo, but there are signs that it could be linked to a host of other conditions ranging from irritable bowel syndrome, even to Alzheimer's disease.

Will, what exactly is Ceebo? I always find these four-letter acronyms slightly terrifying. Are you saying that treating it could be a key to tackling these other conditions?

I think it's important for our listeners to understand that what we know about Ceebo is a work in progress at the moment. We don't want to make promises that the scientific data can't yet keep. However, there are some encouraging discoveries, as well as some Ceebo myths that, frankly, I think we need to bust.

All right, well, let's not hang about then. Will, let's start at the very beginning. What on Earth is Ceebo?

Okay, so to understand this, let's take a journey into the body, literally into the body, Jonathan. Imagine that we're both inside of a stomach and we're just floating around in some gastric acid.

Delightful. Well, you always take me to the best holiday destination. So if we continue our journey down south, we'll move from the stomach into the small intestine.

And what you'll see around you is that the walls are tightly wrinkled. And this is to increase the surface area. There's a lot of absorption happening here. This is actually where 95% of nutrient absorption takes place is in this small intestine.

95%, that's amazing. I didn't realize.

Now, the small intestine is about 7 meters or 22 feet long. It would be like taking a very long walk through the countryside. While on this journey in a healthy person, we would occasionally encounter bacteria, but it would just be a passerby. Then most of the bacteria live in the large intestine, which is further down. The large intestine is almost like the metropolis for our gut microbes.

Will, as I've learned through many conversations with You and Tim and so many other scientists, these bacteria, we now are really important for our digestion and our immune system, and they make chemicals that are really important for our health, right?

That's absolutely correct. In a healthy body, we They have a symbiotic relationship with these bacteria, which means that they're in balance. But in SIBO, this relationship has shifted, and things, unfortunately, have fallen out of balance.

What exactly do you mean by shifted, Will?

Like I said earlier, SIBO stands for small intestine bacterial overgrowth, and the key word here is overgrowth. Now, let's re-imagine our walk through the small bowel countryside. Because in a SIBO sufferer, Suddenly, this has become a hostile place. It's overrun with bacteria. They're not supposed to be there. They're spilling out of the city in huge numbers. Unfortunately, many of them are hooligans.

This is your overgrowth idea, right? I guess overgrowth didn't sound good when you mentioned it, and I guess overgrowth is not good in practice.

Yeah. Overgrowth in the sense that there's more of them. They're multiplying, they're forming a mob, and that mob is angry. Rather than you and I having a cordial walk through the countryside and waving hello to the friendly microbes, we are now defending ourselves. That bacterial balance that is supposed to be there is completely thrown off, Jonathan. This brings me It's a myth number one that I want to bust, which is that there's a rumor out there that sebo is an infection, and that is not true. It's a bacterial imbalance, which basically means that sebo is a form of dysbiosis.

Well, I love it when you take down those myths, Will, particularly when they're myths I didn't even realize about until you explained they were a myth, but that's good. Thank you.

Well, this is something that, of course, we find on the internet, and sometimes what we find on the internet, we have to call on Good question, Jonathan. Now, it's important also for our listeners to understand that there are many different types of sebo, and the type is determined by the makeup of the flora that are involved. So today, we're going to focus on the classic form of sebo, which is called hydrogen dominant sebo, and this is driven by bacteria.

Okay, so, Will, that suddenly got quite complicated. Can you help us to understand what does it mean to be a classic form of sebo? What are the symptoms?

With this type of sebo, which is, again, the bacterial type, because there's an extra amount of bacteria in the gut, they're producing additional gas. And naturally, this causes bloating and flatulence, and with it, gaseous abdominal discomfort. But it It also can cause other things like malabsorption and difficulty digesting and absorbing our food. And in severe cases, you can even have neurologic effects such as brain fog or altered mental status. Now, what's interesting is this link between SIBO and other diseases.

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Thank you, and on with the show.

Well, our team did some research, and apparently, they found a review published last year that reported SIBO to be significantly associated with at least 30 conditions including things like IBS, diabetes, heart disease, Parkinson's disease, even pancreatic cancer.

Yes, that is true. These are associations. I think that it's important, though, to also take this with a little pinch of salt. Well, to properly frame that, we must understand that those are all conditions associated with gut dysbiosis, and SIBO is a form of gut dysbiosis. That doesn't necessarily mean that SIBO is the cause or vice versa. They could both be true and be unrelated. They could also both be true and come from the same root cause, yet be different manifestations of that root cause. Like I said, SIBO research is a work in progress. We're here to report where we are today in our understanding of it. One of the major challenges that we face in sorting this all out is that there's, unfortunately, no real consensus on how to properly perform the test for the presence of Ceebo. This really impacts our ability to compare the results between institutions, between research at ease. And so it becomes a little bit of a mess, unfortunately.

Got it. So you're saying we have to be very careful just because you might have SIBO, that might just be a symptom of something else. And it's not that the sebo itself is necessarily causing any of those diseases. Indeed, maybe those diseases are causing sebo as a byproduct, just like we might feel fatigued or have inflammation or whatever else. Will, will you tell us a bit about the testing methods? Because in fact, I can't go for a walk into your intestine. I'm pleased to I think. So how do we understand whether or not we have this?

Well, the good news is my intestine is a friendly place, Jonathan. But nonetheless, I want to actually kick off with a really important myth. This is myth number two. This is one that Actually, I'm very excited to talk about because I think it's important. You cannot diagnose SIBO with a poop test. I've seen this so many times, including in the care of my patients, where someone is diagnosed with sebo because of the stool says they an overgrowth. That is 100% wrong. Poop tests measure what's happening in the colon, not what's happening in the small intestine. The bottom line from my perspective is that if you are being told, based upon a poop test, that you have sebo, don't buy what you're being told.

Got it. And that's back to, for example, Zoe, part of this is that we do this poop test. We measure the bacteria in your gut, but this is like your large intestine where it's meant to be. I think, well, if I understand right, what you're saying is SIBO is all about bacteria being in this, you call it the small intestine, which actually sounded quite long and quite large, in fact, but before, and that's the place where you're not expecting to have lots of them. Am I understanding this?

That's right. If we wanted to properly understand whether or not you have an overgrowth of bacteria in the small intestine, we would want to sample from the small intestine, or we would want some surrogate marker for what's happening in the small intestine. We wouldn't want a test that really is reflecting what's happening inside your colon, which is what a test is.

Got it. So what do we do?

Well, so the gold standard is a test called a sterile jejunal esprit. The issue with this test, by the way, I should mention, is that it's invasive, it's expensive, and frankly, very few clinicians actually do this. I've worked with dozens of gastrologists, none of them were actually doing this test. What we actually do is a breath test, Jonathan. The advantage of the breath test is that it's non-invasive. Basically, what happens is the patient will drink a sugary liquid, and it goes down into their gut, and wherever it comes into contact with bacteria, those bacteria will metabolize that sugar and produce hydrogen. And so the breath test is measuring the production of that hydrogen. Based upon how much hydrogen is produced and how soon after consuming this beverage, the hydrogen is produced, you can determine effectively whether or not there's sebo.

Well, that sounds very clever. And I think given a choice between a doctor sticking a tube all the way down my throat and through my stomach or having a drink of a sugary liquid, I'm going for the sugary liquid every time.

Yes, understandable. But at the same time, there is a trade-off that we take in the process of getting the convenience of this non-invasive test.

I somehow knew you were going to say that. Will go on. Help us to understand it.

Yes. So if you know me, then you know that I'm not a huge fan of these tests. I understand that we do need them, but unfortunately, I don't have tremendous confidence in them. And the reason why is because There's a very large number of false results. It could be a false positive, and if it's a false positive, then you're going to be treated with antibiotics when you're not supposed to. It could be a false negative, and if it's a false negative, then we're going to be confused and not treat you for sebo when in fact, that is the diagnosis that we're supposed to be treating. Some of the things that can affect the results on this test include antibiotic use, abnormal gut motility, which can come from a number of different reasons, fiber intake and how much fiber you've been consuming in recent days, whether or not you're using a laxative or an anti-diarrheal drug. Exercise, like how much you exercise can actually affect the results that we get on this test. What you see here between these different things is there's many different ways in which we can actually get tripped up on this test result.

This is a bit problematic when it comes to using this test clinically to treat our patients. It's also problematic when it comes to the research, because this is typically the test that's being done in these research studies. And so once again, it affects our ability to be very confident in how we approach Ceebo in these studies.

Just to make sure that we've got this, you're saying this is the best test that anyone uses, but it's not a super accurate test. So in comparison to, I didn't like a blood test where you're getting this really good score of something. This has a lot of times where maybe it says, hey, it's positive, but you're saying it's actually for some other reason or it's negative and it's missed. So it's not highly accurate?

Yeah. I think the bottom line is that we need better testing for SIBO in order to really refine our process, both in terms of the research and what we do on a clinical level.

Let's step into your practice, Will. What would you do if someone that you're treating returns with a positive SIBO breath test?

The important thing from my perspective is the process. I want to start by first asking the question, why would this person have SIBO? There should be an answer to this question. This is not something that just comes out of nowhere.

Can you give us some examples?

Definitely. Sebo can be brought on by abnormal bowel motility. I would be asking the question, does this person have chronic constipation, diabetes, which massively affects our bowel motility, low thyroid, gastroparesis, which is a condition where our stomach is not properly emptying, or chronic opiate use, which among all the drugs that exist on the planet, those are the most powerful drugs in terms of affecting bowel motility. Sebo can also be caused by other things like abnormal gut anatomy. For example, if the patient has had an abdominal surgery, removal of the last part of the small intestine, or if they have Crohn's disease. Some people that have Crohn's disease, they develop strictures within their small intestine, scar tissue, where it gets tight and narrow. This can create a pocket where sebo forms. Then last but not least is low stomach Stomac acid. Stomac acid is there for a reason. When there's low stomach acid, then this allows bacteria to build up and this can create sebo.

Because in all these cases, you're saying why these bacteria are hanging around in here? And you say one of the reasons is maybe food is hanging around in here, whereas actually it's supposed to be pushed through this first part of your intestine, and then it sits around in the large intestine afterwards. Is that my hazy understanding of what's going on?

So if you think about stagnant water, Jonathan, it's stagnant water where the mosquitoes form, right? And in the same way, it's stagnant intestinal fluid where the microbes build up. And that stagnant water could come from abnormal motility, where things are just not moving through and they're just pooling and sitting there.

And that's when you say abnormal motility, because that's not a word I think we use all the time. You're saying it's not being flushed through, but actually this part of our guts is supposed to be flushing this through quite fast, Will?

Well, not necessarily fast, but at least things are moving. And if things are not moving, then they're just sitting there. And when they're just sitting there, then you create this pool where the bacteria can start to multiply and grow, and you can create sebo. Or alternatively, if you have one of these abnormal anatomical issues, then that also, for example, if you have a stricture, then fluid will build up in front of that stricture because things are slowing down in that specific location. That's really what you're seeing here is whether it be pooling of the fluid or if it's low stomach acid, it's the fact that we're just not keeping control over the bacterial numbers because of the stomach acid issue.

Are there certain types of medicine that are common that could bring on sebo?

We were just talking about the stomach acid. If we were to say, what is the number one cause of low stomach acid in the UK and the US? It's very clear. That is the use of proton pump inhibitor drugs, which actually cut stomach acid production. These drugs, it's not really surprise, have been linked to increased risk of developing sebo. If you are a person who's using a proton pump inhibitor and you have developed sebo, then one of the things that we would really want to do is build strategies to try to get you off the proton pump inhibitor, which allows your body to fall back into balance.

I think you're saying if you can, it's best to understand what the root cause of the problem is and treat it. What are the other treatment options?

The typical approach is for someone to say, take this antibiotic, to stop eating fiber. This actually is problematic. Although this might work in the short term, the treatments have the potential for long term collateral harm to the gut microbiome. There was a study published in Nature Communications that I love where they found two major risk factors for developing small-intestinal dysbiosis, which basically means sebo. The two major risk factors were reducing fiber intake and recent treatment with antibiotics. When our conventional therapy is just antibiotics and reducing fiber intake, perhaps we're actually creating problems for ourselves. This may explain why sebo relapse rates are so high. Hi.

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So it's not to discredit antibiotics. There's clearly a role for antibiotics in the treatment of SIBO, but I think that they have to be measured and controlled. We have to be very thoughtful about this. We have to remember that, and this is, I think, one of the big lessons when it comes to Zoe, you don't fix the microbiome by destroying it. You fix it by building it back up. Going back to this prior study in Nature Communications, they found that consuming fiber actually protects the microbiome. Now, this can be hard to hear if you're a person who's had sebo because you're probably yelling at your podcast right now saying, Dr. B, fiber hurts my stomach. I don't feel well when I consume fiber. We have to be smart about this. The way that we do it is to start with a low FODMAP diet. Because low FODMAP sources of fiber, they produce less gas. They will make you more comfortable. And then what you can do is ramp up over time as you start to reintroduce those FODMAP foods eventually.

And we discussed that really in detail, didn't we, on another podcast on FODMAP. So I think if that's relevant for you or anyone you know, I would actually I would really recommend that because I think Will did a great job talking through at a high level how that works and why that's relevant for people with these particular problems. Our team that was researching this also found one study that reported a 29% drop in hydrogen from bacteria after only two weeks on a low FODMAP diet. So that sounds like pretty promising stuff, Will?

Yeah, that is promising. And there was a little bit more in that study that was interesting. They actually used a probiotic called Sacromyces bouvardiae. In this particular study, the evidence indicates that this probiotic Sacromyces bouvardiae, when used alongside a low FODMAP diet, actually increases the reduction. Jonathan, you mentioned 29% drop in bacterial hydrogen excretion, and actually you can crank that up to 41% by doing both. So both Vofod Map with the probiotic together. Now, it's really important for people to understand that it needs to be the right probiotic. Probiotics are not universally and categorically the approach to healing from SIBO. If you choose the wrong one, you can actually make your symptoms worse, which actually brings me to my third and final myth that I want to bust, Jonathan.

Hit us with it, Will.

Antimicrobials. There are many people out there who believe in herbal antimicrobial protocols and will elevate them as if it's safer than using an antibiotic. I say, no, I don't think that that is true at all. Antimicrobial is synonymous with antibiotic.

These are ways to kill bacteria inside your gut.

Right. We're destroying the bacteria. Either way, that's what we're trying to do. The difference is that one is in supplement form and the other is a tightly regulated medication. Now, the problem is that the one that's in supplement form, not only is it less regulated, But there's less research to demonstrate the efficacy or the risks. When it comes to being evidence-based, and also the way that I approach these issues clinically as a medical doctor, is I'm thinking about risk versus benefit. I want to know that the benefit outweighs the risk. How can I possibly do that if I don't know what the benefit or the risk is in this particular case? From my perspective, I would rather go with the thing that I actually know what I'm getting myself into than the thing that sounds attractive, but We have no evidence to prove it.

Will, pulling all of that together, what's your verdict on sebo?

Here's my takeaway. Sebo is real. I am not trying to sit here and make it sound like sebo is not a real thing. It is. It's an overgrowth of bacteria in the small intestine. I want people to understand that there should be a cause for sebo. Things like abdominal surgery, medication, altered bowel motility, the way your intestines move. We need to find what that is. We need to understand the root cause of the problem. Now, new research is suggesting a link between sebo and numerous other conditions in the body. But our knowledge at this point is still quite limited. I'm not quite ready to sit here and say SIBO is causing this or this is causing SIBO. What I want is to see more research, more evidence emerge so that we can understand this more completely. Nonetheless, If you are being diagnosed with Ceebo, the way that we approach this is, yes, we treat with antibiotics, but no, we don't cut our fiber. Instead, we transition to a low FODMAP diet, and we gently we start to reintroduce FODMAPs as tolerated, and we ramp up over time. The approach, by the way, Jonathan, I should mention, so you gave a shout out to our prior episode on the low FODMAP diet.

Absolutely, you should listen to that episode if this is something that you're dealing with. The second episode that I would recommend is actually the protocols after antibiotics that we did between you, Tim, and I. The reason why is because the approach is the same here. When you take the antibiotic after you're done, we want to rebuild the microbiome. That's what we talked about in that episode.

And so I'm guessing fundamentally, there's a similar story here, which is that you don't want to throw the baby out with the bathwater. And this, I guess, is your fear of ending up eating no fiber forever and having this really damaged and restricted microbiome where it should be. We know how important that is now for our health. And so somehow, I think we'll If I understand right, you're saying you've got this problem, so you got to understand how to deal with it. But in the long run, you want to be getting onto a diet that is going to be able to support your health. And rather similarly to the conversation we've had about my living with There's a lot of food intolerances in the past that potentially you can make changes over time that actually can get you to a place where you are eating a lot of fiber, you are getting a much better microbiome with a lot more of those good bugs inside it. And that is where ultimately you're suggesting people want to end up.

My perspective on this comes from, I want us to be thoughtful about the way that we approach this. I don't want our approach, which is what is currently being done, is to destroy the microbiome and continue to destroy the microbiome with the hope that somehow we will be better. It can make you feel better for a short period of time, but it actually is not getting you away from this problem. The way that we get you away from this problem is through healing, healing the microbiome, building it up, nurturing the good bugs, and supporting them. When we do this, we are actually reversing dysbiosis. I want people to think about this as a dysbiosis or a damaged gut microbiome. When we reverse it, we can take it to a place where not only is SIBO not present, but we are elevating our health, we are rising the tide on our health, and we get the benefit of a healthy gut microbiome throughout our entire body. That's a big part of what Zoe is all about. We want to help you heal and nurture your microbiome and take it to a better place.

Well, thank you so much for that. I think that was a brilliant whistle stop tour of something that is, I think, new for many of us, and I think as always, shows you some of the opportunities and challenges as there's this new area of research and not all the answers are clear. Now, if anyone listening to this has ended up being more interested in knowing more about their own gut microbiome, having heard Will so elegantly explain why it's so important for all of our health, then you may well be interested in learning more about becoming a Zoe member. As part of that, you get to test your own gut microbiome and understand how many of these good and bad bacteria you have. This is something I do regularly. And most importantly, get this personalized program to help you to understand how can you adjust what you're eating for you and your body in order to support a healthy microbiome and in order to help you feel better now and hopefully live for many more healthy years in the future. Now, you can learn more about this. Simply go to zoe. Com/podcast, and you can also get 10% off your membership there.

As always, the Zoe Science and Nutrition podcast is not medical advice. It's for general informational purposes only. If you have any medical concerns, please consult your doctor. I'm Jonathan Wolf.

And I'm Will Balsworth.

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