106- Is the FODMAP Diet the Best Option for SIBO and IBS with Angela Pifer

Bryan: [00:00:15] Scientific research about the human body can be very confusing. And we are seeing a lot of that confusion right now in looking at how viruses interact with our bodies.

And what gets even more confusing is when research is used to make broad treatment plans that are adopted very quickly. But then when new research that trickles out, showing these protocols might not be the best option. It can be a slow process to change the course of these treatment plans. What's up everyone.

I'm Bryan Carroll and I'm here to help people move more, eat well, and be adventurous. And in today's episode, Angela Pifer and I are going to talk about how widely used the FODMAP diet is for treating IBS and SIBO and how the research might not fully agree with the current uses of the FODMAP diet. We are going to be dissecting a lot of research papers in this episode, so let's get this party started.

Angela Pifer is one of the nation's foremost functional medicine, nutrition and health experts, and an accomplished speaker and radio personality for 25 years in the health and fitness industry, and the past 15 years as a functional medicine nutritionist focusing on the areas of digestive health, functional gut disorders, I roid autoimmune and SIBO.

Have earned Angela recognition as a GoTo gut expert who can show even the most health challenged, how to restore their gut health and vitality. Thank you for coming onto the show, Angela. 

Angela: [00:01:42] Thanks, Bryan. Thanks for having me.

Bryan: [00:01:44] Of course. And so you've been in the health field for 25 years, which is a pretty long time.

You've seen a lot of changes, I'm sure. And then especially the last 15 years in the functional medicine side of, Of it as well. So can you talk to us about your background? What got you interested in? I would love to hear the changes you've seen over the years. 

Angela: [00:02:03] Oh my goodness. Well, yeah, I was trained through Bastia university and, before functional medicine even became a buzz term.

Yeah. This is how natural paths are trained. This is how nutritionist at Basti are our trains. You know, we're, we're, okay. Used to looking for the root cause and treating the person as a whole and not running after symptoms, you know, and that's kind of the crux of a functional medicine as a whole. my background, my, I was a, trainer and wellness advisor for years.

I did a lot of radio, and around wellness for people prior to stepping into nutrition. my, my love at that time was actually gonna go down the route of, being a psychologist and getting my PhD in psychology. and I turned on a dime. I took a nutrition in nursing three Oh one at Basta, excuse me, at the university of Washington.

In my senior year and just turned on a dime. I didn't know, you know, I, I knew how to eat healthfully. Don't get me wrong, I didn't know nutrition as a field, but when I was sitting there amidst, you know, three to 400 students, and they were talking about hot dogs, hamburgers and Mac and cheese as major food groups for kids.

Oh my God, I gotta do nutrition. So it was like. Well, like shift shift gears. And thankfully bast year, it was a stone throw away because as I looked at all of my options in Seattle, being a Seattle girl living here my entire life, it was, it was phenomenal. I still live about seven minutes from last year.

It's with great. So, I trained, through their master's program in nutrition. and then I've gone on to get, certification of functional medicine. And we, we really practiced. I mean, woke medical providers, practice integrative medicine. We practice functional medicine. It's just, it's just the nature of what we do when we evolve.

And really. Great teams to support patients and work with patients and treat each one as an individual and treat the patient, not the labs. We look at the patient. 

Bryan: [00:03:55] Unfortunately, those a major food groups for children still seems to be around. So that hasn't changed much in 25 years. But that could be, a lead into the topic today, which is going to be around IBS and the FODMAP diet.

So can you talk to us a little bit about, IBS. In general, like how many people, percentage of people that have it and, different conditions that could fall under the category of IBS. 

Angela: [00:04:21] Yeah. Would you say, so in the U S population, the last study show about 10 to 15% of the population has IBS, which is a lot of people.

When you start to look at that population, what's, what's interesting to me, I mean, being, being in practice for this long, I worked with, IBS and functional gut disorders from the start. I worked with emotional eating from the start, which really tied into my psychology, you know, degree and all that education.

And so as I went through, there seemed to be a shift in gears in terms of patient presentation about seven years ago, and my colleagues that are in this field say the same thing. All of a sudden SIBO came. Blair, you know, the train just hit the station. It was very interesting where we knew what to do for IBS, which was beautiful.

Worked for 99% of the people all of a sudden stopped working, like sea boat came on. So I had to change gears and figure out what is this, how do we treat it? And this group of people needed so much more handholding. So we have this group of IBS patients in the U S right. And it's actually. Studies are showing that.

depending on the study, and I know this is a, this is a wide range here, but four to 78% of people with IBS actually have SIBO. Oh. If you go to your doctor with IBS symptoms and they're running all these other tests, you go to your GI doctor. It's a, it's a functional presentation. You don't really see.

Know, they don't see immune cell changes in the gut. They don't, you know, they're not seeing, you know, microvilli, Changes. They aren't seeing physical changes. They're seeing that when they go in the gut spasms a bit, they see other symptoms that people would have. You know, where the Rome criteria, you're going to have a certain amount of, a cramping, loose stool, you know, that sort of thing over a period of time.

And then you'd get this diagnosis. But you know, you get that diagnosis and you, you kind of be your son on your way. So. is we look at this, we really need to see as we're looking at IBS, irritable bowel syndrome, how many of those people actually have SIBO, how many have IBS? and what can we do to help them?

Like we really have to identify what it is first. 

Bryan: [00:06:24] And so you hear different terms, IBS and IBD thrown out there. Are they interchangeable or are they different? 

Angela: [00:06:30] They're not. IBD is inflammatory bowel disorder. and though IBS can have a little inflammation. IBD is in a whole nother world and realm.

Yeah. It's just there. They're just completely different. So this isn't Crohn's, this isn't ulcerative colitis. This isn't any Epic lettuces. you know, irritable bowel syndrome is something else. and it can be, You know, learned over time, anxiety, stress, innovation issues. There's a lot of different issues that can come with it.

When we start to jump over into the SIBO realm, we're looking at different causes for that. there's something that is affecting motility. or interfering with motility within the small intestine that is allowing a niche to take hold and more organisms build up in that area. And although we have, you know, way more organisms in the large intestine into the trillions than we do in the small intestine into the millions, we're supposed to have a microbiota there, but we're not supposed to have too much, you know, so when we eat foods and those foods pass down through that overgrowth.

there's a fermentation that's happening as those organisms breakdown in deductible fibers that we can't break down ourselves. And when that happens, they are consuming those in there creating this gas  you have two things that go on for people with IBS and with SIBO. There's this osmotic shift from foods that come down drawing more water and more irritation into the small intestine, which carries over into.

Know, loose stool for people, or you can have too much fermentation going on from that overgrowth and that, you know, there's some stretching distension in an area that should not be distended. there's pain, there's bloating, there's stolen with the intestinal track, and there's, there's just a lot of symptoms that can come with it.

Bryan: [00:08:14] And when you're talking about dissension, some people can look pregnant like six months pregnant or whatnot, and I can have him pretty quickly now since it. it's a bacterial overgrowth. Is there a specific strains that's usually involved or does the strain not matter as long as something's overgrowing?

Angela: [00:08:32] Yeah, so I'm, I like to say SIBO stands for small intestinal bacterial overgrowth. But when we look at SIBOE, there's actually organisms that aren't bacteria. The archaea that produced, the  that produce methane are not bacteria. So I like to say it's just about small intestinal bowel overgrowth is my favorite way to say it.

and there are different organisms at play. What's really interesting is, dr Pimentel out of Sierra Cedar cyanide and the mass program. Is mapping the small intestine when we've not had that map before. So, I think in the coming years we will have more and more information on the small intestine and a little bit more, Specifics on what is involved here, you know, as of yet, you can go in and do an aspirate. You can go through, an endoscopy down into the small intestine. Getting into that upper, you know, the duodenum, to do the jejunum to the ilium, 20 feet of small intestine. And with that, two of you can basically go down into the duodenum and the upper edge Regina, pull it back out as you test that, pulling some fluid with it and you can culture it to see what's there.

That's kind of the gold standard so far, seeing what's there. they created a device that actually, collect that, and goes down further. and so they're going to map that out. So we'll know more. I mean, to date, we've, we've had that upper GI aspirate that they can test. And then we've also had stool testing to look at.

That stool is not looking at anything small intestine. So, you know, so, Klebsiella pneumonia, equalize and not the, not the pathogenic, one of the, the virulent form. and then, you know, R K I'm with antigens there, you know, the, the M Smithy I were probably the most prevalently and bald.

but there's definitely more, then that, and we'll know more is that, the masters, program is continues. Yeah. 

Bryan: [00:10:19] I like how you call it small intestinal bowel overgrowth because you have SIBO, you have a CFO for the fungal, and instead of just combining them all into one saying, I think would be a lot easier.

Because then you started to get a little bit confused and the whole research into the microbiome and everything is so fascinating because it's like you said, we're just kind of gathering information, data and seeing what's there. And then the next. Five, 10 years, we're going to learn a lot more about it, but right now, it's kind of the information gathering period.

Angela: [00:10:51] Yeah. So the stool sent a stool testing. That's done. as we look at, Rob Knight and Dr. Gilbert, basically they created, a type of sequencing a PCR. RS 16 sequencing to look at stool sampling. And they use that in the lab. They use that in their labs for studies when they're actually testing, their subjects, they're doing, multiple, like hundreds of different samples to create this database and use it for comparison.

As we kick over and start to look at all the stool sampling that's offered through practitioners and direct to the public. there offering those services based on that style of testing. But that style of testing was not meant for a single sample. and there's also no interpretation. We have no ranges for healthy subjects because.

Honestly, a hundred people could have, which they wouldn't, but they could have the same microbiota and they're all reacting differently. We have different phenotypes. We have different reactions to our environment and what could be, you know, veer or pathogenic. And one person is not in the other. So, it's really, you know, if you're looking at GI map, Genova diagnostics, doctor's data, all the stool sampling that's being done, that's all based on that.

Testing, and yet we don't have a way of interpreting it. So, it's interesting to hear both of them speak and they're, you know, they, they don't see much, Oh wait, scientific weight put on any of them, any of those, a stool, sampling, reports. And so it's quite interesting as we start to look at that, or, you know, people are really trying to figure out what's.

What's going on within themselves. And there's a, I think a lot of practitioners are leaning on those readily, and yet that's not what they were. That style is not what they were meant to be used for. what's also interesting is that we've got to, you know, we've got a virus. We've got, you know, a hundred times more present in our microbiome.

we've got, our fungus zone. We want to say that. And, it's, I think it's quite interesting where. it's inexpensive to run the PCR testing. And, that could be readily available to the public. And yet we have all these other things going on within our us. You know, even if you ran all of your viruses, and let's look at the list, what's the issue.

So it's kind of the same thing. You've no idea what's actually being Bureau Lennar reacting in you. So it's interesting as we just look at the stool testing as it relates to any of the SIBOE studies that have been out there, and you know, how much of a conclusion can we draw? 

Bryan: [00:13:19] And this is probably gonna take us down an interesting, warm hole that we probably don't want to spend too much time in.

But I've heard Karen Krishna and talk about the stool samples as well. And I know there's a lot of practitioners out there that are. Like you said, they're taking those stool samples and then they're creating protocols and making, decisions on treatment process. Based off of that. Do you think at this time we should not be treating that way and we should be getting more data?

Angela: [00:13:47] Yeah. So, I don't run the stool samples at this point, knowing what I know, I don't run those labs. When I see those labs, they're interesting. Do we see patterns over all that are overgrowth? Do we see patterns over all that are undergrowth? do we, I, I love all the digestive markers. You know, are they a malabsorbing fats?

are there, pathogenic. species present. Like there's, there is some info to gather from those, but the idea that we can actually look at just the PCR testing and say, ah, your high end, this one and your low and this one, you have X, Y, and Z, or you're high in this one. That's your issue. We're going to treat that  show.

Show me the studies that back that up. 

Bryan: [00:14:27] Awesome. Well, when it comes to SIBOE, is there any specific ways to treat it or is the treatment process pretty widespread? What would you do for it? 

Angela: [00:14:39] Yeah, so see about what's really interesting and why it's so difficult. you know, as we're looking for, it's considered a recurring condition.

and why to me, it's considered a reoccurring condition is because people are trying to treat it as a primary issue. SIBO is a secondary issue. It's not primary, meaning that it is set up for other reasons, and you have to get to that piece. You have to figure out what set it up and treat that to resolve.

SIBO. to me, anyone that gets a fresh test goes in a round of antibiotics and walks away, probably had just more of a, a bit of dysbiosis. They, you know, there was a little bit of change gathered from that, but, you know, to have a full blown case of SIBO taking antibiotics, antibiotics one round, probably something else is going on.

and it, I, I don't know that it was necessarily SIBO. So Steve-O is a secondary condition. And so from that, as we treat. we get to the root cause. What is interfering with motility? What is affecting motility. You know, taking a step back, looking at the patient overall, and then, there may be a point that you have to treat SIBO directly, and that's absolutely fine.

and then with that, we would treat that, hopefully, cleaning up the diet, supporting digestion, supporting, liver bio flow. And, Doing herbal, you know, antibiotics that would, that would usually be the first. A step approach. we always have to look at this as doing the, the foundational piece first, and that's cleaning up the diet, supporting digestion, supporting motility.

I'm getting to the root cause and then figuring out at that point. Do you still need to treat? How has the SIM, how's the patient feeling? Cause we're treating the patient at the lab. We never want to run breath test after breath, test and treat, treat, treat, treat, treat. We have to treat them 

Bryan: [00:16:23] as interesting about the antibiotics because that's going to kill off the, bacteria.

But if it's not bacterial base, if it's something else like of fungal overgrowth, yeah. You'd be wiping out the potentially beneficial bacteria that could be trying to keep the fungal overgrowth under control. 

Angela: [00:16:42] Yeah. it's honestly very good point. they've done a couple of studies on that where people, and there were a hundred subjects in the study and, everybody presented the classic SIBO symptoms and they went in and they actually did the aspirate.

we, we talked about it a little bit earlier and when they cultured that third of the people had SIBO, a third had CIFO, which is small intestinal fungal overgrowth. And a third had both. So of those hundred subjects, two thirds of those people had a fungal issue in the small intestine. If you give them antibiotics, it's going to aggravate the fungal issue.

doesn't affect the fungal issue and whew, thanks. He's opened up a lot more niches for us. Well, that's again, that's one of the reason why I always think herbs first. antibiotics are for people that can't handle herbs. No matter what you try. It doesn't matter if it's a tincture of something they don't do well, antibiotics might be helpful, but you also do geese support as you go through that.

You have to, because we can't make people 

Bryan: [00:17:38] work. Let's talk about. Like from a food and dietary standpoint for IBS, a lot of the recommendations right now as a FODMAP diet. and I would love to hear your ideas around that. But first off, what is a FODMAP diet? What does it stand 

Angela: [00:17:53] for? Yeah, it's an acronym.

It stands for fructose. A Brookdale like a saccharides di saccharides, monosaccharides and polyols. And basically it's different foods and indigestible fibers that we bring in with our diets that can, cause two things. One, that osmotic shift that we talked about. So, the dissect saccharide within that group, within that acronym is lactose.

And, if people don't readily digests lactose. lactose will build up in the small intestine and it'll cause an osmotic shift and that will cause loose, watery stool in cramping. It's very similar with the other groups of FODMAPs, but it's per the individual, what does the individual react to? So basically, the FODMAP diet was created for IBS.

It wasn't created for SIBO. Um, it turns out that it can work quite nicely for SIBO to calm down symptoms. Because, you know, pretty much everybody was SIBOE has IBS like symptoms. And as we start to look at that, you know, you can, you can slow down that osmotic shift. You have it, you know, you have a population that's more sensitive to GI symptoms and reactivity, so you can calm down that osmotic shift.

And you can also, with the diet, if you go all in with it, you can remove foods. that are passing by that overgrowth that they were consuming and producing that gas, which then caused symptoms as well. what we have to highlight, however, is that the diet is not in any way shape or form a direct treatment for SIBO.

It doesn't start out the organisms. And that's really why everybody went all in with it for so long. And that's why it's still to this day. You know, UFC Ebo, you go on a FODMAP diet, you can't quote feed what's in there. You're not, you're . Even though when it's passing through, they're consuming and producing that fermentation.

It's not fueling a growth of organisms in your small intestine. And that's the difference. So it's not as if. You know, for a visual, you've got SIBO in a Petri dish and you're putting some FODMAP on it and it's bubbling over. It's not getting, growing in port, worse and worse, but people are equating it that way when they're eating because they get symptoms.

And that feels like, Oh, it's, you know, SIBO is growing bigger and bigger. Like, no, you're just getting that fermentation reaction. So as we look at the diet, You know, being in practice and focusing on Steve O for so long, I see person after person that my typical patient has been, had SIBO for, you know, three to seven years and they'd been through, seven to 10 doctors and it just antibiotic round antibiotic round, herbal herbal or roll antibiotic round, tons of tests run and they're never getting to the other side of it.

And they'd been on a FODMAP diet the entire time. And there's been periods of time where they're only on a really restrictive FODMAP diet. And you know what? They still have SIBO. It doesn't starve it out. And we've got studies that show this. There's actually very good studies that look at, the low FODMAP diet feeding people.

three, two, I'm sorry. Pardon me. seven to nine grams of FODMAP for the low FODMAP diet and 50 grams a FODMAP for the high FODMAP diet every single day. For people that have SIBO for three weeks or six weeks, methane doesn't go up. Hydrogen doesn't go up on a lactulose breath test, and then the low-FODMAP, it doesn't go down.

So it's not starving it out and it's not making it worse. That's what's interesting. So you, you take a group of people that already have SIBO, and, uh, the typical typical person would probably consume around 17 to 23, 24 grams of FODMAPs within a day. and so you take that person and you're near tripling.

The amount of FODMAP that they're taking in, which is like massive amounts for three weeks or six weeks, and the levels don't go up. Yeah. Yeah. It's very, so,  symptoms go up. some symptoms do actually resolve. so it's just a, it's interesting. And what I also think about too is we know with nothing production methane, Further slows the intestinal track. And so I start to think about that because some of the studies are looking at methane dominant. see bone patients and they're feeding this beating high FODMAP loads. so with that, if you were then fermenting and you're producing more methane, you would think there'd be more slow down, which would create more of a niche for SIBO to grow.

And yet, when you test it, methane production is not up. There's not more with antigens. They're producing more methane. Mm. So. When we look at the FODMAP diet, what I've seen time and time again is that not only do you have a person that already has dysbiosis, they already have IBS symptoms. They're already dealing with chronic symptoms.

Now you're sticking them on a crazy restrictive diet and, affects them emotionally. It affects them socially. They can't go eat anywhere. They can't eat with their family. You can't produce, you can't make a meal. For the entire family that you're going to enjoy. and you know, yes, you can on a low FODMAP diet, there's recipes that you can use, but any of the usual family meals have things on them.

You know, we're in the FODMAPs. It's, it's, it makes it very difficult. So people start eating, you know, a piece of chicken and carrots every single night. They do, they, they, and I say with great respect, they dumb it down. They, they look at the diet and they say, well, I'm just going to eat simply. You know, really restrictive because anytime I go off this, I have a reaction.

I'm going to make SIBO worse and I want to get rid of SIBO, and they're just stuck in this. Little ruts and they can't get out of it, and they're backed into a corner. And that's what going on. This diet does to the vast majority of people that go on it. And the other carbohydrate altering diets are no better in terms of we've, we've got FODMAPs, we've got the SIBO specific food guide.

And then we've got the BI phasic diet, which is basically the SIBO specific food guide combines button-up and SCB. This specific carbohydrate diet, so it's more restrictive than FODMAP and the  and why that was created by Alison Seabeck, or she feels that there are some polysaccharides that are in the a low FODMAP diet that might still be triggering for people.

And then the BI phasic diet basically takes the SIBO specific food guide.  introduces it in phases, so none of those diets have. Those other two diets don't have any studies behind them. They're more restrictive than a FODMAP diet. They can't be any better. They can't be like, it's, it's gotta be the same thing.

You're going to alter carbohydrates that much within a diet. You're going to make the, the gut, the intestine, more dysbiotic. if somebody has methane, um, SIBO and it's more constipated, you're pulling all those fibers that help keep them regular. You're sticking on something that is, I'm really restricted.

It really restricted and, you know, affecting them emotionally. So it's, we're really at this pivotal point where when we start to, you know, the SIBOE symposium that happens down in Portland. each year, last year, they had a full track that was on, emotional eating and disordered eating around SIBO.

Hmm. Um, the SIBO specific,  diet changed to the SIBO specific food guide. And that's wonderful. And she's always said, miss Alison C Becker's so lovely. She's always said that, you know, You know, this is a guide. These are foods that are less likely to cause symptoms in somebody that has SIBO. And yet that's not how once that diet is applied and everyone like grabs it and runs with it, that's not what happens in the day to day life.

everybody is going, going in with both feet, fully restrictive and thinking that I've got to starve it out. I've got to start it out. And in doing so, they starve themselves emotionally. They starved themselves physically. And, they start themselves socially and you know, to me is we're looking at rebalancing the intestinal track and digestion.

as you know, you can't be under a bunch of stress and rebalance that you want relaxation, you want flow, you want connection with your food. You want, that food to give you energy that you want that food to support your immune system and help balance everything. And if we're on a really restrictive diet and have such fear around food and reactivity and concerns, if there's ever a symptom, which there's lots of symptoms when we look at SIBO, Mmm.

It's, it's, it's, how does that digestive system flow? 

Bryan: [00:26:16] It's kind of interesting because if you. Restrict the diet so much and you're losing all this variety of, foods. You could be putting someone into a situation, like you said, where they're only eating two things and then they're going to be losing out on micronutrients.

It could potentially change the microbiome. There's a lot of impact over the longterm. They could develop some type of sensitivity or whatnot to it as well. And then if, if that's the case, then what happens? Now? You can't eat anything. You're just on like the elemental diet. Right? Yes. So, yeah. Yeah. It's, it's, it's a super interesting conversation that have in it.

I also find it very interesting that low-FODMAP super high FODMAP, the methane never changed. That's very interesting, 

Angela: [00:27:02] right. Right? And when you really get in and look at the studies, you have to really, as, as we all should, right? We should never take the title of the study at face value, nor the summary you have to get in and actually look at what they studied.

What did they compare, what was the finding. and when you really delve deep into the studies, There's a lot of studies that lactulose breath test. The whole premise of it is that you, you do a food prep for 12 hours. Basically the day before you do the food, the, the breath test, you're going to alter your diet to reduce the fermentation load in your colon.

So when you do the breath test, you drink lactulose, which ferments all the way down through the small intestine, and you can then detect an overgrowth that fermentation and offgassing that exchanges from your lungs and out your breath into the breath test. You actually can see if there's an overgrowth along the small intestine.

So you do the food prep the day before you fast for 12 hours, and then you, you know, get up in the morning, wait two hours, and you do the test. you do the test for three hours. You don't eat, you know, you're, you're not eating prior to this test. But when you start to get in and look, a lot of the studies that are looking at low-FODMAP and a breath test, a vast majority of them did not food prep properly.

One of them provided, Ooh, that was high FODMAP. and, they actually breath test. You know, they might do a fasting the first one, but then they breath test while people are eating a breath test for up to 15 hours. And then they're looking at that data and saying, look what we found. Like, well, you're not even, that's not, that's not, we're not looking at anything that that test was validated for.

That's not how that test was validated for use. So you really, as you're looking at, so as a clinician, as you're looking at the SIBO studies and the FODMAP studies and the, the breath testing studies, you have to look at these. I'm just point by point, and that's why I wrote, you know, if that two page article near 70 citations, like we have to look at every one of those studies and say.

Wait a second. How did you test this? This is not how we, you know, this isn't how we test this. You can't draw conclusions off this. We don't. We don't even know what you're looking 

Bryan: [00:29:12] at. It is a great example of the difficulty around nutritional and health studies is because there's so many different variables that can happen.

There's so many mistakes you can make in the process. Do you have all the observational studies where people, you know right out, Oh, this is what I ate over the last 15 years. Well, do you actually remember what you ate over the last 15 years? Cause I don't remember what I ate for breakfast yesterday. So 

Angela: [00:29:40] yeah, that's a big one.

So most of them are questionnaires.  then say, you know, in the last. Last six months or last year, on average, how many pieces of fruit did you eat on a weekly basis? And that's then what they then say, aha. yeah. I'm conjecture here, but you know, multivitamins are linked with cardiovascular disease. You know, it's, they're, they're looking at this observational data that's not even, it's not real.

It's not a, correct. A review of what a person has done over the last year. You can't even, you know, if you feed somebody Amil where they've done this study, if you feel some feed somebody a meal and take that meal away and you give them a piece of paper and say, write down what you just had. They underestimate what they age.

We all want to think we eat a certain way. we're, we're good. More often than not, you know, it's, if you start actually tracking which one I have, when I work with anyone, they actually track in their journal everything by mouth, how they're feeling. any symptoms that come up, any supplements that they're taking, they track all their lifestyle.

you know, activities, how much they're sleeping. I look at that for four or five days before we put a plan together, because doesn't matter what they tell you, it matters what they tell you. I don't mean that it's a they're, they're going to tell you what they think of everything, and then you get to see some things in practice.

And what I always hear. Every single time. Oh, that week wasn't my usual week. You know, I eat a lot better than that. Oh. We had this big thing come up at work. Well, that's, that's our life week by week. Right. If there's always an event, we're always not home every night. So we have to look at, you know, what is actually in, in motion for the patient as well as we're working on that.

And that's, that's I'm a hub. With all the doctors in when, when I work with the patient, I'm definitely a patient advocate. As I'm working with my patient and I try to connect all the doctors that we're working with as that hub and actually show them, you know, you'd have 15 minutes with this patient and you're treating X, Y, and Z.

That's great. This is actually what's happening day to day. And when they see that they're, Oh, let me, you know, I didn't realize that. So it's, it's just interesting, you know, we've got a, we've got a really  kind of nail down what's happening on a day to day patients for our patients, so we can make the best use of our time and treat them properly, 

Bryan: [00:31:59] which let's go into different treatment options.

So since, low FODMAP diet, might change, it might not, we don't fully know because the methane levels. 

Angela: [00:32:11] It won't change it. 

it actually makes people more dysbiotic. it, it, yeah, it, it, it doesn't change it, it doesn't start out the organisms, it makes them more dysbiotic. all the, all the media hype out there about a low FODMAP diet lowering histamines is not true.

the study that I break down in the article that I wrote, did not find a statistical significance and they didn't even test your on histamines properly. and there's over a hundred Google results. Excuse me, 100,000. Pardon me? Google results. four, a FODMAP and histamines like, it just spread like wildfire and it, we're not going to get it back.

So, it, it won't. So, so I want to be mindful here because people with IBS and people of SIBO that have IBS symptoms are going to have to alter their diet in some way to settle symptoms down so they're not debilitating every single day. It doesn't mean you have to go on a restrictive plan. It means that you can look at the list of foods and say, these are foods that are a little bit more likely to, you know, more likely now a little bit.

They're more likely to cost them gems and people that have IBS or SIBO. Um, are there things here I'm meeting on a regular basis? could I track my intake and track my symptoms? What am I symptoms flaring? and for a person, you know, there's, there's auto-immune present. If there is, if there are other conditions that are really getting fired up by GI symptoms and a person's.

reactions to diet are so great that they're getting in the way of that person moving through their life. They have a hard time getting to work. They have a hard time sleeping, you know, all of it. That would, they would be a very good candidate for doing an elimination diet with FODMAP plan. But that elimination diet is three to four weeks on the diet.

And then you challenge the different groups figuring out which you are reacting to. as a clinician, when I work with somebody, I can pick it out 99% of the time. What do you know your react to you in the past? Let's track everything, you know, track your symptoms and, what, you know, give me a list of foods that you feel are more safe.

Because sometimes people don't eat everything they eat. Yeah. Four to five days. So, you know, as we look at that, it's somebody that's trained. You can see the patterns, you can see what they're reacting to. We can also reverse engineer it, so to speak, fructans, you know, garlic and onion. Leaks, those are foods that are more likely to cause symptoms for people.

lactose, fructose, those are, except you know, a FODMAPs that are more likely to cause symptoms in people. So we can, we can look at those and alter those first without pulling everything and putting people through, an elimination diet that they don't have to go through. 

Bryan: [00:34:50] Awesome. and then do you do anything with, the microbiome potentially.

Trying to change any of that in your protocols or what, what's your thoughts around all that? Because so many people are taking probiotics. I take him and those four ways or . 

Angela: [00:35:09] Yeah, so again, we've got to treat the individual. there's, there's no, there's no algorithm that treats SIBO. To me, that gets somebody into recurrence because if you look at it as you have symptoms, you're going to test, it's positive or negative.

It's positive. He treats. You move on, wait, now I have symptoms. You go back up to the top. That's just getting people in that recurrence. So, Things in the toolbox are absolutely probiotics or based probiotics, bacillus coagulans. there's, there's good probiotic studies that actually normalize a breath test.

So. You know, we've, we've got to look at the data and we've got to look that the majority of people with SIBO actually feel better on a probiotic, but you can't take anything with, FOS or GOs like those. Basically the FODMAP peace, those prebiotics, you don't want those in your  in your probiotic. And if you react to one probiotic, try a different one. I think sometimes people get really scared off of them. And what I've found too is that, and this is where a lot of the myth is propagated online, is that a person's going along not feeling well, but not really feeling a really bad, Kind of complacent with their symptoms set.

As things have shifted and they start a probiotic and have a really big reaction, and they say that probiotic caused my SIBO. It never  caused theSIBOO. It can't  cause theSIBOO. It didn't. Does not happen, but it flare their symptoms to the point where onset, right? That's where they realize, ah, now I react to a lot more things.

And it's kind of, you know, it's one of those triggering events, but it didn't cause SIBO. And so now we've got lots of people online saying, you know, it caused my SIBO when it didn't.  probiotics do amazing things. from. You know, I'm blocking pathogens from adhering to the lining. I'm helping to, you know, crosstalk with our immune system, to train it properly.

There's, you know, there's, there's so many good things that probiotics do. different immunoglobulin therapies can be very helpful. and then, You know, supporting the person? Do they, did they have a suppressed immune system? Do they have, poor bile movement? everyone's going to need help with motility and not do you go to the back mood?

it's supporting the migrating motor complex and the cleansing wave that's coming through and what you need to do for that. everyone needs an assessment on digestion and proper signaling. are they gastric emptying properly? Are they signaling digestive enzyme release? do they have issues digesting food, is, you know, are things not moving properly through them?

So it's, you know, it's, it's a really broad stroke when we start to look at SIBO because again, let's set it up what's happening with the, within the intestinal Tresamme. 

Bryan: [00:37:50] Yup, that makes sense. And then you, you mentioned like people having light symptoms or sometimes that are pretty mild. They come on and off.

Would you say that there are mild symptoms or it's come on so slowly that they have kind of adapted to it and they believe that's their new normal or their normal, how they feel, and in reality, once they, I feel a lot better than those mild symptoms were actually a lot worse than they originally thought.

Angela: [00:38:17] Yes. To all. I feel like as people move through that complacency piece, and again, I say that with  with great respect, it's, and we're so used to just getting on with it, especially women. we just get on with it and we've got things to do. And I don't know why I have chronic burping. I don't know all of a sudden why I can't go to the bowel movement, you know, have a bowel movement as often.

I might try some things to settle that down, but. You know, until it's until you're doubled over in pain or in bed for a period of time, don't say, Oh, something's going on. So, oftentimes, it isn't until you clear that symptom to people realize, Oh, I was dealing with that all day long and I didn't, I didn't realize they feel so much better on the other side.

Bryan: [00:39:02] Well, is there any final things you want to touch on when it comes to IBS, FODMAPs, SIBO, et cetera? 

Angela: [00:39:09] Yeah. Yeah. The main thing I'd say is for  patients, if your practitioner is trying to put you on a FODMAP diet or as recommended a FODMAP diet, or does he have a specific food guide or by basic diet, you need a plan of what, why?

First of all, why? Why are you putting me on this? If it's a story about organisms send in my article, it doesn't start about the organisms, so if we just go from that standpoint. let's make sure if it is going to be used, that there is an in and out plan that this is used only as an elimination style diet three to four weeks, and you start challenging the food groups on the other side.

For the patients that are hearing this, when you go on this diet, it is going to calm down symptoms in most people. It is very hard at that point to challenge the food groups because you don't want to bring on more symptoms. You get relief from symptoms, and it's, you know, that's, that's good. But you have to challenge, you have to move past that diet.

You cannot stay on it. It's not healthy. you're going to cause more dysbiosis over time.  you've got to move off of it. So, there's always going to have to be some reintroduction and some adjustments to that. for practitioners listening, you know, the main things that people are using the FODMAP diet are to start about the organisms, normalize the lactulose breath test.

you know, drop histamines. None of those are true. It doesn't do any of those. So you've gotta be really mindful that you're not using this as a bandaid because you have somebody in your office and you, you're just adding it on. Like we have to be mindful that we're only using that with as a smaller group of people.

 I do see about day in and day out, I've got  people all over the world that I work with and, I don't ever put anybody on a FODMAP diet and I get SIBO cleared. All the people that come to me are on a altered diet and we expand immediately. What five foods would you like to bring in that aren't garlic and onion?

So we start with those. We introduce them slowly. We make foods easier to digest. you know, I'll cook foods, eating slowly, mindful eating, all of that really slow people down. it might be that they try a tablespoon of something and it doesn't work. They're going to try that again in a couple of weeks or maybe a month.

We sometimes have to go very slow, and that's, that's what makes it difficult. People, people will think, okay, I'm going to expand. And they'll go eat a cup of something and react, and it's, we just have to go very slow with the introduction, I'd say, with fun, excuse me with  IBS and SIBO. Okay. You're going to need to alter things in a certain way to calm symptoms down, but it's, you're not going to get to net zero with your symptoms.

You have to treat the root cause. and the diet again is just going to be a bandaid. So just be mindful that you're not going on that for the wrong reasons. be mindful that is a practitioner. You're not sticking somebody on a FODMAP diet that's underweight. Me mindful that you're not sticking somebody on a FODMAP diet when they have methane dominant SIBO because you need the fibers.

Bryan: [00:42:09] But in this episode, I love it. Well, people can find you at SIBO, guru.com you'll also have a couple of other websites. You want to talk about those real quick? 

Angela: [00:42:18] Yeah, absolutely. So I have a FODMAP recipe site after all this conversation, right. My eye simply SIBOe.com. And why I offer that is because I help people expand off the FODMAP diet.

And the first step for them is to expand within the diet that were again, where that person is eating chicken and carrots. Most nights. There are a lot of other foods to eat. And I show them how to do it very simply. I also show them how to challenge with different groups, the FODMAP groups on there, how to introduce foods very slowly, and it's a stepping point to first expand diet, and get more variety in and then start to expand it off of there.

so simply simply C  dot com and then my other, I have a low FODMAP bone broth company. it's got prescription gurus on.com. I've got RX, a guru.com, and you can find that online if you're in the Seattle area. We sell at PCC markets, the met market. all the local co-ops. And then you can also order us online.

And again, the main reason I made that is for people that have inflammatory bowel disease, people with IBS, people with a SIBO, that's something that can help heal their gut. And, you know, they can have it on a daily basis without worrying that there's garlic or onion in 

Bryan: [00:43:34] there. We will have all these.

Different websites and the links to the articles that we were [email protected] slash one zero six so it'll all be right there so people can see where to go. Thank you so much, Angela. This was a fantastic conversation. I loved just the depth of it. I think it's super powerful that you were able to, you know, go deep into this type of subject because like you said, so many practitioners FODMAPs away to go and they hand it out and then you go off on your own and you never eat.

Talk to your practitioner again and then you're stuck on it forever. So yeah, the more we can help people, the better. 

Angela: [00:44:12] I agree. And I think as well for, for GI doctors, they're handing this out more often there. they used to not, I think as a field they thought SIBO was ridiculous. The, the last year and a half have been, an about face for a lot of them.

Not all of them by any means, but for a lot of them. And now that they have a FODMAP diet to hand out, they're handing it out right readily. And how often as an IBS patient receive a patient? How often do you see your GI doc? So basically you're, you're getting that diet handed to you and you were leaving that office.

You might see them six months out. You can't be on that diet for that long. and so it's, there's no, there's no follow up with that. There's no, support with that to be had in it. 

Bryan: [00:44:55] Check out your sites. Yes. Thank you so much, Angela. 

Angela: [00:45:00] Of course. Of course. Thanks for having me on. Bryan is a great conversation.

Bryan: [00:45:04] If you want to see a full breakdown of all these research articles mentioned in this episode, head on over to summit for awanas.com/one zero six to access all of the show notes. And if you have some digestive issues that could be related to Zebo, make sure to go over and check out the resources Angela has available for you.

And did you know that I have an entire section with all the different items and resources that I recommend on my website? You can reference back to [email protected] slash recommends next week. Dr Jill, Krista is coming on the show to talk about mold, so let's go learn a little more about her.

I am here with Dr Jill Christa. Hey, Dr Jill, what is one unique thing about you that most people don't know. 

Dr. Jill: [00:45:52] I love to dance and had a chance to dance across three countries in Africa and learn traditional African dance, and it was a blast. 

Bryan: [00:46:01] Which countries? 

Dr. Jill: [00:46:02] Zimbabwe. Botswana and Zambia. 

Bryan: [00:46:05] Wow. Yeah. What will we be learning about in our interview together?

Dr. Jill: [00:46:11] We're going to be learning all about mold and how to break the mold. 

Bryan: [00:46:16] Mold is such a lovely thing to deal with. I love it. What are your favorite foods or nutrients that you think everyone should get more of in their diet? 

Dr. Jill: [00:46:24] Colorful vegetables, absolutely. You can't go wrong. Go for color. Eat the rainbow.

Bryan: [00:46:32] And then what are your top three health tips for anyone who wants to improve their overall wellness? 

Dr. Jill: [00:46:37] Respect your body's need for sleep. Number one, get outside number two, and number three, get away from screens in front of that screen more than you think you are. 

Bryan: [00:46:51] Very true. Mold is a fascinating topic and was a big player in my own health journey.

What'd you can hear about next week? So until then, keep climbing to the peak of your health.