SIBO (Small Intestinal Bacterial Overgrowth)

siboDo you suffer from bloating, burping, farting (gas), stomach aches, abdominal pain, nausea or acid reflux, constipation, diarrhea or both?  Perhaps you have been diagnosed with IBS (Irritable Bowel Syndrome). You may have SIBO.

When there are too many bacteria in the small intestine (they are supposed to be in the large intestine) these bacteria feed on carbohydrates (grains, beans, sugars, nuts and seeds, fruits, and vegetables) producing hydrogen gas and methane.  The bacteria also disrupt normal absorption of nutrients, like B12, and may create changes to the villi and mucous in the intestines causing leaky gut and immune system issues. At the bottom of this blog are some great links to more information on SIBO.

How do we get SIBO? 

  1. Anything slowing the intestinal motility (PPI’s- Proton Pump Inhibitors like omeprazole, pain medications like opiates, being hypothyroid).
  2. Anything blocking movement through the intestines (adhesions from surgeries, constipation, damage to the migrating motor unit that sweeps intestines)
  3. Reduced stomach acid, bile acids, or digestive enzymes from the pancreas which all typically inhibit bacteria in the small bowel.
  4. Failure of the oleo-cecal valve such that bacteria from the colon enter the small intestines.


How do you know if SIBO is what you have?

The lactulose breath test that measures hydrogen and methane.  Your doctor can order this for you and you either do this at home with a kit, or at a doctors office or lab where they do this test. Read more about this test here…


How do I treat SIBO if I have it?

Treatment might include antibiotics using Rifaximine +/- neomycin or metronidazole (read more about antibiotic treatment here… ). Herbal approaches that have been helpful include Berberine- up to 5 gms a day, and Allicin (allimed is the strongest), cinnamon, and oregano.  Two combination formulations that have been used at a dose of 2 caps twice a day for 4 weeks include:

  • Biotics FC Cidal with Biotics Dysbiocide
  • Metagenics Candibactin-AR with Metagenics Candibactin – BR  (you can learn more about this here… )


After eliminating the bad bacteria, it is important to keep the intestinal motility so that the SIBO doesn’t return. Low dose Naltrexone has been used with some success but lacks extensive testing. You can read more about this here…

Long term prevention is most likely maintained by a diet low in carbohydrates and starches. Several diets have been proposed to be beneficial and are reviewed nicely by Dr Allison Siebecker on her very educational web site ( )

Diets that can be helpful include:

  • SCD (Specific Carbohydrate Diet)
  • GAPS (Gut and Psychology Syndrome Diet)
  • LFD (Low Fodmap Diet)
  • SCD + LFD
  • Cedars-Sinai Diet of Dr Pimentel


You would think that doctors would know about this, right? Sadly, we doctors are often slow to learn new information.  When new knowledge is introduced it is met with skepticism or just dismissed. I know that was my initial response when I heard SIBO.  It then gets published and eventually gets considered by those doctors who are searching for answers. It can take decades before the majority of doctors even hear about new innovative approaches. I remember my MD peers dismissing probiotics for a couple decades before the volume of published data became undeniable. I feel SIBO is one of these areas to consider for those suffering from the symptoms of SIBO and getting labels like IBS (irritable bowel syndrome), or no answers at all.


SIBO-The Finer Points of Diagnosis, Test Interpretation, and Treatment

The Second Opinion Series- The Digestion Sessions


SIBO Symposium


Dr. Paul




Olive Oil Best For High Temperature Cooking and Frying Food

olive oilWhich oil should you use if frying, stir-frying, or deep frying your food?

So let’s be clear; steaming, baking, or poaching your food without adding a lot of oil is generally preferable unless you desperately need the added fat in the oil to survive (malnutrition for example).  Many of us do love the taste of oil fried food and if you are going to cook this way (I still stir-fry), which oil is the best?  This study “Monitoring of Quality and Stability Characteristics and Fatty Acid Compositions of Refined Olive and Seed Oils During Repeated Pan and Deep- Frying Using GC, FT-NIRS, and Chemometrics”, (you can read it here… ) looked at olive, soy, corn, and sunflower oils and which produced the most harmful compounds when used for high temperature cooking.

I was happy and surprised that olive oil performed best.  Happy because this is one of the healthiest oils to use in your kitchen anyway, and surprised because I had been misinformed in thinking that olive oil was really only safe when used cold pressed and unheated. Extra-virgin olive oil is still one of the best nutritionally and it is still preferable to avoid high temperatures.

The oils were used in repeated frying sessions at 160 and 190 degrees C and pan-frying potatoes at 180 degrees C. This study showed that olive oil had the least oxidative deterioration and all oil performed better at the lower temperature.  Sunflower oil had the worst oxidative deterioration and production of trans-fatty acids with heat exposure.

Moral of the story:  use olive oil.  This study did not include coconut oil which is another good one to use in cooking.



Dr. Paul


Gluten-Free Pregnancy– Reduce Diabetes!

gluten freeType-1 diabetes is no longer rare. This used to be called Insulin-dependent diabetes mellitus (IDDM). It is now known that the immune system destroys the pancreatic islet cells that produce insulin.  Once destroyed there is little chance they will recover.  Your child or you will need to take insulin by injection or pump daily for the rest of your life.

Type-1 diabetes has been on the rise.  In the years 2002–2005, 15,600 youth were diagnosed in the USA.  In the under 10 years age group, the rate of new cases was  1 in 5000.  I have had about 2 new cases a year in my practice of 10,000 so that fits with my experience. 

It was thought that we didn’t know why the immune system was attacking the pancreas.  I have a few ideas that I will share at the end. 

What if you could do something to significantly reduce the chance that your unborn child would get diabetes?  Turns out that the study “A maternal gluten-free diet reduces inflammation and diabetes incidence in offspring of NOD mice” (read here… ) showed that moms who were gluten-free prevented their offspring from getting type 1 diabetes!

While this study was on mice, preliminary studies are showing that being gluten free for pregnancy and while breast-feeding seems to be protective.  I would add that you avoid wheat and gluten altogether.  Sadly these grains have been so altered, through hybridization and genetic modifications, that our immune systems just don’t recognize these proteins as food and we mount an immune attack.  Inflammation results and there is also the probability that parts of partially digested gluten protein looks enough like the proteins in the islet cells of the pancreas that our immune system thus attacks the pancreas.

The study found that fetal and early life gluten-free diets reduced the development of diabetes and changed the gut microbiota resulting in a less inflammatory immunological milieu in the gut and pancreas (to use the words of the authors).

What this means is that bacterial diversity and certain strains may be more protective than others.  We know this to be the case.  Probiotics (good bacteria) decrease inflammation. It seems that gluten is not only directly pro-inflammatory but also changes the bacterial makeup of the gut.

I agree with this study and hypothesis.  If inflammation in the gut is bad, we should avoid all the things we can that would potentially trigger unnecessary inflammation. So what are some of the other offenders?

1.  Gluten, from wheat and grains (the more refined the worse it is).

2.  Aspartame (NutraSweet, Splenda) our body converts to formaldehyde = autoimmune attack on every tissue it reaches.

3.  Antibiotics (they destroy the good bacteria leaving you vulnerable).

4.  Sugar, junk food– it is pro-inflammatory.

5.  Vaccines (especially aluminum containing and giving many too young). We know that the current schedule shifts the immune system to a more allergic state.

6.  Foods high in histamine (for those vulnerable– see that blog from earlier this week)


I’m sure I’m forgetting a few key ones. Please respond in the comments with the main ones I’ve forgotten.


Dr. Paul





Reduce Your Child’s Risk of Diabetes by Avoiding Cow Milk Formula

nomilkBovine Serum Albumin (BSA- cow milk protein) has been found to trigger diabetes in genetically vulnerable mice and thought to be a mechanism where our own immune systems attack our own islets of Langerhan cells in the pancreas, causing insulin dependent diabetes mellitus (IDDM).  Serum antibodies against BSA have been found to be elevated in children with IDDM.  The amino acid sequence of BSA is similar to that of human pancreatic B-cells, which could explain how antibodies made against cow milk protein (BSA) could attack one’s own pancreas and trigger diabetes. Studies show less diabetes by delaying cow milk protein introduction with greater risk if cow milk formula is introduced before 4 months age and even greater risk if introduced the first week of life. Exclusive breast feeding for the first 4 months is associated with significantly less diabetes.

Gut permeability to large molecules is greatest at birth, and decreases significantly each week of life, making it important to exclusively breast feed for 2-  months if at all possible, and the benefits continue for those who can breast feed for up to a year or longer. These studies make a case for doing everything possible to avoid formula in the early weeks of life when these non-human proteins, like BSA, can be absorbed and interact with the infant’s immune system setting them up for future risk of diabetes, other auto-immune disorders, and allergies. 

I know I am guilty as a physician for excessive worry about weight loss the first week of life, and jaundice (hyperbilirubenemia) which is aggravated by poor weight gain that first week of life. Hyperbilirubenemia (high bilirubin), if allowed to remain high for too long (a couple weeks or more), can result in permanent brain damage (kernicterus). Jaundice should not be ignored, however the quick response to supplement with formula may not be the best idea, if giving mom and baby another day or two would allow breast milk to come in adequately and enable that infant to avoid formula. 

One study showed that liquid formula did NOT trigger antibodies to BSA and thus did not cause diabetes.  It was thought that the heat treatment of the liquid formula likely destroyed the BSA.  This might suggest that if one must supplement with formula early on, use liquid formula. Initially I would also highly recommend using liquid formula that is in glass bottles rather than the plastic containers. 

Take Home message: Breast is best, and giving only breast milk for as long as you can but at least for the first 4 months, will greatly reduce your baby’s chance of getting insulin-dependent diabetes. Other studies have implicated BSA in other autoimmune processes like autoimmune thyroiditis, and we know that gut permeability issues are involved in celiac disease. Healthy patients without these disorders do not have antibodies against BSA. Nothing could be more important than maintaining your infants gut integrity, and nothing is better at doing that than exclusive breast feeding.  Probiotics are another important tool, especially for those who must use formula.


Increased levels of bovine serum albumin antibodies in patients with type 1 diabetes and celiac disease-related antibodies. Read the study here…

The predictive significance of autoantibodies in organ-specific autoimmune diseases. Read the study here…

Infant formula ingestion is associated with the development of diabetes in the BB/Wor rat. Read the study here…


Dr. Paul


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