During SIBO treatment, do you prefer eating prebiotics and taking them, or holding back during treatment?

This is a great question, and this is kind of going back to that FODMAP diet or microbial reset diet. I would say we’ve gone back and forth over the past four or five years.

Oh, sorry, Carol just asked, “Please explain the term “biologic” in the context you’re using it.”

Biologic is—sorry, I’m going to go back to this because it relates to the prior question—monoclonal antibody. Again, the question was on one of the homework [assignments] where the patient was recommended to use one of the, Entyvio is basically the name medication, right, and this is like, Humira is another one that might be more familiar to you, but these are monoclonal antibodies. Another term for this class of medications is “biologic,” so I kind of use those interchangeably, so it’s just whatever’s more familiar to you. Yes, thanks for the clarification.

Going back to during the treatment for SIBO, do you prefer eating probiotics or taking them out? For the past four or five years, we’ve kind of gone back and forth at CCFM, and there have been times where we said, “Okay, based on the strategy. It’s kind of eat the probiotics to activate the bacteria and make them more susceptible to the botanicals that we’re using.” And then we went through a phase [of], “No, no, starve them out,” and so then we’re using antimicrobials to kill them off and we’re starving them out. These are two different mechanisms to killing them. I would say right now I think we’re leaning more toward taking out prebiotics, and also probiotics, during at least the initial phase of treatment. I would say right now [that the] pendulum is swinging a little bit more toward removing FODMAPs, removing prebiotic supplements, and even removing probiotics at least during the initial phase of treatment. What I tend to do for my patients is I ask them about their symptoms, and so, if those fermentable foods that I mentioned are big offenders, broccoli, cauliflower, Brussels sprouts, onions, garlic, for my patients because when we do the antimicrobial protocol,there are so many supplements, and you’re taking them at five different times in the day, some on an empty stomach, some with food, and, again, this time of year, we’re coming into the holidays. I think that sometimes, if I put the dietary restrictions plus all the supplements, I don’t get as good compliance. People feel really overwhelmed, understandably, and it can feel like a little too much to manage. If my patients say, “No, I feel fine when I eat broccoli. I feel fine when I eat cauliflower, onions, and garlic. None of these things bother me.” Then, I’ll often say, “You know what? Let’s not worry too much about that microbial reset diet or the low-FODMAP diet.” I’m not going to add in supplemental prebiotics at that time, but I’m not going to worry about the diet so much. I’m going to say, “Let’s really focus on the antimicrobials,” and then I’ll sometimes say, “Let’s have no probiotics during the first 30 days,” and then I’ll start reintroducing the probiotics after about 30 days. But if, during this discussion with the patient, they say, “Man, I really feel like after broccoli, cauliflower …” whatever their triggers are, “I’m really feeling bloated; I’m feeling a lot worse,” whether it’s the brain fog, whatever their symptom is, that’s when I do a strict microbial reset diet and I use that low-FODMAP diet. And again, we’ll get into this more as the course goes on, but that’s when I’m going to get into using a therapeutic diet and being strict about taking out prebiotics, FODMAPs, etc., but those patients feel better symptomatically, and so, they don’t mind monitoring their diet that way because they’re starting to feel better.

Again, I would say sometimes, there’s probably room for flexibility. I don’t think there’s 100 percent consensus out there [on] the SIBO. It’s just to keep your eye on where the pendulum is going and probably talk to the patient, because remember, there are so many different flavors of small intestinal bacterial overgrowth and dysbiosis, and each one of your patients is going to be different and respond differently. Sometimes, just asking them what their symptoms are and how we can help [them] feel better and be successful with the protocol that we want to use. That’s my approach right now.