What is SIBO with Dr. Vivian Asamoah

Welcome to the Get Healthy Tampa Bay Podcast with Dr. Kerry Reller! This week, I'm excited to welcome back Dr. Vivian Asamoah, a gastroenterologist specializing in holistic and integrative gastroenterology. In this episode, we delve into SIBO (Small Intestinal Bacterial Overgrowth), covering its symptoms, causes, and testing methods. Dr. Asamoah shares treatment strategies, including diet, antibiotics, and lifestyle changes, as well as preventative measures to avoid recurrence. Tune in to gain valuable insights on managing SIBO and improving your gut health.

Dr. Vivian Asamoah, or “Dr. V” as her patients affectionately call her, is board-certified in Gastroenterology, Hepatology and Nutrition, she is located in the Katy area, where she serves her community, and the greater City of Houston. Dr. Asamoah balances Conventional Medicine and Functional Medicine to achieve optimal health for her patients. She brings over 15 years of experience to her practice.

0:28 Welcome back, Dr. V!
1:03 What is SIBO?
3:54 The Etiology of SIBO
6:12 Differentiating SIBO from IBS
9:10 How to Test for SIBO
12:23 Types of Bacteria and Gases in SIBO
13:31 Treating SIBO: Diet, Antibiotics, and Lifestyle
16:54 Recurrence of SIBO and Preventative Measures
22:00 Severe Bloating and its Causes
31:10 Addressing Stress and its Impact on Gut Health

Connect with Dr. Vivian Asamoah 
Website: https://www.drvivianasamoah.com/
Instagram: / drasamoah  
Facebook: / drvivianasamoah  
Twitter: @DrVivianAsamoah
My linktree: https://linktr.ee/drvivianasamoah
Private Facebook Group: / naturalgutrelief  
Health Guide and 7-Day Dietary Protocol Handout: https://drive.google.com/file/d/1o-4K...

Connect with Dr. Kerry Reller
Podcast website: https://gethealthytbpodcast.buzzsprou... 
My linktree: linktr.ee/kerryrellermd
Follow on Facebook: / clearwaterfamilymedicine  
Follow on Instagram: / clearwaterfamilymedicine  
Clearwater Family Medicine and Allergy website: https://sites.google.com/view/clearwa...
Podcast: https://gethealthytbpodcast.buzzsprou... 

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Transcript

Kerry: 0:28

Hi, everybody. Welcome back to the Get Healthy Tampa Bay podcast. I'm your host, Dr. Kerry Reller, and today we have a very special returning guest, Dr. Vivian. Tell us you know, a little bit about you again and who you are and what you do.

Vivian: 0:42

Hi, Dr. Reller. Thank you for inviting me on the show again. It's nice to be here. My name is Dr. Vivian Asamoah. I'm a gastroenterologist based in Houston, Texas. My practice is a little bit different because we incorporate a holistic and integrative aspect into our practice of gastroenterology. And I'm really happy to be here to talk about SIBO.

Kerry: 1:03

Yay. I think that's why you're one of my favorite gastroenterology practices because you have this unique approach to it, which I think is so important these, this day and age for sure. Yeah. So I always say SIBO so I'll have to

Vivian: 1:16

Oh, maybe it is SIBO.

Kerry: 1:18

I don't know. You would know, not me. But anyway, so we're talking about an acronym. So can you briefly explain what SIBO, SIBO is and

Vivian: 1:27

Yeah, Sibbo, Sibbo, or Sibbo, I've heard the British say, Sibbo. So it is S. I. B. O. Small intestinal bacterial overgrowth. And basically it presents with symptoms and they could be big symptoms as you know, a lot of gut symptoms are vague and can represent anything right? It could be, you know, a little bit of lactose intolerance or it could be a colon cancer. You know, that's the gut symptoms. It's hard to tell. But SIBO is in the differential to consider when your patient has chronic symptoms of abdominal bloating. Bloating is number one. Irregular bowel habits like change in bowel habits from diarrhea to constipation has been tagged with a diagnosis of IBS and we'll talk about that correlation between SIBO and IBS. There is a test you can do for it, but basically it is when the microbiome in the small intestine, the small bowel is altered. The small bowel is supposed to be a relatively clean, I wouldn't say sterile, but a relatively clean environment. And when you have overpopulation of certain path, you know, bacteria, fungi, parasites, You get this imbalance in your microbiome. When we refer to the term SIBO, it's usually for bacterial overgrowth in the small bowel.

Kerry: 2:46

Yeah, that's a great overview of it for sure. So I think one thing always confuses me and maybe other listeners as well is what we think the etiology of this or how does this occur? Do you even know?

Vivian: 3:00

well, how does SIBO occur? So we'll talk about it's, it's an imbalance in the microbiome, right? So let me see, it is the microbiome is the bacteria in the gut, right? Most of the microbiome, our microbiome, which is all the bacteria that actually help us function because we kind of live in synergy with this microbiome. Most of this exists in the gut. We've got a little microbiome in our mouth, we've got a little microbiome in our ears, in our nose, in our vaginal area, everywhere, but most of it lives in the gut. And we talk about when there's an imbalance in this microbiome. We call it dysbiosis, right? And I think all of us have a little bit of dysbiosis, a little bit of imbalance. Like if you go out drinking too much, someone threw some antibiotics at you, you're on some wrong medication. All of that can shift the microbiome. What you eat, how you sleep, the stressors in your system all affect the microbiome, right? And when you go from a place of just a mild imbalance that can often recoup, right? If you go back to sort of a normal lifestyle to a more severe or aggressive shift where there's overpopulation or Underpopulation of certain bacterial strains, then you get SIBO. So, you know, I think we're all walking around with a little bit of dysbiosis here and there. And it's just the extent of the severity that can vary like that changes. Right. But to really be specific with your question, I think GIs have been looking at this a lot more because of that diagnosis of IBS, right? IBS is kind of this a weird, bogus, kind of like hazy, vague diagnosis. When we've done our scopes and we've done our labs and we don't know what's going on, we're like, Oh, it could be IBS. But IBS is based on a specific motility criteria called the Rome IV criteria. So if you have abdominal bloating, change in bowel habits, ongoing intermittent symptoms for over six months, current, we say it's IBS, but then it could be something else that's not diagnosed, and there's a group of Cedar Sinai, the doctor being Dr. Pimentel, who's sort of like our guru when it comes to IBS and SIBO, who has shown that A significant proportion of our patients tagged with a diagnosis of IBS diarrhea actually have SIBO, and if we can identify the SIBO and treat the SIBO, we can see some of their IBS symptoms getting better. But even with that, Dr. Reller, it's not that simple. You know, I think we're on the brink of kind of understanding where IBS comes from, how it correlates with SIBO, and what are the best strategies to treat. But we are, it's all still in where it's constantly evolving. It's a moving target. We're really just discovering everything now.

Kerry: 5:54

Yeah, it's definitely under a big area of research for sure. And I think some of the things about the etiology you mentioned were, you know, possible antibiotic usage and things like that. I've also read or heard that, you know, sometimes people get it after traveling to another country and some sort of viral GI illness or something.

Vivian: 6:12

Mostly infectious. IBS. So those are your patients were like, you know, I traveled to Guatemala or Ghana and I got a nasty infection. And ever since then, my gut has never been the same. And it could be even up to 5 to 10 years later. So I'm studying show right? Ever since then, my God has never been the same. And that could be a chronic SIBO

Kerry: 6:33

So how can you differentiate like SIBO or SIBO from IBS like symptoms and everything?

Vivian: 6:39

Yeah. So, I don't know that we, we want to differentiate the way I think about, about IBS in my gastroenterology practices. I'm always trying to figure out what is causing the IBS. IBS is not like, chronic pancreatitis. It is a diagnosis. We see that we can see it on CT scan, right? IBS, there's no test to prove that you have IBS. If one doctor could say IBS, another doctor could say BBS. Like so it's just, it's just based on this criteria, right? So what we try and do is really figure out, hey, let's not tag our patient with this diagnosis. Let's see if we can get to root cause, what is causing the symptoms. And sometimes, you know what it's diet. right? It's something in nutrition. Are you eating a lot of processed foods with a lot of emulsifiers and and additives? You know, are you eating a ton of dairy? Can you do a dairy free challenge? Because if you do a dairy free challenge, right? And you get off dairy and all your symptoms go away, was it IBS? Or was it lactose intolerance or protein allergy? Right? We don't know, right? Protein sensitivity. So we try and figure out, you know, we want to rule out celiac in all our patients with predumed diagnosis of IBS. We want to rule out dairy or fructose malabsorption is very often underdiagnosed in IBS patients. We want to rule out pancreatic insufficiency, like could this be exocrine pancreatic insufficiency? So we'll do stool testing. Of course, we wanna make sure it's not IBD, which is that we often get the two confused, right? IBS is irritable bowel syndrome, IBD is inflammatory bowel disease. This is an autoimmune condition of, chronic condition of the gut, right? Crohn's disease, uc. We wanna rule that out. And then when I do my workup, I wanna know if it's sibo. Right. SIBO would explain the symptoms of IBS. So I just put it in my protocol in working up a patient for chronic symptoms of bloating change in bowel habits, even skin issues, joint issues. And it's been ongoing for a while whether it's post infection or not. I do the test I want to know checkbox is this SIBO. Right. that's kind of how I look at things.

Kerry: 8:52

Yeah. So you mentioned bloating change in bowel habits and everything. So those are the mostly the presenting symptoms or any really symptom of IBS. You're kind of ruling out SIBO. Yes. Okay. So one big thing is how do you test for it? Where can you find the test?

Vivian: 9:09

I know so I wish the test was readily available. It is readily available. The issue is in most insurances are not covering. The cost of a test ranges from 250 to 350 a kit can be shipped to the patient. Instructions are clear because there's a special way you have to do the test. So it's there. Often these companies will have like a video about how do I do the test because you have to eat a special diet that's low carb for 12 the day before fast for 12 hours and then do the test because The test comprises of drinking a sugary substrate that's going to go in your GI tract. And then if you have bad bacteria the bacteria are going to like, get on that substrate and break it down and release a couple of gas, three gases, hydrogen, methane, and hydrogen sulfide. And our body doesn't naturally make any of these gases. So if it is released and the way it's releases that the bacteria will break it down, release these gases, these gases will get into the bloodstream, the bloodstream will get into your alveoli of the lungs, and then you'll breathe it out. Right. So it's a breath test. Right. And so our body doesn't make that. So when you do find positive, then. We assume that there's bad bacteria. No bacteria is bad, but there's imbalance in your microbiome causing this effect, right? And so there are several companies. One of them is Gamelli TrioSmart. They do the three tests. It's one kit. They give you results for all three. It is a three to four hour test. You can do it. You get, your patients can do it at home. So you can actually, or now they actually let patients order it themselves. It doesn't even have to be ordered by a physician anymore. Some patients are coming to me and saying, I did my SIBO test. It's positive. Now, what do I do, Dr. V? And I'm like, Oh Lord.

Kerry: 10:53

mm-Hmm.

Vivian: 10:54

Commonwealth Diagnostics is another that does testing. Arrow Diagnostics is another company. Those are the three companies that we use Commonwealth. Aerodiagnostics as well as the TrioSmart by Gamelli. And it's shipped to the patient's homes and they can do it. You can also keep it in office so they can pick up a kit and do it. The billing is done after, the company bills the patient directly. Medicare will cover for the TrioSmart. Interestingly, Medicare is the only one that covers for the breath test. So I very often will you know, when I'm working with a patient who's in the Medicare category and there's a diagnosis of IBS and very often our older patients have been on antibiotics. They're on chronic acid blocker and things like that. I will often take the advantage and do the test and see.

Kerry: 11:42

Are there any differences between the gases or what sort of information do we get out from knowing? Which one was it?

Vivian: 11:49

Yeah, so we now know that the different gases are produced by different bacterial species, right? So we know that hydrogen, most likely Klebsiella species strains will release that Campylobacter strains and then when it comes to the methane, those are usually archaea. A different class of not really bacteria. They're called just a different class of pathogens like methanobacter and methanosmithiae. So different species of bacteria release different types of gases.

Kerry: 12:23

Okay, so I guess I should ask, well, how do you treat it and is there any way to treat differently based upon which ones you find.

Vivian: 12:31

So I think my practice is a little bit different. If you look at the current American Gastro Association guidelines, if you Do a SIBO test and it's positive typically hydrogen dominant or even hydrogen and pain dominant. You treat with antibiotics. You put the patient on a low FODMAP diet. That's a special diet to reduce the risk. Some of these gas forming foods in your system and and then and then you hope for the best, right? Like you hope the you hope the best. So yeah, there are antibiotics to treat in my practice. I think that I recognize that SIBO is an evolving diagnosis. So many changes. I also recognize that it starts with food first, right? So I always kind of start with nutrition. Like, what are you eating? Trying to understand the root cause of why the SIBO, right? Why do you have bacterial overgrowth? Because it can occur. For many different reasons in our studies, and I'm sure Dr. Reller, you were exposed to this as well, but we got very little training and teaching on SIBO in med school and in residency we heard that, okay, if you had multiple surgeries and you have scar tissue, you could have obstruction and stasis, if you had gastric bypass, you could increase your risk of dysbiosis and SIBO patients with Crohn's disease, IBD, right, are higher risk of SIBO, but we didn't, or short gut syndrome patients, but we didn't really go into much detail as to what it meant. So now things have changed. We know that SIBO, I think SIBO is more like a spectrum from dysbiosis to very severe bacterial overgrowth. And so I kind of personalize the care and the treatment approach for each patient because sometimes I'll just change the diet, we'll change the diet, we may just do a little FODMAP diet, and I repeat the breath test, four to six weeks later, SIBO's gone, no antibiotics, and so I'm leaning less towards antibiotic and focusing more on nutrition changes, what are the stressors, is my patient anxious, is there stress, is the vagal nerve working well, you know you know, is there anxiety? Is she chronically on antibiotics, he or she, like, what can I remove? and see if we see changes and how can I repair the gut first. But in more severe cases when it's very classic, like I just got back from India and it's been four months and I'm having horrible diarrhea. Of course I rule out infection, rule out parasites. And if I test placebo and it's positive, I treat with antibiotics and I treat with rifaximin, which is Xifaxan. If it's hydrogen dominant and if it's hydrogen and methane, The recommendation is to do a combination therapy because we want to address both, you know, the gram negatives as well as the methanobrevibacter strains and I do rifaximin and flagyl or rifaximin and neomycin, if I can. The sensitivity in terms of efficacy is a little bit better with the combination treatment.

Kerry: 15:27

Yeah. Depending upon which of the bugs you're trying to cover

Vivian: 15:30

It depending exactly exact for two weeks. Yeah.

Kerry: 15:33

So how do you get patients to get better by implementing some of the lifestyle changes?

Vivian: 15:39

So it depends on every patient, but really the focus is really removing any potential pro inflammatory foods that we know will cause dysbiosis. We know there are some pro inflammatory foods that cause dysbiosis. We know that there are medications that will alter the gut microbiome. So in terms of medications, antibiotics, chronic use of antibiotics, right? It's not uncommon for me to see my patients who have acne chronically on doxy have gut issues. Yeah, it's not uncommon or someone who's just received multiple courses of antibiotics for a pseudo bronchitis like every three months or sinusitis, right? So we're trying to kind of see, hey, should we be careful with that? If you don't really need it, let's avoid it. Then the chronic use of acid blocker medications, the proton pump inhibitors, the high dose pantoprazole, omeprazole, those medications definitely affect the gut microbiome, right? Lots of studies are showing that when they look at the microbiome in a patient who used this PPI is chronically and they do whole genome sequencing on their stool compared to someone who doesn't use PPI. There's clearly a difference, right? They are missing the the great lactobacilli. They're missing those strains, right? They're increasing the risk of having opportunistic infections and dysbiosis and placebo. So I try and eliminate that. And then we look at their processed foods. Are you drinking a lot of alcohol? Can we get rid of that? All of those are. Potential triggers, right? And changing your microbiome, even medications chronically use like NSAIDs. So we try and clean up the diet, and we really focusing, I usually work with the low FODMAP diet, because it helps relieve a lot of symptoms, and we'll do the low FODMAP diet for about four to six weeks, and then go through the three stages of the low FODMAP, eliminate, and then slow reintroduction, and then personalization of the reintroduction. So we'll use that protocol, and while doing so, we may start some patients on things that we know help for IBS, like high dose glutamine powder has been shown in many studies to work extremely well in terms of healing that gut barrier. So glutamine at about 5 to 10 milligrams. We may start some prebiotic or probiotic if they handle it for some time. We work on all the lifestyle components in terms of stress and whatnot. Of course, before this, I've made sure there's nothing else going on, because a lot of patients also have to understand you can have SIBO and Crohn's. You can have two things going on, you can have SIBO and endometriosis, right? So you can, it's, we always try and look for, hey, what is the cause? What else is going on here? And SIBO is kind of like diarrhea. What is causing this? Because sometimes if you don't identify what is causing, it comes right back.

Kerry: 18:20

How often do you have to get like a colonoscopy on these patients, like ever or no?

Vivian: 18:25

so it depends on age and it depends on the symptoms, right? But if I'm noticing on the blood work that there is some malabsorption or iron deficiency, you know, something that just doesn't fit a typical IBS, I will go ahead and, and proceed with upper and lower. Yes.

Kerry: 18:43

And then I think I cut you off, but what were you saying?

Vivian: 18:46

We were talking about the nutrition aspect, so I usually will do the low FODMAP diet and very, or I will sometimes use the elimination diet protocol. I like the elimination because it's a way to just clean up your diet. Like it's very similar to the whole 30 where you're getting rid of sugar, you're getting rid of coffee, you're getting rid of a lot of these pro inflammatory foods anyway. It's a nice way to clean up your diet and just focus on nutrition alone and adding prebiotic probiotic and some gentle supplements like glutamine and there's evidence for a lot of this, the glutamine. Probiotics, not so much. I would say in a handful of 100 patients, 50, 50 to 60 percent of them with that alone are better.

Kerry: 19:29

Wow. I was going to ask you, like, what is the kind of the

Vivian: 19:32

50 to 60 percent of them

Kerry: 19:34

amazing. Mm

Vivian: 19:35

are better, right? But then there are some patients who absolutely need the treatment for SIBO. I'm just thinking of a patient I saw recently. So another patient category or group that's going to be higher risk for SIBO is our patients with scleroderma because of the motility impairments, right? So our scleroderma patients are often prone to acid reflux, oesophageal motility issues, gastroparesis. So again, delayed emptying, anything that delays the flow in the small bowel, it thinks they're going to be puddles just sitting there waiting for fermentation. So I do have a patient with a severe scleroderma. And she has every time I test her, she's chronically SIBO chronic every time. So I keep her actually on a very low dose Cyfaxin one pill a day. And she has done extremely well over the past year, no recurrent symptoms. So it really depends on patient by patient case. And I've just learned that although the recommendations do say treat for 14 days, Everyone is a little different. The cause of the SIBO and how they respond to diet and their underlying co like chronic condition, changes how I manage patients. Yeah.

Kerry: 20:50

So how come it tends to recur in some patients and how do you prevent that?

Vivian: 20:54

Yeah. So we think there are a couple reasons why SIBO will reoccur in someone like in the patient I just explained with scleroderma, its a chronic illness, right? So that's a progressive thing. In our patients with Crohn's disease, if the Crohn's is not well controlled, if they're not in remission, and they're having a lot of inflammation and stricturing, that will also affect flow. So anything that affects motility will also affect SIBO, will increase the risk of recurrent SIBO, right? When the root cause is not identified, right, we don't know what else is going on, that will also cause issues. But I think the recurrence can be high in certain populations, depending on what their underlying causes. But in our patients who just have like post infectious IBS or something, relatively simple, usually we treat and they're good. we treat for the two weeks and they're okay. Yeah.

Kerry: 21:45

So I've seen on the internet, like some people posting their pictures of themselves when they feel like they may have this and they look, you know, almost like nine months pregnant. Is that something that you typically see in your patient population?

Vivian: 22:00

Ah, yes, they can feel extremely bloated. The gas just bloats and doesn't flow well. That is true. I think that's a classic what everyone says about SIBO. But of course, you know, I think just to highlight, we see a lot of things on social media, but we also have to be careful, right? I have a female patient who came to us about six months ago and she brought in one of those pictures, right? She was super bloated. So whenever you think abdominal bloating. As physicians, we think of quite an extensive diagnosis, right? And so she had been working with a dietitian. They'd done diet, they'd done this, they'd done also parasite cleanse and whatnot. She ended up just having a 10 centimeter dermoid cyst in her ovary

Kerry: 22:43

Oh, wow.

Vivian: 22:43

that was it nobody did an ultrasound pelvic,

Kerry: 22:47

Did so did. Yeah, that's huge.

Vivian: 22:49

that was causing that was causing her bloating.

Kerry: 22:52

And so I was gonna ask, does it cause bloating, but does the bloating decrease in those cases

Vivian: 22:57

she had surgery, they took it out, and she was not bloated after.

Kerry: 23:01

Yeah. Okay. So after, so some people would describe it as in the morning they feel okay, but at the end of the day,

Vivian: 23:07

So, yes. Our patient had bloating pretty much all the time, right, sort of got worse around time of cycle, it would get much worse for her. But and of course eating and filling up the bile belly, when you've got a mechanical thing like that, you're going to feel worse right after eating, right? Cause food now is adding to that space. But yes, a lot of our patients with SIBO or chronic gut issues. If it's a gut related issue, the one question is, does it get worse after you eat and does it get worse at the end of the day? And usually it's getting worse at the end of the day, cause you were eating. And the bacteria is kind of breaking down from like saying this feasting and this hydrogen and methane, and it's not getting out of you. And so it's accumulates. This gas just accumulates. Yeah.

Kerry: 23:51

Do you think there's a role for intermittent fasting to help treat?

Vivian: 23:54

We do advise our patients to at least have four to six hours in between meal and avoid snacking. We don't necessarily do like strict intermittent fasting, but we know that that four to six hour window without snacking is really important for something called the migrating motor complex to, it's like the, it's like the vacuum of your small bowel. During that restful time where nothing is happening your small bowel does like a little sweep and moves like waves, it just moves when you're constantly snacking it doesn't do that. It's erratic, right? And so that's sweeping and I'm calling it like a vacuum is a way to sweep out any extra bacteria, any growth, sweep it all down to the colon. Right. And so we believe we do believe a lot of studies, a lot of, I would say a lot of experts, there's a lot of anecdotal expertise and a lot of motility studies that show that it is helpful to let that migrating modal complex do its work. And it can only do its work during downtime, which is fasting periods. Right. And that is one good way to avoid the recurrence, but yes, I do use quite a bit of intermittent fasting in my patients who have severe SIBO and SIFO, which is another fungal overgrowth.

Kerry: 25:12

Was going to ask about supplements and prebiotics, like atrantil. How do you say that one?

Vivian: 25:19

A tarantula is a combination of certain supplements. I can, there's like a horse chestnut. I forget exactly the and atrantil. And there are some small studies. I think the population size of that study was very small. There are only 24 patients showing that maybe it helps with bloating. Some patients, maybe it helps with methanogenic overgrowth, but it is not one of the most robust studies. I do. I have tried it in some patients. I've got mixed results. But some patient for some, it helps a lot for the bloating, but the study again is very, very small. The biggest head to head comparison we have is a study by my mentor, Dr. Mullen that looked at herbal anti bacterials from a company called Biotics Research, which usually contains a combination like oregano, berberine grapeseed extract. Like, it's usually a combination and they actually did head to head trials compared to Zyfaxan, right? Faxum and the antibiotics and it actually showed equal response

Kerry: 26:18

Interesting.

Vivian: 26:19

terms of not only in terms of symptoms, but also in terms of SIBO retest. Okay.

Kerry: 26:24

That's pretty good. So I have a couple. Okay, so we talked about the slow gastric emptying and gastroparesis and constipation being risk factors. I guess my question is two part. One is with something like MiraLAX or how do you treat the constipation to help reduce the symptoms from having the slow motility to improve SIBO. And then I wanted to touch upon the new GLP 1s and seeing if you're having any patients with that come in with having problems with SIBO.

Vivian: 26:53

Yeah, so the 1st question is about, gastroparesis and constipation. And how do we tackle that to help with SIBO? Is that right? Yeah. So, so with gastroparesis, you know, we focus a lot on nutrition and what our patients are eating, avoiding the foods that will cause more gastroparesis. Which tends to be a lot of roughage, like raw veggies and high fat foods, right? In general. And we try and manage the, the, if the gastroparesis is severe, we will prescribe pro motility agents or pro kinetic agents with constipation, sometimes actually just dealing with the constipation, just being aggressive and having a routine for the constipation is very, very important, and so we are very aggressive about treating constipation, like understanding why the constipation and then helping patients understand that you can't wait for the constipation to get really bad before you take something you kind of have to stay on top of that. So helping with motility to improve that definitely helps reduce the risk of recurrence of the sibo. And then with the GLP ones, I mean they do just that. They cause gastroparesis and constipation. And we were actually talking about this in an integrative doctor's forum about are we gonna see more sibo? How is it's gonna affect things? I don't know that I've encountered a lot of patients on GLP ones with. I don't know if I've seen them in my practice, but I think the work of those small peptides are very complex. You know, they do slow down motility, but I also believe that they do indirectly by working on that insulin resistance help reduce inflammation in many ways. So there's like this yin yang, like there's so many benefits and there can be side effects. And from a gastro perspective, we notice a lot of the side effects. in the beginning and as we are titrating up the dose. But once our patients get to a stable sustained dose, we see less side effects or their primary care doctors like yourself, Dr. Reller are able to titrate them down to a dose that's tolerable. But I haven't seen, I haven't really, maybe it's coming. I just haven't yet, but maybe it's coming. Yeah.

Kerry: 29:10

Yeah, I mean, I would say that SIBO, it takes a while to diagnose. So it wouldn't be surprising if it's not to you to the, you know, gastroenterologist

Vivian: 29:18

so many GI symptoms with the GLP 1. So for the longest time, they could just assume it's all related to the GLP-1s

Kerry: 29:24

Mm hmm. Yeah. Well, interesting. Yeah, definitely, you know, Hopeful, like you were saying, with treating the inflammation too,

Vivian: 29:31

They help.

Kerry: 29:32

yeah, gotta be a fine balance. And you mentioned stress earlier. How do you take an approach of treating stress that might be causing these symptoms as well?

Vivian: 29:42

so it could be a triggering, I definitely don't believe stress causes everything, but I truly believe that stress can exacerbate, make symptoms much worse, heighten them and make it difficult to kind of address. So the first step is really Addressing the stress factor, right? A lot of patients come in they're like, my tummy hurts. What are you going to do, doctor? Give me a medication. What are you going to prescribe? And first kind of acknowledging in our practice, we say there are three pillars, right? The nutrition component, the testing component. Hey, let's see what's going on. And the stress and lifestyle component. So we talk about each component. And so we don't have a visit where we just say, okay, we're going to do this test, this test. We always have a visit where we talk about all three components and the stress. Okay. Okay. What's going on in your life? How is your stress level? You know, what, what are the biggest triggers? Do you notice your gut symptoms get worse when you are stressed out or when someone's making you mad, right? And then there's chronic stress and acute stress. So we try and explain that to the patient. And so that first conversation our patients usually don't want to talk too much about it, but it brings some kind of awareness. So they at least go back and think and reflect. And at the second visit, we can dive in a little more into that. So, and they say, yeah, you know, I think I have noticed that this is happening with this. So just the education and letting them know that you're not crazy, but stress can directly impact your gut symptoms, because of that gut brain axis. So letting them know that there is definitely a correlation, right. In terms of neurotransmitters and how your vagal, your vagus nerve works. So it's. It's normal, right? It's expected. It's the process. So now let's see how we can address things. But I usually recommend very simple things. I start off by asking them, what do you do for stress relief? Because I can't tell everybody to meditate. Not everyone like whatever, you know, you know, so I asked them, what do you do? And then they talk about, they start thinking about, well, this is, I spend time with family. I do this, I do that. And then I kind of describe what I do. I was like, I listened to comedy and I just laughed by myself in the car on my way home. And that helps me. So I get them to really see the connection with ways they can naturally and organically reduce stressors. And then I may give them a simple handout or do box breathing with them, which is the four in, four hold, four out, four hold breathing and just go through the process with them. Let them do it and say, do this three times a day in your car before you step out to go to work or go home. So the starting those little techniques, but we've been lucky to find excellent GI psychologists that we refer our patients to when there's a, and you know, with GI and chronic illness, there's a lot of stress, and there's a lot of stress that makes healing the gut issue more difficult, right? And there's a lot of anxiety around having the gut issue. So GI psychologists are psychologists, but they are super specialty trained in gut psychology. And they do a lot of work with our patients in terms of gut hypnosis, in terms of thought therapy, mindful work, imagery, visualization work, which really helps our patients.

Kerry: 32:43

I did not know that existed as a like niche of psychology. That's so interesting. Yeah. Yeah. But I also ask my patients, well, how do you manage this stress? I think that's the first thing I usually ask too. I think it's a good way to see what they're already doing. Like you said, and I think a lot of people think some of these things are woo or whatever, but it really can improve things. So kind of getting them to understand that is useful as well. Well, is there anything else you'd like to share about SIBO or did we miss anything that's important for listeners to know? Oh my

Vivian: 33:16

I think you know there's a lot it's an evolving diagnosis of course it's a passion of mine I'm really interested in reading everything about SIBO because I really feel like dysbiosis and microbiome issues and chronic inflammation is the root cause of a lot of our diseases today, right? But the solution is fixable. A lot of it can be diet and lifestyle and things like that, right? So if we have easy solutions for most of us, not for all of us, but if we have, you know, It's not, not easy, but solutions that I feel you are in your hands as the patient, right? I like to empower my patients and know that, you know what, you can manage this. I'm here to help, but this is something you can really control by changing your diet and addressing lifestyle issues. I think that's great. The last thing to share is that there is a lot of information right now out there about gut health. And on social media, on Tik Tok, on Instagram. And there are a lot of influencers selling supplements and sometimes they're very expensive. Like I saw this cute bottle and it was like so fancy. It was like a golden probiotic. And it was like a hundred dollars for 30 pills. And I was like, what is this? And when I looked at the ingredients, it was no different to maybe having a little bit of kefir in the morning or having some wholesome dairy with probiotic in it or just eating a lot more plant. So there is no quick fix when it comes to gut health. It takes time. And it is a lifestyle change. Identify what you are doing, but there is no quick fix probiotic. There is no quick fix supplement. And if you're working with someone, it's helpful to work with someone who's experienced and well versed, who understands the data, understands the doses that you should be on, even if you're using a natural supplement, than just getting some stuff over the counter, some random stuff that's all mixed. Because I always say supplements are medication. They can have side effects. They can affect your liver. They can cause other issues. So I know they're not FDA approved, but they're not all safe. And so you really want to trust someone knowledgeable to make sure your diagnosis is clean and clear before jumping on the bandwagon of an influencer who may never even have SIBO before and doesn't really know, but they're just promoting their brand. So get advice from a health care professional before just purchasing things online because it's kind of scary out there.

Kerry: 35:40

Yeah, no, I agree. There's so many different supplements and things. They're not well regulated and there's not evidence on all of them. And it's just really, I would agree. Do your homework on everything because I heard us first before using them.

Vivian: 35:55

Yes. Yeah.

Kerry: 35:56

So you tell us you have a very I guess active Facebook group that I think could be very educational for listeners. So how can they find that and where else can they find you?

Vivian: 36:05

Yes. So thank you, Dr. Reller. So my practice is Houston Gastro Institute. We're based in Katy, West Houston, Texas. And we enjoy sharing a lot of information and being strong advocates for our patients when it comes to information about gut health. And talking to health care professionals who are experienced and in their fields, like experts in their field. And we share this information through a platform called the natural gut relief. It is a private Facebook group, but anyone can enter, and we share a wealth of information in terms of nutrition. Our dietitians are on there sharing resources and handouts. We try and interview a guest at least once or twice a month with an interesting topic. And everyone's welcome to join. So that's the natural gut relief on Facebook. for

Kerry: 36:56

Perfect. All right. Well, we'll put all that information in the show notes and thank you so much for coming back onto the podcast. This was a lot of fun and I think highly educational, like so many good points and important things in this episode that people need to pull out from it. So I appreciate

Vivian: 37:14

Thank you so much,

Kerry: 37:15

that.

Vivian: 37:15

Thank you to Get Healthy Tampa Bay podcast. I love being here.

Kerry: 37:21

right, thank

Vivian: 37:21

right. Bye bye.