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🔦 WELLNESS SPOTLIGHT: THE LIMITATIONS OF BREATH TESTING FOR SIBO

After contracting three major foodborne pathogens during a trip to Kenya, my lifelong digestive struggles took a dramatic turn for the worse. The emergency antibiotics I received only further paralyzed my already sluggish gut.

When other health problems began emerging years later, a naturopath diagnosed me with SIBO through lactulose breath testing (LBT). Despite symptom improvements after herbal treatments, my test results paradoxically worsened with each round.

An appointment with a surly GI doctor left me even more frustrated. The doctor dismissed my four positive LBTs, stating that SIBO was only legitimate if linked to a surgical condition causing injury to the small intestine. Furthermore, he claimed that a duodenal aspirate (a fluid sample from the small intestine)—not breath testing—was the golden standard of SIBO testing. This experience left me eager to understand the reliability of breath testing, especially given the ongoing debate about its accuracy.

The Shortfalls of Lactulose Breath Testing

1. Breath Testing for SIBO and IMO

• The lactulose breath test has a sensitivity of 42% and specificity of 70.6%, meaning it can miss many true positives and produce false positives.

• In contrast, glucose breath tests offer better accuracy with 54.5% sensitivity and 83.2% specificity. In one study, 48% had false-positive results, which were caused by colon fermentation of unabsorbed glucose.

2. Factors Influencing Breath Test Results

•  Gut motility and orocecal transit time (OCTT) (the time it takes food to travel from the mouth to the small intestine) can significantly affect test outcomes.

• Rapid gut transit can lead to false positives because the substrate (lactulose, glucose) may reach the colon before being fermented in the small intestine, indicating rapid transit rather than bacterial overgrowth.

• A rise in hydrogen levels on the breath test may reflect substrate reaching the colon quickly, not bacterial overgrowth in the small intestine.

3. Breath Tests and Carbohydrate Malabsorption

• Breath tests may also indicate carbohydrate malabsorption rather than bacterial overgrowth.

• Inflammation in the small intestine can damage the gut lining, reducing glucose transporter function, leading to malabsorption and increased fermentation by microbes in the gut or colon.

4. Methane Breath Levels and Gut Production

• Breath methane levels are often used to diagnose methane-dominant SIBO but have been found to poorly reflect actual gut methane production. Methanogens, such as Methanobrevibacter smithii, are found in most healthy patients, typically in the colon.

Alternative Methods and the Need for a Holistic Approach

As at-home breath testing becomes more accessible, understanding its limitations is crucial. These test results must be interpreted within the broader context of symptoms and overall health—not taken at face value.

While breath tests provide a valuable starting point for SIBO diagnosis, they aren't definitive. Glucose breath tests offer greater specificity than lactulose tests, with fewer false positives from colonic fermentation. Recent research suggests that flat-line or elevated baseline hydrogen patterns may indicate excess hydrogen-producing bacteria, potentially guiding more personalized treatment approaches.

For a more comprehensive assessment of small intestinal function, testing with multiple substrates (glucose, fructose, and lactulose) can reveal a more complete picture of your digestive health.

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💡HEALTHY HACKS: HEALING WITH HERBS

A multi-center study found that herbal therapies are at least as effective as the antibiotic Rifaximin for treating SIBO, with 46% of patients treated with herbal therapy having a negative follow-up breath test compared to 34% of those treated with rifaximin.

But which herbs you ask?

The Multi-Center Team used 2 herbal combination formulas together, at a dose of 2 caps 2 x day x 4 weeks, for each formula:

• Biotics FC Cidal with Biotics Dysbiocide, or

• Metagenics Candibactin-AR with Metagenics Candibactin-BR 

Dr. Alison Siebecker, co-founder and former medical director of the SIBO Center for Digestive Health, uses:

Methane SIBO/IMO: Allicin plus one of the following: berberine, oregano, or neem

Hydrogen SIBO: Choose 2: berberine, oregano, or neem

Below are her recommended supplements:

• Allicin (a component of garlic): Allimed, 2 caps 3x daily (for methane)

• Oregano: ADP Oregano by Biotics, 2 caps 2x daily

• Berberine: Berberine Complex by Integrative Therapeutics, 3 caps 3x daily

• Neem: Neem Plus by Ayush, 2 caps 3x daily

The personal recommendations I received from Goulds Natural Medicine Clinic in Australia to decrease Methanobrevibacter smithii & other SIBO bugs:

• Partially hydrolyzed guar gum (PHGG): 1 tablespoon daily (don’t mistaken this for regular guar gum; it’s much too viscous).
  
  In a randomized trial, patients with SIBO were given either an antibiotic called rifaximin on its own or rifaximin combined with PHGG for 10 days. The antibiotic alone cleared SIBO in about 62% of patients, while the combination treatment was more effective, clearing it in 85% of cases. Among those whose SIBO was successfully treated, most saw an improvement in their symptoms—about 87% in the rifaximin-only group and 91% in the group that took both treatments.
  

• Biogaia Probiotic Drops (L. Reuteri) – 5 drops twice daily (lunch & before bed). Separate from tincture by at least 2 hours.
  
  A study conducted on 20 adults with functional constipation found that Lactobacillus reuteri (DSM 17938) significantly reduced methane production over 4 weeks.

These are the tincture recipes given to me by Goulds to treat my mixed hydrogen and methane SIBO:

525 ml Herbal tincture #1: 7.5ml twice daily (am & pm) in 25ml water for 10 weeks:

• Clove 75

• Oregano 100

• Cinnamon (true) 125

• Pomegranate husk 125

• Thyme 100

525 ml Herbal tincture #2: 7.5ml twice daily (am & pm) in 25ml water for 10 weeks:

• Clove 75

• Oregano 100

• Pomegranate husk 150

• Oak bark 100

• Propolis 100

525 ml Herbal tincture #3: Take 7.5ml twice daily (am & pm) in 25ml water for 10 weeks:

• Clove 75

• Cinnamon (true) 150

• Pomegranate husk 150

• Thyme 100

• Peppermint 50

Many local herbalists can create custom tincture mixes, but one provider I had good luck with was Naturopath Herbals out of Australia. They can produce affordable, custom-made blends of liquid herbal extracts formulated by a qualified Naturopath. 🌿✨ Worldwide shipping is available. Have a look!

Hydrogen Sulfide, a new bug in the SIBO landscape

Naturopathic doctor Greg Nigh proposes that Small Intestinal Bacterial Overgrowth (SIBO) might be an adaptation to sulfate deficiency rather than a primary problem. He suggests taht hydrogen sulfide (H2S), produced by certain gut bacteria, acts as a substrate for sulfate production, which is crucial for various bodily functions. Modern environmental factors impair sulfur metabolism, leading to sulfate deficiency and subsequent SIBO as a compensatory mechanism. Treating SIBO by merely eradicating bacteria may fail because it doesn't address the underlying sulfate shortage.

Actionable Steps for H2S SIBO:

1. Take nightly Epsom salt baths (4 cups in a 20-minute soak) for a week to increase sulfate levels.

2. Consider supplementing with a low dose of organic molybdenum (no more than 150 mcg twice daily with food).

3. Use hydroxocobalamin (a form of vitamin B12) to bind and reduce the toxicity of H2S.

4. Consider Korean Red Ginseng to reduce internal H2S production, especially if fatigue or low-adrenal symptoms are present.

5. Implement a customized low-sulfur diet that supports sulfate production.

💊 SUPPLEMENT SAVVY: WHY PROKINETICS MATTER

Prokinetics are medications or natural agents that stimulate the muscle contractions of the GI tract, promoting peristalsis—the natural movement of food through the digestive system. Unlike laxatives, which stimulate a bowel movement, prokinetics help regulate the Migrating Motor Complex (MMC), a key mechanism that clears residual food and bacteria from the small intestine between meals.

Pharmaceutical Options for Prokinetics

For conditions like SIBO and chronic constipation, several pharmaceutical prokinetics have been studied:

• Low-Dose Naltrexone (LDN): 2.5 mg for diarrhea-predominant cases or 5 mg for constipation-predominant cases, taken at bedtime.

• Low-Dose Erythromycin: 50 mg at bedtime.

• Prucalopride (Motegrity): 0.5–1 mg at bedtime. This serotonin receptor agonist has shown excellent safety and efficacy for motility disorders and prolonging SIBO remission.

Natural Prokinetic Alternatives

For those seeking a non-pharmaceutical approach, natural prokinetics can be effective:

• Iberogast: A combination herbal formula without ginger; 30–60 drops at bedtime.

• Ginger Root: 1,000 mg at bedtime has demonstrated efficacy in promoting motility.

• Ginger-Containing Formulas:

  • Prokine (Vita Aid): 1–3 capsules at bedtime

  • Motil Pro (Pure Encapsulations): 2–3 capsules at bedtime

  • Motility Activator (Integrative Therapeutics): 2 capsules at bedtime

  • GI Motility Complex (Enzyme Science): 1 capsule at bedtime

  • SIBO-MMC (Priority One): 3 capsules at bedtime

  • Bio.Me.Kinetic (Invivo) [UK only]: 2–3 capsules at bedtime.

🥦 BETTER HABITS: EAT BREAKFAST LIKE A KING, LUNCH LIKE A QUEEN, DINNER LIKE A PAUPER

Rhythms exist everywhere in biology, from sleep cycles to menstrual cycles to our immune system. Our biological clock affects a vast array of biological systems within our bodies, and the effect of meal timing has been extensively studied to understand its impact on health outcomes. When someone is in circadian misalignment, they will have elevated glucose, elevated insulin, a completely flipped cortisol rhythm, significantly lower leptin levels (which tends to drive less activity and increased drive to eat), and reduced sleep efficiency.

Meal Timing and Metabolic Health

1. Energy Expenditure and Calorie Distribution:

   • A study found that consuming a large meal early in the day leads to greater energy expenditure throughout the day compared to eating later. This suggests that aligning calorie intake with natural circadian rhythms can enhance metabolic efficiency.

2. Postprandial Glucose Response (the period immediately after eating):

   • Research indicates that eating earlier in the day results in better postprandial glucose responses. For example, a study comparing early and late lunches found improved glucose handling in the early lunch group.

3. Weight Loss and Metabolic Parameters:

   • A meta-analysis showed that consuming more calories earlier in the day resulted in greater weight loss and improvements in metabolic parameters such as LDL cholesterol and insulin resistance compared to consuming more calories later.

Chrononutrition and Circadian Rhythms

Circadian Disruption

Chronodisruption, or the misalignment of biological rhythms, is linked to metabolic syndrome, obesity, diabetes, and cardiovascular diseases. Aligning meals with the circadian rhythm can help reduce these risks.

Time-Restricted Eating (TRE)

Research on TRE highlights its benefits for insulin sensitivity and glucose metabolism:

• A 5-week study restricting eating to 7 a.m.–1 p.m. improved insulin response and reduced insulin resistance.

• Eating late at night is associated with poorer glucose tolerance and reduced insulin sensitivity compared to daytime meals.

• A systematic review found higher postprandial glycemic values after nighttime carbohydrate consumption.

Meal Timing Consistency

Maintaining a consistent eating schedule is crucial. Irregular meal timing can lead to "metabolic jetlag," negatively affecting metabolic health.

Key Takeaways

✅ Consume larger meals earlier in the day.
✅ Limit eating windows to early hours (e.g., 7 a.m.–1 p.m.).
✅ Stick to a consistent meal schedule to align with circadian rhythms.
✅ Avoid late-night meals after 8 p.m.
✅ Start the day with a nutrient-rich breakfast for better metabolic outcomes.

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