Methane SIBO with Dr Allison Siebecker | Ep. 84

Love this podcast. Support this show through the A-Cask supporter feature. It's up to you how much you give, and there's no regular commitment. Just click the link in the show description to support now. Welcome to the Healthy Gut Podcast with Rebecca Cromes, the place where you can learn how to achieve a happy, healthy gut. He is what's coming up on today's show. Welcome to episode 84 of the Healthy Gut Podcast. Today I'm with Dr. Alison C. Becker, and we're talking all about a methane overgrowth in the small intestine. Now, if you haven't already listened to it, I do recommend you go back the previous episode and listen to our first part of this two-part series on Hydrogen Dominant Cibo. When Dr. Alison C. Becker and I recorded this interview, it was prior to the new classification of methane Cibo, and it is now being referred to as intestinal methanogen overgrowth, or IMO, rather than Cibo methane dominant, or a Cibo with a methane dominant presentation. And the reason for this is that there has been more research done. There's ever-evolving research on Cibo and overgrowth in the small intestine. But the things that create methane gas are actually not bacteria, they're methanogens. So they're not true in representing the B in Cibo, which is small intestinal bacterial overgrowth, but instead they belong to the domain RKR. They also might be overgrown in the colon, not just the small intestine. And so it's because of this that this new term has been proposed, such as IMO, for methanogen or methane dominant overgrowth in the small intestine, rather than Cibo. So please bear with us in this interview. We did record it prior to the change in the way we describe methane overgrowth in the small intestine. But every time we talk about methane, Cibo, just remember we're actually now talking about IMO. If you would like a transcription from today's episode, don't forget that you can get that for free if you're a member of the Healthy Gut Podcast. All you need to do to join is sign up at thehealthy Gut.com/podcast. It's free to join, which is fantastic, and you will get an email with the transcription sent to you every week when there is a new podcast released. So enjoy today's episode with Dr. Alison Sebecker as we talk about intestinal methanogen overgrowth, formerly known as methane dominant Cibo. Welcome back to the Healthy Gut Podcast, Dr. Alison Sebecker. Hello, I'm happy to be back. And today we're going to be talking about methane dominant Cibo. And I encourage you to go and listen to the episode that I released last week, which was all around hydrogen dominant Cibo, with Dr. Alison Sebecker. It's a great foundation piece. And even if you don't have hydrogen dominant Cibo, we covered so much useful information in there that I think it's really worthwhile going and taking a listen to. So pause this recording and go and listen to that one if you haven't already. But today we're talking about methane Cibo, what it is, what the difference is between hydrogen Cibo, and what we can look for as a symptom picture. So let's start off with what is methane dominant Cibo, and why is it different to hydrogen? Right, so just very briefly, we have these three different gases that we have in Cibo, hydrogen, methane, and hydrogen sulfide. And these correlate with different symptoms. So the methane gas correlates with constipation. And it isn't just that it correlates. It's actually been shown to directly cause constipation. It's not like, well, they're associated, but we don't know why. We know for sure it causes constipation. I believe, if I'm remembering the study correctly, it was like a 69% or 70% slowing of the transit, lengthening and prolonging of the transit, when methane was infused into the small intestine of test animals. So we know that it interacts with the nerves and the neurology in the intestinal lining. And it's like a gazotransmitter. It has an effect, it's not inert. So now there's a bigger question here about what is it? Because the bugs, so to speak, the bacteria are different than the hydrogen and the hydrogen sulfide. And these are actually not bacteria. Technically, they're archaea. Some people call them argy. And they're just a different sort of microbe. And the main one that has been shown to be living in humans in our intestines, causing constipation, is M. Smithii, Methano, Brevybacter Smithii. So it's even been narrowed down to sort of one organism, and it's an archaea, not a bacteria. So because of that, the name for methane seabo has been proposed to be changed. And now it's being referred to by Dr. Pimentel, and some of his colleagues, as Methanogen bloom, instead of sebo-methan type. It's still the same thing we've always known it to be. They're giving it a new name now. And part of this is because it's not bacteria. So it doesn't fit into the bacterial overgrowth. It's an archaea. And also, the word bloom is a word that means one species that is overgrowing, but maybe even in its own organ where it normally resides. And we know that the methanogens can reside in the small or large intestine or both. So again, then it's not exactly localized per se in every case to the small intestines. It doesn't quite fit the sebo name. And then bloom means it's just this one organism that's blooming or overgrowing. So there's all these different reasons. The last one is that the term overgrowth for the gastroenterologist, that term is associated with a small intestine in their minds, even though for the rest of us it isn't, but it is for them. So it's just a problem in the terminology for them. So for all these reasons, that is the new name, or the proposed new name. I haven't quite caught on with it yet. So I still say, you know, sebo-methan type. But what I like about this is that for quite some time, Dr. Pimentel has been saying it's a different disease, and it's because it's got a different organism causing it. He believes it has a different cause. I mean, we can see from the studies that the majority cause, which we actually did not talk about in our hydrogen diurea talk, but the majority cause in that circumstance is food poisoning, but it is not the main cause. And we don't know what the main cause is in methane type sebo, or methanogen flim. So it's just a little different, and it's good to think of it in a different way. And the real reason why I like this perception shift is because we've always known that it requires a different treatment, and it's actually a little harder to treat. And now that all makes sense. When we realized, okay, they're not actually even bacteria. They're archaea. Now you know why you need a different sort of treatment approach, and why the whole thing looks a little different. What are the symptoms for someone that has this methanogen bloom? Primarily, it's going to be constipation and it sets it apart. But you just would also have all the regular sebo symptoms, which are awful. So abdominal bloating or distension, pain or discomfort. Of course, the main thing is that any of the symptoms come from eating or drinking, and then you can have food reactions in particular to carbohydrates. That's what sebo sort of defines sebo, and which I'm still calling it as you see. See, I'm not changing my language. It's the same thing, just a new name, right? So then those reactions might not just be digestive, but also like headaches or any sort of systemic, non-digestive symptom that comes from eating can be related to this. And that's because sebo can cause leaky gut. And then we have acid reflux, we have burping and farting, nausea, a feeling that food sits in the stomach and won't go down. Very common is anxiety, brain fog and depression, with anxiety being more common than depression, very common. And so about these symptoms, there is a grouping of symptoms that is a bit more typical to methane, and that would be the constipation with acid reflux. Acid reflux, burping, and nausea. And that is because all of those are sort of like backward upward symptoms. Like, things are coming back up. Or you feel as if they are. And they're certainly not moving down. And so, but the backward upward symptoms, nausea, acid reflux, and what was the other one I said? I just forgot. Burping and farting. Thank you, burping. It's burping, burping more so than farting. That is like, if somebody just reports those to you and they're constipated, that would be like a classic methane symptoms. Not everyone's going to have that. And, you know, not everyone has acid reflux with methane, but that is classic. And we think it's because in studies, it was shown that methane gas actually creates a little bit of reverse motion, hyper motility in the small intestine. So, there's a little bit of backward motion going on just a tad anyway. Are you saying anything with the symptoms, correlating with weight gain or loss with people with this methanogen bloom? I'm trying to check. I know it's hard. It is hard after calling it methane dominant SIBO for all those years. Yeah. So, the studies that Dr. Pemantel and his team have done have shown that it's associated with weight gain and obesity. But clinically, I don't see it very often that way. So, I don't know why for me and actually several of my colleagues, many of my colleagues, there's a bit of a disconnect between what the research shows and what we see clinically. I'm not sure what to make of that. But it's important to know for anyone who finds that, you know, the typical, I didn't even talk about this in the last episode either, but the typical circumstance with weight and SIBO is that you're underweight or you're losing weight and you find it hard to put weight on. So, that's typical, but it's important to know if you're the type that is kind of gaining weight and find you can't lose weight. There is a research association with methane and that type of SIBO. I see with my coach and clients that the general picture is people who are underweight, can't gain weight, find it very difficult to. But I am that other category of people where I gain weight incredibly easily, I find it very difficult to lose weight. It's frustrating because I'm not going out and eating McDonald's every day and, you know, I'm still gaining such huge amounts of weight sometimes. And interestingly enough, for me, my most recent breath test showed methane was present for the first time, for the last previous four years it was always just hydrogen and now methane has raised its little head and it said, "Hello, I'm here." It was really interesting for me to see that. And I'll be interested to see next time I do a breath test, what's happened whether the methane has stayed or gone. And just on that piece, what do you see? Like, is it common for people to have both gases or is it more common for people to generally have one over the other? I see most people have both. That is the most common presentation that I see. Both gases are there and then, you know, they may have a mixed picture but it may be that they're just diarrhea or constipation and I think it just depends on what gas is sort of predominating. Sometimes that correlates with what we see on the breath test and sometimes it doesn't, but I don't really worry about it. I treat it all the same anyway. What about if there's a person that has methane-dominant SIBO as diagnosed by their SIBO breath test but symptomatically they're different, they might have diarrhea instead of constipation. What might be happening in that picture? We were just talking about this. So this has been a big question in conundrum for the longest time because there's always been this subset. I mean, if you're practicing, you've probably seen it. It happens. Dr. Pimentel gave me a thought on this just recently. And I just shared it in my quarterly newsletter, which you can sign up for on SIBO info if you don't receive it. It's free. And that was that that could be hydrogen sulfide. So hydrogen sulfide gas, we haven't been able to test for that yet. The technology has just been developed and coming. But all along we have not been able to test for that gas. So we wouldn't know if it was there. And we would only know if we saw flat-line tests. But then what we've learned now from the research that's being done is that that's only a fairly small percent that have the flat-line. So there really was this gas there that we just couldn't see. So probably that's what that is. Is there is hydrogen sulfide. And hydrogen sulfide gas is associated with diarrhea in the SIBO studies that have been done so far, which is only a year old now. And so probably that gas is there at high enough level to compete with and out-compete the methane. And it's causing diarrhea. So you're seeing both gases, but you got the diarrhea. Or you're not seeing both -- sorry, you're not seeing them, but they're there. Let's talk about treatment options for methane SIBO. So what is in our kit bag to treat it? Given that we know it's archaea, it's a little trickier to treat than hydrogen SIBO. What are we looking at for treating that? Well, we have our three main antibacterial treatments -- pharmaceutical antibiotics, herbal antibiotics, and elemental diet. And so we'll just go through them. So for the pharmaceutical antibiotics, the difference here is we need double antibiotic therapy. So refaximen is the antibiotic we use for all cases of SIBO. But when you have methane type, you need to add a second antibiotic to it. And that is either going to be neomycin or metronautosol. The main study was done on neomycin and it showed effectiveness. You know, much more effective than if you just used refaximen or if you just used neomycin. There have been studies done with just metronautosol and also much lower effectiveness. There wasn't ever a study done on refaximen and metronautosol. But clinically, we've always known we can do that. Dr. Pimentel let us all know that and we've all been doing it and we see it. So those are the two options. And so you take them together. You swallow them at the same time and you just do it for the same length of time. So that's key. And it's a huge missing piece. If a doctor was not educated on this, they might just give refaximen and it's more often than not as effective. Now I have talked to some gastroenterologist who said I always find that it works. This was years ago. And I don't know. I guess they just had a handful that that worked for. But I see failure after failure of that. And that's why they come to me because they were given refaximen only and it didn't do the job. We just repeat it add in the Neomisot or the metronautosol and then they think I'm like a miracle worker. And it's just simply that that is the standard of care. And the other doctor didn't know that yet. So for herbal antibiotics, we use the same core herbs that we use for the hydrogen type, which is the burberry nerves. And we went over this more extensively in the other recording. So burberry herbs oregano and neem. But then like the pharmaceutical situation, we have to take one of those and now add in an herb that is more effective for the methane. And so that would be Allison, which is the antibiotic aspect of garlic, one of the main antibiotic aspects of garlic. And we choose that instead of whole garlic or garlic oil or something like that, like crushed garlic in a pill, because garlic is highly fermentable. It has high FOS and it can bother a lot of people, really aggravate their symptoms. So we prefer to use the more purified out Allison. And we find that's really well tolerated. The one that we've been using all these years is called alley med. It has three levels of potency, alley max, alley ultra, and alley med is the top. We typically use that at six pills a day. We started using that at three pills a day and then it was actually Dr. Keller who said, "I think we should go to six." And we got much better effect. So we always get better effect when we go higher, but then you're paying more. And you know, you might react more. So the other one that we know that can be helpful is the product that's called neutron teal. And it's a combination of red corbracio bark, concrete tree, which is horse chestnut, and then a little bit of peppermint leaf. And this is working. It has some direct antimicrobial ability. But the main thrust of it is to actually inhibit the production of methane gas, like inhibit its formation. So it's got a different principle behind it. And that's been out a few years, had some studies down it. I've seen, you know, good results. And then I've also seen people not responding because that's what I see with everything. It doesn't matter who I see and what I give. Some people were great what you give and some people it doesn't. I mean anything I give, so anything we use. So one of those two, the standard would be the Allison. So for example, you would do burberry in the normal dosage you would do, plus Allison. Or you would do oregano plus Allison or nem plus Allison. Or you could use just a trontile, or you could substitute the trontile in place of the Allison. So that's what we do for the herbs. And by the way, I didn't clarify this also in the other one, but the typical time frame is two to three weeks for pharmaceuticals, but it's four to six weeks for herbs. I don't tend to go too much farther than six weeks because at least in the patient's I see, they tend to become tolerant to what I'm giving usually around six weeks. Of course there are exceptions. And I've certainly seen some people that are still having an herb be effective for them, taken for months and months. It's just so common of a pattern for me that I don't go too much longer. So that's the typical treatment course is maybe four to six weeks. Now we have elemental diet. Elemental diet is very effective for the methane type SIBO, just as it is for the hydrogen. It's very, very effective across the board. It's just amazing. And yet there's always times where whatever we give just wasn't a match. It didn't quite work. But elemental diet is another fabulous one. And there's all different ways you can do that. You can do homemade, which is the recipe. It's free on my site. And then there's various commercial ones that you can do like positions elemental diet. Vivanex plus Neocate Junior. There's various ones. Can we take the pharmaceutical antibiotics and herbal antibiotics at the same time? Yeah. Some people what they like to do is they'll take refaxman and allyson. Because they don't want to take the Neomysin or the metronodysol. Because the Neomysin and metronodysol are typical antibiotics with typical concerns, safety concerns, side effects, and you know, disruption of the microbiome, et cetera. So they'll do refaxman plus allyson. And you could also do refaxman plus allyson to try that as well. What about using things like pro kinetics? So there's a lot of talk in the SIBO communities just around how to get my bowels working. Constipation, and I know this picture because it's been my struggle for life, is really debilitating. It's got its own challenges as opposed to diarrhea, which has its own set of unique challenges. But when you have not gone to the toilet in days, sometimes a week or more, you just feel miserable. And should we be taking a pro kinetic right from the start of our treatment? Should we wait until we've done our herbs or our antibiotics? What can we do to get the bowels opening? Okay, so the first thing I would say to do to help the bowels, and I'm going to come back to pro kinetics, but the first thing would be an osmotic laxative. And I would recommend most everybody who has, really everybody who has constipation, you do need to treat the constipation. You do need to make sure you're going to the bathroom every day if at all possible. And you know, that could be, you might have to work to see what's going to be the best effect. But my number one favorite would be an osmotic laxative. So the options would be magnesium or vitamin C. Those are your sort of your classic ones. Another one would be potassium, actually, which I was just talking about recently at the SIBO symposium. Magnesium, there's two forms that are quite good, oxide or citrate. And if you're chronically constipated, you'll probably need around a thousand milligrams at night before bed is typically how we take it. I think it's better if you sort of just take it all in one dose and then you might get your movement in the morning. Some people prefer to take it all space throughout the day. You can do that too. But a key thing with magnesium, it's a bit finicky, all osmotic laxatives are, where you need to space it away from food. Because otherwise the food will make you absorb it better into your body. So what we're trying to do is let it sit in the intestines where it's a large molecule and then osmotically it will draw water towards itself from your body into your bowels. And so I would say two hours would be a good spacing from food. Now that can be tough at night. What if you had like a late dinner or what if you decide to have dessert or a snack and then now it's only been half an hour and you're going to bed. This can matter. You do need to put your mind to it and you'll see the difference in effect usually if you can wait the two hours. Vitamin C is another one a lot of people use. That you need to use more of. So more, I would say for chronic constipation, more from 5,000 milligrams and above. Maybe even going up to 10,000 milligrams depends on the circumstances. And the dosing finicky with all of these, you have to sort of go up and down and find what's right and then something can throw it off. You ate dinner late and then you're like, why? Oh, no, I'm more constipated. Why is it not working? And it's all these little things you've got to figure out. But it's very important to get the bowels moving. And if an osmotic laxative doesn't work and also by the way, also you can use potassium, just take it as the label would recommend. Then you would need to go to something more like a stimulant laxative and hopefully that wouldn't be needed. But a progenetic would be another option. And especially in combination with osmotic laxatives, there's studies that show that's a great combination. So yes, you can bring a progenetic in right from the start whenever you would want. Progenetics in general work a bit more so on the small intestine and even the stomach versus the large intestine. But some of them do have an effect on the large intestine. And I think all of them, if you got high enough dose, which might not be even all that much more, we'll start moving a person towards diarrhea, so or bowel movements, you know, large intestine effect. So you can start right at the beginning, but I would start with magnesium first and see if that can take care of things. And you can bring the progenetic in at any time. But for SIBO itself, not for the symptom of constipation, the time for the progenetic is after you've done your treatment to try and hold any gains you've made, especially after the test is negative, to be sure that you don't relapse or at least give you a chance to hold a bit longer. It would be great if you could just clarify the difference between progenetic and laxatives, because I know some people can be a confusing thing we think. Well, both of them make me go to the toilet. Why are they different? So I think as you just said, laxative is more around large intestinal bowel and bringing water in, stimulating the large bowel and progenetic is more about stomach and small intestine. Is it as simple as that in terms of our classification? That's a good question, hey, I've got loads more just like this coming up after this break. We're back in a moment. So, I think as you just said, laxative is more around large intestinal bowel and bringing water in, stimulating the large bowel and progenetic is more about stomach and small intestine. Is it as simple as that in terms of classification? The actual technical definition of a laxative is to stimulate a bowel movement. That is not the definition of a progenetic. It's not concerned with bowel movements at all. It's to amplify and coordinate, and the coordinate is very important. Typically, we're more interested in like the esophagus and the stomach and the stomach to the small intestine and the small intestine. The motility part is not necessarily associated with a bowel movement, even in the large intestine, actually, because there can be, usually if somebody's all, their muscles are all, there's no motility, you get some motility going, they still might need the osmotic laxative to be able to have a bowel movement. It's all sorts of pieces here. So, the key thing is that progenetics, it's only when you're taking them more so like throughout the day, and at their more full dose, that they can lead towards a bowel movement, and they don't often do that. They don't often lead to a bowel movement. So, we're trying to actually get the small intestine to move there, and you may not feel anything, although some people who are quite sensitive can feel like a cleaned out feeling that's not a bowel movement cleaned out feeling. It's an upper, middle feeling, like the bloating. I've sensed this. I had patients tell me this for years, and then I was able to sense it. It's a very specific and different feeling, and it's totally different than having a wonderful bowel movement. It's just feeling like things are working correctly. For a CBO person, you'll know it when you feel it, but the important thing here with laxative and progenetic is that the patient not think that their progenetic is a laxative and that their laxative is progenetic, particularly to not think that their laxative is a progenetic, because laxatives have no effect at all. What we call laxatives on the small intestine motility, zero. So, the mistake would be, I don't need to take this progenetic, because I'm already taking magnesium. That would be a real mistake, because we need the progenetic for a very specific reason for your CBO having nothing to do with bowel movements. It's interesting you talk about that very specific feeling, and I use magnesium daily. I have my magnesium hit at night just before bedtime, and that guarantees me a morning bowel movement, which is wonderful. I was just telling you, Alison, about how the progenetic of choice, most pro has recently changed its formulation, and it no longer works as well for me, and I've run out, and I'm not using a progenetic at the moment, and I really feel it. I feel this sense that it all is not quite as right as it once was when I had magnesium and my progenetic support on board. So, even though I'm going to the toilet daily with my magnesium, I still feel quite sluggish, because my small intestine isn't getting the support that needs, so it's interesting your patients talk about that. I've always felt that, but I just never had put, I guess, I'd never articulated it. I have felt it myself. It's an incredible thing when you have that clean, small intestine feeling. It feels so good to a CBO patient when you get that. That's how you know the world is right. Exactly. I just want to touch on something before we move on, and you talked about in the CBO piece, when we're just thinking about CBO, more so than trying to get movement, and all of that food through that are just around the timing of the progenetic. Can you just clarify if we're just thinking about CBO right now and our CBO treatment when we time that progenetic use? Yes. So, you would want to be on your progenetic shortly after finishing your antimicrobial treatment, and honestly, you could begin it right away. That would probably be best for preventing relapse. However, whenever you take a new medicine, you could have a side effect or a reaction. So, it can be a little complicated if you started immediately because we're trying to assess how you feel now that you're finishing your antimicrobial treatment, whatever it is. You finish that. It stopped. How are you doing? We need to assess those symptoms, and sometimes things change in the week or so after you finish your treatment, and you might actually start to even feel better and better. We want to see these trends. So, you have to be a little cautious if you start the progenetic. What if you all of a sudden now have a reaction? Or what if by chance it happened to give you diarrhea? I've seen this time and time again, so there's no real one right way and one right answer, and you might already have information in a certain patient's case or something to do it a certain way. But I would say if you could just wait a few days, like maybe two or three days, you at least get a sense of something. If you start the progenetic on day three and then all of a sudden you get a symptom, it's pretty easy to see, and you'll track it better. But the thing is relapse, or maybe we should call it backsliding, between treatments, is so common at about two weeks. So, if you wait a month, even if you wait two weeks, that could be too long. So, I don't really advise waiting more than about a week, just as a pattern. Is there a reason why we shouldn't take a progenetic during treatment when we're doing our herbs or antibiotics? There's really no reason that I can think of, you know, I guess one theoretical thought could be, well, might it push the medicine through your small intestine quicker, and you don't quite absorb it, and it doesn't really get to do its effect there in the small intestine, and then it moves down into large intestine. Honestly, I'm not really worried about that. I mean, people have brought that up, and I think in our minds with our anxiety and see, but we could think these things, but it's more the answer is you just don't need to take a progenetic when you're in the middle of your treatment. You just don't need to, but you could, you know, if you didn't, it could save you some money, right, and then you just start it right back up again. But if you're using it for some symptom relief, then you continue it. If you think it's helping you, you feel good, you take it, and also LDN. Typically, we titrate that dose up. That's a low dose, no truck zone. It's one of our progenetics that we use like a progenetic. Anyway, since you had to titrate it up, you don't want to be going on it and off it and off it. So once you've gotten yourself on it, don't stop it during a treatment because then you're going to have to titrate back up again. That's annoying. Yeah, that is annoying. Let's touch on diet. Should we be following a specific diet for methane dominant SIBO? Is there anything around food that has a negative or detrimental impact to how we feel when we've got the methanogens living in our small intestine? I don't see any difference. I don't believe so. I think just all the SIBO diets are great for all the types of SIBO, particularly the methane and hydrogen. So there is no advice that I have that I can see in my practice one way or the other of what you need to do with your diet when you have methane. I've heard, you know, Dr. Pimentel with those studies having to do with waking. He has some faults on that. And I haven't seen those things bear out clinically, at least in my patient base. You know, with fiber, I think I've heard tell if I'm not mistaken that Dr. Jacobi has been experimenting and recommending some fiber in various forms. I'm sure very slow introduction with the methane cases. In my experience, I just see fiber really making it so much worse. If you start low and slow, then that can be fine. But just like stepping back big picture, I just I don't see anything different that is needed. My own experience is low and slow is what wins the race for me. And it's with my supplements, it's with my medications, it's my food reintroduction, everything. I can't go full steam ahead. I can't start at the full dose of anything. I can't start at the full serving of the food when I'm trying to bring in a new food. I have to go slow. And for me, it can be frustrating because I'm a bull out of a china shop. I'm always a million miles an hour. But I get such better results and I feel so much better when I slow things down and I just give my body the chance to deal with it. And perhaps because I've got this impaired mobility piece that things are slow going through my system. That if I put too much in in one go, it's just overload. My body doesn't have the chance to really process it. And particularly with lentils. And so interesting because for years I was vegetarian and I ate so many lentils and beans. And I was so bloated, no wonder I was so bloated. But I really like eating them. And for me, I you know, I just can't go and eat a bowl of dal. It just that's an explosion, you know, of gas waiting to happen. But I have to have a tablespoon or two and just eat it slowly and build up, tie, trade it up rather than going and eating a whole lentil curry or something like that. So just, you know, for my listeners, you know, even when your numbers reduce, sometimes you just need to still go a little slow and work with what your body is dealing with. What the picture is. And if slow motility is part of your picture, you know, work with that. Yeah. And I think one of the things I wanted to say is I think Dr. Pimentel with his studies has, if I'm not mistaken, has, sorry, I haven't read them recently. I read them all before, but found that fat might be not as good for methane. But in fact, I don't, I just don't clinically see that. That's one of those ones. Fat can stimulate actually bowel movements. So I don't know. I'm not sure what to make of all that. What we're all seeing sort of different. So that's why I just sort of feel like at this, this point in time, the standard SIBO diet is so fine. What's the outlook like for a person with methane SIBO? We know it's a more challenging SIBO to treat. Does it take longer than the hydrogen dominant person to get to a point of, you know, resolution or perhaps just a reduction in symptoms where they're happy? Do you see the methane person ever truly clear it? Or is it these people making up more of the chronic cases? What do you see? It's tricky to treat. It takes longer. I have seen people fully clear. Isn't that lovely? Even chronic. I have seen it. But it is a lot trickier. One of the things that we'll see is we'll give the treatments. And you'll see the methane gas comes down on the retest if you're doing retesting. And then the hydrogen goes up. And this is part of like the longer, more complicated trickier treatment course. It's frustrating. What none of us know is how come the treatment just couldn't lower them both at the same time. But it doesn't work that way. It seems like the treatment goes first to getting rid of the methanogens. And so what happens is hydrogen gas is actually converted into methane gas. That's how methane is made. It takes four hydrogens to make one methane. So when we get rid of the methanogens, unless methane is being made now, you still apparently we didn't get rid of the bugs that were the bacteria that were making hydrogen. And now we see that. We don't see this in every case, but a lot. It's common. Very common. So then now you have to now go and do another course and focus on the hydrogen producing bacteria. And when we do this, typically we'll still keep a little bit of methanogen treatment in there just so that they don't come back. And we just get rid of any extras that maybe we can't see or they're at low level. But you focus a bit more on the hydrogen. You just do another treatment and then you know, so it'll come down. It'll work. But weird stuff happens like that all the time. There's this thing that Dr. Sandberg Lewis and I named pissed off methanogen syndrome where now you've given a treatment and then you look and the retest is the methane's higher. Usually in a case like that, usually the symptoms aren't worse. And we feel like we're seeing an artifact. We're in the middle of treating. And we just keep treating. I just think we were in the middle and we weren't done. We need more time. And so if everything was going great, we might keep the same treatment. If it wasn't, we'll switch. We just keep treating and it'll come down. If the symptoms get worse, that's concerning. And then that gives pause. And I'm not prepared to troubleshoot that right now on this podcast. But sometimes that happens. Anyway, it is trickier. I think it's because we're dealing with archaea and not a ton. You know, all this, you know, hundreds, hundred-year service since antibiotics have been discovered. The focus has been on treating bacteria, but not archaea. So that's new to us. And you know, there is another, there is another pharmaceutical I think that sometimes can help with that. And that is Alinea, which is not as oxenite. Not always, but sometimes it has been shown in studies to have some effect on archaea. So that's another option. But other than these, these piddly studies here and there, we don't know what the best approaches. And we're learning more and more. Oh, there is also a drug in research with Dr. Pimentel's team. And it's a statin, I believe it's lowest statin that has been made to not absorb into the body and be prolonged release. This statin has the ability to all statins have the ability to inhibit the methane production, the inhibited enzyme in the M-Smithii. And this drug is not to market yet. It's called Sin-10, S-Y-N-10. I'm sure it'll get a fancy name when it's ready. But so people have experimented with red use rice, because that's how to have a statin effect. And in the beginning, Dr. Pimentel and even people from my team, we were trying just regular statins, which, you know, have horrible side effects. The effects were like, "Meh." And that's actually what allowed him to realize what he needed to do to make the drug more effective. And the red use rice, I mean, I had a couple people were like, "Yeah, we think it's working." And then it didn't. And very spotty. I mean, certainly somebody could try it if they wanted. But so anyway, it's trickier. It doesn't mean it won't ever go away. It just takes longer. Well, I think that's great to hear that you've had even chronic cases be able to be resolved and clear their SIBO and feel better. Should we be looking for a 100% resolution, or is there perhaps a less firm piece that we should be going towards, perhaps 70% resolution? What's your take on that with all of the patients that you've seen? Where should we be aiming our sites? Okay, so there's this prognosis piece where a third of patients are not chronic, and they're going to be cleared, and they're going to not relapse, like ever, and they're done. Like, that's what everybody wants. They all want that. Those people, 100% is reasonable for them. It's different. That's a different set of people. Then we have the two thirds that are more chronic. Those people, I think we should aim for 80 to 90%. I like to aim for 90%. And the reason I like to aim for that is because often if we get somebody to 80%, and the way that is judged is by their report. It can be a little complicated because maybe one symptom is 100% better, and another symptom is 50% better, and whatever. It's the patient's decision on that. We talk about that. But if somebody is 80% better, and then we do one more treatment round, usually they'll get to 90%. But how long will that last? It lasts a while, and then you know the relapses can come. Most gastroenterologists are shooting for 80%. That is very realistic. I think 90% is a little bit more pie in the sky. But I can often get people there with a lot of fiddling, you know, another round, and just all these fiddling. So 80 to 90%. And that's important to know because you have to remember that you have usually most people have an underlying cause that's present causing the SIBO, or it would be gone, you know, and those underlying causes, which can be various, have symptoms of their own. So for instance, something like adhesions, or something like endometriosis, endometriosis will cause, you know, pain, abdominal pain, vomiting, diarrhea, whether a person has SIBO, or they don't have SIBO, those are the symptoms of endometriosis. So we have to remember there's a cause there, and even just the slow motility, if you know, we think the physiologic underlying causes, slow motility in the small intestine. That can just slow motility, even if you didn't have bacteria accumulated yet, say you don't have SIBO yet, you're clear. You know, you can have a bloating and burping and discovery. If you wanted to hear Alison and I talk all about the underlying causes of SIBO, head to episode two, why back in the early days of the Healthy Gut Podcast, and we dive into that in a lot more detail, episode two and three is where Alison joined me. As somebody that has achieved, I would say, sitting hovering between 80 and 90% improvement from where I first started out, as someone that has SIBO today. My SIBO is back in full force if you look at the numbers, but symptomatically, I am so much better. And instead of being dogmatic about having this approach, I must never feel a digestive symptom ever again, and if I have anything, it means failure. I've changed my perception and my approach. Today, I acknowledge I have a chronic condition. I have multiple underlying causes that are leading to me to have this bacterial overgrowth and RKO now overgrowth in my small intestine. And so it's not normal for me not to have any kind of symptom because I've got so many things going on. But for me, it's about how do I manage it? And if I have a little bit of bloating, a little bit of constipation, then I use that as my markers of what's going on. And I don't freak out over it now. And instead I say, thanks, Body, for giving me that signal. I'm listening, I'm watching. What did I do in these last few days that might have led to a flare, or is it time for me to go and speak to my naturopath and perhaps it's time to do another round of treatment? But I don't approach it with fear like I used to. I used to be terrified of a single bloating episode because I used to think, oh my gosh, that means my SIBO is back. And today I just go, no, it's messaging from my body and I'm listening to it. Even with my SIBO, it's actually quite rare for me to get big, bad bloating episodes like I used to. It's really interesting because my numbers are just what they were at the start, but my symptoms are so much better. And so you can live a wonderful life. Even with SIBO, SIBO doesn't mean it's end of life diagnosis kind of thing. You don't have to freak out. And a relapse doesn't mean the end of the world either. And I used to think it did, but it doesn't. Yes, this is beautifully described attitude and the typical pattern we see in chronic SIBO with continued treatment and management, continued treatment and management over the long term creates exactly what you've just described. The relapses are farther apart. The person feels better and better and better. You know, there are relapses so in those times, but the relapses are not ever as bad as they were in the beginning. And so the both the relapses are better and the in between the remission periods are better. And there's an overall positive trend upward. And we just see this over and over again. And it's because also I think people learn how to manage their chronic condition better and better and better. And the management techniques get fewer. You usually need less of them, less things. And it all just becomes like second nature. And the acceptance is a huge part of it. If you're thinking I need to not be chronic and I need to have this gone, you know, you might be fighting against your reality there. But the positive trend up is the absolute norm, which is great to hear. Doctor Alison Sebecker, thank you for coming back to the Healthy Gut Podcast and sharing your knowledge and wisdom with us to talk all things methane. And if you'd like to listen to our interview on hydrogen, make sure you tune into last week's episode, which aired first. And then this was the part two of that discussion that Alison and I have had in Seattle when we were here attending SIBO CON 2019. Doctor Alison Sebecker, you've got a fantastic website, SIBOinfo.com. And I encourage everybody to head there and sign up to your quarterly newsletter, which you put out. It's free to join up and it's such a wealth of information. Thank you, Rebecca. So fun to talk to you again. Thanks for coming on the show. I hope you enjoyed today's episode, episode 84 with Doctor Alison Sebecker. It's always a joy to interview her and learn more about overgrowth in the small intestine. If you would like the transcription from today's episode, where we talk all about intestinal methanogen overgrowth, you can do that absolutely free just by becoming a member of the Healthy Gut Podcast. Head to thehealthygut.com/podcast to sign up and you will get an email with the transcription from every episode in season three. And don't forget to leave a rating and review of the show. I absolutely love hearing from you and it really helps other people with SIBO or IMO know that this is the right podcast for them. I look forward to seeing you next week with our next episode. You've been listening to the Healthy Gut Podcast with your host, Rebecca Coulmes. To learn more about the Healthy Gut or our podcast, head to thehealthygut.com/podcast. We would like to thank Red Lemon Productions for the production and original music score of this podcast. To find out more about their services, head to redlemanproductions.com. The Healthy Gut Podcast is a production of the Healthy Gut. Thanks for listening.