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Angela Pifer Functional Medicine Nutritionist
I help people create healthy habits. I'll show you how!
I help people create healthy habits. I'll show you how!


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SIBO Guru Angela Pifer PODCAST: Why Treating SIBO Alone May Not Be Enough
This week I joined Stephen Anderson, host of The Holistic Practitioner Podcast on iTunes. I discuss common misconceptions, underlying causes, and my clinical insights.
You can listen here:
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Latest article from Functional Medicine Nutritionist Angela Pifer, SIBO Guru: Which Diet Best Treats SIBO?
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Functional Medicine Nutritionist, Angela Pifer writes: A phase 2 clinical trial on humans is currently in progress that sounds promising; evaluating the effect of lovastatin lactone on methanogens and symptoms in patients with irritable bowel syndrome with constipation.

If you recognized the word 'statin' in lovastatin, yes, you are correct. This is a statin drug!

Statins can inhibit archaeal cell membrane biosynthesis without affecting bacterial numbers as demonstrated in livestock and humans. This opens the possibility of a therapeutic intervention that targets a specific aetiological factor of constipation while protecting the intestinal microbiome. While it is generally believed that statins inhibit methane production via their effect on cell membrane biosynthesis, mediated by inhibition of the HMG-CoA reductase, there is accumulating evidence for an alternative or additional mechanism of action where statins inhibit methanogenesis directly. It appears that this other mechanism may predominate when the lactone form of statins, particularly lovastatin lactone, is administered.

The study is being done by Synthetic Biologics, Inc., who describes themselves as a "clinical-stage company focused on developing therapeutics to protect the microbiome while targeting pathogen-specific diseases."

They announced the study and preliminary findings at the  American College of Gastroenterology (ACG) Annual Meeting in Honolulu, HI. The research was sponsored by Synthetic Biologics and performed at Cedars-Sinai under the direction of Mark Pimentel, M.D., FRCP(C), Director of Cedars-Sinai Medical Center's (CSMC) GI Motility Program and Laboratory, and Chairman of Synthetic Biologics' IBS-C Clinical Advisory Board.

"The presentation at the ACG Annual Meeting highlighted the therapeutic potential of SYN-010 (lovastatin) for IBS-C," stated Jeffrey Riley, Chief Executive Officer for Synthetic Biologics. "As we continue to move our IBS-C program through two ongoing Phase 2 clinical trials, this research, along with SYN-010's novel modified-release formulation of the widely prescribed lovastatin lactone, provides a strong body of support for SYN-010's efficacy in reducing methane levels in the gut. We continue to expect topline results from the first Phase 2 clinical trial of SYN-010 during the fourth quarter of 2015, and topline results from the second Phase 2 clinical trial during the first half of 2016."

Synthetic Biologics' proprietary SYN-010 is a modified-release formulation of the lactone form of lovastatin that is intended to reduce methane production by certain microorganisms (M. smithii) in the gut while minimizing disruption to the microbiome. Methane produced by M. smithii is perceived as the underlying cause of pain, bloating, and constipation associated with IBS-C, and published reports have associated higher intestinal methane production with increased constipation severity in IBS-C patients. SYN-010 is intended to act primarily in the intestinal lumen while avoiding systemic absorption, thereby targeting the major cause of IBS-C, not just the symptoms.

The CSMC poster, entitled "Lovastatin Lactone Inhibits Methane Production in Human Stool Homogenates," included data from studies comparing the effects of different statins and statin forms (lactone vs. beta-hydroxyacid) on methane production by stool homogenates from five female donors with high levels of breath methane. Dr. Pimentel concluded that, of the various statins examined, lovastatin lactone was the only effective inhibitor of methane production in the stool homogenates, significantly inhibiting methane levels by -65% compared to the control stool.

"This lovastatin data suggests that SYN-010 has therapeutic potential to diminish the production of methane in the gut, thereby treating the cause of IBS-C, not just the symptoms," said Dr. Mark Pimentel.

I am encouraged at the prospect of a front line treatment to knocking down methane producers! This, coupled with the right herbal antimicrobial protocol and then gut healing and rebalancing may finally offer some long term relief for chronic constipation sufferers with stubborn methanogen levels! I am looking forward to seeing the Phase 2 trial results and I hope that they track these patients out over six months, a year and beyond. We need to continue to look for LONG TERM results for reducing methane producer.

Angela Pifer | Functional Medicine Nutritionist
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The goal with a SIBO breath test is to identify an overgrowth of microbes in the small intestine, by measuring the production of hydrogen and, or, methane production in response to the sugar solution that is swallowed at the start of the test. The two sugar solutions that are used with SIBO breath testing are glucose and lactulose. Many times I have heard patients voice concern over using a lactulose breath test when they are lactose intolerant. Let me clear this up and share with you some tips for getting the 'cleanest' SIBO breath test results.

The two sugar substrates used with these tests is lactulose and glucose. I prefer the lactulose three hour test. Lactulose is a synthetic sugar that is made in the lab. It is not digested or absorbed by human cells and that is why this is used - so it travels the length of the small intestine and makes its way into the colon. It is not lactose. Having a lactose intolerance does not exclude you from taking this test. If you have a lactose allergy, then you should not take this test. True lactose allergies make up a very, very small subset of the population. Again, you can absolutely take this test if you have lactose intolerance.

It is pretty fascinating if you think about how this test works. I ingest a sugar solution, and then breathe into a tube at twenty minute increments. The microbes that are in my small intestine ingest the sugar, and release gas as a byproduct. The gas builds up in my small intestine and passes through the lining into my blood stream, which then circulates in my body and the gas is exchanged through my lungs and expelled out into my breath, where we can measure gas production. Gas production is measured in parts per million at baseline (the start of the test) and then in twenty minute increments during the ninety minute or three hour test.

A test is positive if there is a greater than 15 ppm (parts per million) rise in hydrogen over baseline, a greater than 3 ppm rise in methane over baseline, or a combination of hydrogen and methane rise of greater than 12 ppm over baseline.

What we are also looking for is a double peak of hydrogen and, or, methane – once when the sugar substrate hits SIBO microbes in the small intestine (often by the 90-120 minute mark) and a second when it enters the colon and the large numbers of microbes in the colon consume the sugar substrate and produce gas.

When I review SIBO breath tests, a good majority of these have a high baseline of methane. This still may be considered a positive test, if the patient has been fully compliant with the test prep instructions. But, what we would rather see is a very minimal gas production at baseline to then compare the rise in hydrogen and methane as the sugar substrate moves along the small intestine.

I also prefer Quintron and CommonWealth Labs for this test, since they also measure CO2 levels with each vial. This measure tells us whether the test interval was collected correctly or not.

Obviously everybody wants to have their test results be as accurate as possible. The test prep instructions are meant to greatly reduce the fermentable load from supplements, medications, food and drink, and to minimize any exposures, like poor oral health hygiene, that will skew the test results. This also means trying to minimize gas production at baseline.

My post today offers some suggestions to minimize a high baseline reading on your SIBO breath test. Let’s first talk about what you will be doing to prep for the test.

When prepping for the test (whether you are using the SIBO Breath test with glucose or lactulose as the sugar substrate) it is imperative that you follow the patient preparation guidelines that are offered by the test provider.

These instructions often include:
1. No smoking, or being around second hand smoke, the day of the test.
2. That you brush your teeth prior to the test and use good oral hygiene practices (this reduces the number of microbes in your mouth that may compromise the test results)
3. No sleeping an hour prior to the test or vigorous exercise the day of the test.
4. That you wait 14 days post antibiotic treatment, a barium study, use of an enema or colonoscopy and that you wait at least 7 days post PPI – or, proton pump inhibitor use, prior to starting the breath test.

The day prior to the test you will be instructed to prep for the test by limiting your diet to only a few ‘prescribed’ LOW fermentable foods, these often include chicken, fish or turkey, white bread, white rice, eggs and clear broth.

If you are offered further advice on the preparation of your test, please adhere fully to these instructions.

Here are a few additional suggestions to prepare for your test:

1. If you consume clear broth, make sure that this was not prepared with fermentable vegetables like garlic, onion, mushrooms or celery. Even though this is a clear broth and you are not consuming the actual vegetable, the fermentable compounds in these vegetables are water soluble. These will leach out into the liquid and likely cause a symptom reaction and they may skew the test results.
2. Use a brand new tooth brush the morning of the test
3. Use a mouthwash with a 3% hydrogen peroxide solution, mixed with equal parts water and swish for two minutes prior to starting the test (Do this prior to starting the test; do not repeat during the test).
4. At the time of the test, if you are experiencing constipation (meaning that you’ve gone multiple days without having a bowel movement) consider doing the food test prep for two days to further reduce the fecal matter that is in your colon, which will reduce colonic fermentation (which can also skew test results)

Lactulose is considered a controlled substance and is only available through a prescription. If you are having a hard time getting a three hour lactulose breath test, I recommend visiting CommonWealth Labs website Your doctor does not need to have an account with this lab. All they need to do is to fax the requisition to CommonWealth. CommonWealth mails the kit to your doctor. You would pick the kit up, perform this test at home and then send the test kit in with your payment. I recommend that you fill out the requisition and give this to your doctor. All they will need to do is to sign it and fax it.

Angela Pifer | Functional Medicine Nutritionist

Schedule and appointment with Angela:
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NEW VIDEO! Seattle Functional Medicine Nutritionist, Angela Pifer - Is SIBO an autoimmune condition, or can it be triggered by one? If you have severe constipation or gastroparesis AND SIBO, and you've had food poisoning, this video is a must!
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Join Functional Medicine Nutritionist and SIBO Guru Angela Pifer as she discusses antibiotics and SIBO - (Xifaxan, Rifaximin, Neomycin) used to treat SIBO work for only a small percent of people (meaning that they cure SIBO within 1-2 rounds). The vast majority of people are given multiple rounds of antibiotics. Is this causing more harm than good?
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Seattle Functional Medicine Nutritionist - Is food Intolerance or "sensitivity" testing able to show you what you are really reacting to? Join SIBO Guru Angela Pifer as she discusses the validity of these tests and why, if you have SIBO, this test isn't worth running in the first place.
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Should Probiotics be Part of SIBO Treatment?

If you are looking at SIBO, like I am – that SIBO is a symptom of an extreme imbalance in the gut and not a primary condition, or infection, then probiotics must be part of your SIBO treatment therapy. Otherwise there is no way that you will be able to get your gut back into balance. Probiotic therapy must be a pillar of SIBO treatment. But, what should you take?

Which probiotics, when to include these during the treatment phase and how much to use, are all questions that should be asked as it pertains to your exact case. I do not use the same probiotics with each of my SIBO patients. But, at some point during the therapy, I do include probiotics as part of every patient’s SIBO treatment protocol.
I spoke at length about why probiotics should be included in a previous video; you can watch the video here:

Some doctors are recommending probiotics to their patients, but often times, they are recommending the wrong ones. Direct to consumer probiotics market directly to doctor’s offices. Yes, some do have studies showing that they can benefit the gut. But, we cannot infer that if these benefit the average gut, or if they benefit a person with an inflammatory bowel disease, that they will benefit a person who has SIBO.

Whenever I work with a new patient, I have them line up their supplements and take a picture of what they have tried and what their experience was with the supplement. You can view the pictures here:
One patient had tried each of these products.

There are ingredients in these products that WILL trigger a SIBO response:

Jarro Dophilus – maltodextrin, tapioca starch, contains dairy (milk) and soy (if an issue)
Florastor - has 33 mg of lactose!!!
Align - has lactose (milk) and sucrose (latter isn’t an issue for most SIBO, but good to know)
Culturelle – has inulin
Jarrow Ideal Bowel Support - has potato starch and soy (if an issue)
Pears YB – has pectin
Probio Pure's – has tapioca starch
Prescription assist - has prebiotics

VSL3 – has maltose (this is glucose, and SIBO patients do not usually react to this). Each 2 capsule serving has 225 billion lactic acid producing flora, the sachets have 450 billion, and this will trigger a reaction in the small intestine – this is too high a dose – when it comes to probiotics, more is not better. VSL3 has some studies showing that it is beneficial in study subjects with various inflammatory bowel conditions. For those patients, with an inflammatory bowel disease (in their colon) treatment would include 150-225 billion flora. You would need to target the large intestine with this dose.

Introducing any of these direct to consumer probiotic lines will work again SIBO treatment. Aside from VSL3, there are ingredients in each of these that should not be introduced until flora balance has been restored. These ingredients will continue to fuel the overgrowth of organisms in the small intestine and make it harder to knock out long term.

For patients with SIBO, I often start with less than 1 million dose of flora, taking targeted probiotic strains at 1/4 of a million dose. My patients are instructed to open the capsule and take a partial dose as we begin the introduction of probiotics into their SIBO treatment regimen.

Angela Pifer | Functional Medicine Nutritionist
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