 Hi everybody, we are live. I'm Siobhan Sarna with SIBO SOS. We're so glad to have you and we have the incredible right up there, Dr. Allison Seebecker of SIBOINFO.com and right Dr. Michael Ruscio who is here to talk to us about his very thoughtful response to is SIBO real? An evidence-based response. So it's a pleasure to have you both here. Thank you so much, Dr. Seebecker. Thanks for chiming in and greeting us and welcoming Dr. Ruscio and the whole crowd who's here. And Dr. Ruscio, thanks for taking the time to share this insight. My pleasure, my pleasure. So I just wanted to say hi and thank Michael for writing this incredible response because I know so many people were, so many patients were really concerned, upset, worried, freaked out. I heard that from so many people and everyone was like, can someone please make a reply? And then Dr. Ruscio, you did it. So thank you. I can't imagine how much time it must have taken for you to do that. It's really a labor of love and I really appreciate it. Thank you. Yeah, well, the fact that it's helping people is worth all the hard work. So my pleasure and thank you for letting me elaborate on it. Oh, we're in. Okay, so Allison, are you gonna hang out for a little while? Yeah, I'll take my camera off and I'm just gonna listen. Okay, great, love you. Thank you, Dr. Seebecker. Okay, Dr. Ruscio. So I know that there was some alarm that went through the functional health community when that blog post from another credible expert really questioned whether or not SIBO was real and you took your time and you really dove into what I feel you already knew from your own experience and created a very thoughtful reply based on evidence and your own personal observations. So tell us what you observed and how you want to approach this and how you want everyone to be thinking about is SIBO real? Well, as we wait into this conversation, I think there's a foundational issue that kind of undergirds this entire topic that's very important to understand, which is if you find someone who uses very strong language, I would be extremely cautious. And one of the more notable critics of SIBO, one of these recent critical articles used very strong language. She had a very friendly demeanor, but the word choice was very strong. SIBO does not exist. People do not derive benefit. The condition is bogus. It doesn't, the testing does not assess the amount of bacteria in the small intestine. These are all very strong statements. So the reason I took a very strong issue with this, one of these criticisms was that the person was clearly ill informed and they were making very, very absolute criticisms. I would have had absolutely no problem if the same article was written and it was written in more of a curious tone. For example, there have been some questions brought up about the validity of SIBO testing. Here are some concerns that we should be discussing. There have been some criticisms of the efficacy of the treatment. Here are some concerns. But when you go to the endpoint of saying the treatments are not effective, period full stop. The testing is not accurate, period full stop. That is an incredibly damaging, ill-informed, intellectually dishonest thing to do. And when you look at, again, one of the point of criticisms using six references to try to refute an entire condition and body of literature is laughable. It's absolutely laughable. And I think it's from Leviticus, the saying, let the fool speak so that he may reveal himself, right? And this is one of those cases where some of the criticisms have been absolutely poorly done and for patients listening to this, it's disheartening because if you hear someone in a confident way say SIBO is not a real condition, a lay person, the patient has a very hard time discerning, is that actually true? Or when someone else says no, SIBO is a real condition, is that true? The scientific evidence is what helps us to answer that question. And unfortunately, when, again, when you hear someone use very strong language that usually means that they are more ill-informed because the more informed someone is, they understand there are data supporting a position, there are data refuting a position, and so that makes someone's position somewhat tempered, right? And this is why I say that dogmatism or a strong opinion can only exist in the presence of ignorance. You have to be somewhat ignorant to the contradictory information to have a very strong opinion. So sorry to be a little bit long-winded in this, but it's a philosophical piece that's really important for people to understand that if you are, you know, where you get your information from is incredibly important. And if the person you're getting your information from makes many strong statements, I would be very cautious that that person is likely ill-informed, and hence that's where their strong statements are coming from. So that I think is maybe the most important foundational piece as we kind of wade into this conversation. So the evidence is out there. Your experience is certainly, you know, years and years with thousands of patients. And, you know, I think what you said was so powerful, all of it, but like it's a very, it was a very friendly presentation. And it was a very much like a, I felt very baited and switched. Yeah. Yeah. And to me, it was, it was, it was infuriating to sit there with, you know, a laughy smiley giggly presentation and then, you know, coming off like you're a friendly, thoughtful person, but then making these statements that are absolutely intellectually dishonest. And sometimes that's, it's the most challenging to identify dishonesty when someone's being dishonest with a friendly demeanor. But that's, and that's where you have to really look at the content of the message rather than the way it's articulated. And as an example, the paper that I wrote contained about 106 references to support, an approach that I think is probably a bit more conservative regarding SIBO than many would recommend. And I think that's okay. I think that's a process of learning. We're going to be auto-correcting. As science learns more, there will be parts of our assumptions that we'll have to cut off because we've learned now that that assumption is no longer valid. And we're always going to be morphing to a more accurate opinion and perhaps on SIBO testing, that may be one of the more, you know, differed from the norm opinions. And I think that's okay. But again, we want to do this in a constructive way and not go from one extreme to another. So yeah, and I'm happy to jump in on any of the details of the paper. Wherever you want to start, I'm happy to start there. Well, I think one of the first things is, if we just do a little mini premise that it is real, one of the things that I think stuck out for me was that there was a question as to whether or not refaximin was even close to working. That was my interpretation. It was like, it was saying refaximin, bah humbug. Yes, there are a lot of relapses, but my understanding, what I took from part of it was that that wasn't even a valid therapy. Did you take that? And is that your observation? Yeah, so it made me two things just to start from a high level or one preface and then to hear a comment about refaximin. If you look at the evidence, SIBO is a real condition. The largest body in gastroenterology, arguably in the world, the premier body in gastroenterology is the Rome Foundation. And the Rome Foundation did convene an expert consensus panel, which means they took numerous experts and convened multiple meetings, multiple panels, multiple voting sessions over several months to come up with a consensus. This is way better than one guy who decided to read for three days and tell you that SIBO is not a real condition. So the Rome Foundation opinion is very, very high quality science. They take a conservative position on small intestinal bacterial overgrowth, but they do recognize small intestinal bacterial overgrowth as the underlying cause of some conditions. And they do recommend, in this case, glucose breath testing. And they do recognize it as a legitimate, diagnosable, treatable condition. And also in North America, the North American expert consensus convened a panel and they also concluded SIBO is a real condition and laid out guidelines for when to test. They recommend the lactulose testing. They recommend a bit more liberal use of the testing, but we see two of the largest bodies in gastroenterology convening expert opinions and coming to the same conclusion that SIBO is a real condition. And we also see meta-analyses, which is arguably the highest level of scientific evidence, showing that SIBO breath testing does have a role in identifying dysbiosis. I use the word dysbiosis discerningly because they indicate that abnormal levels of bacteria and fermentation are clearly identifiable on the tests. Whether or not it's SIBO per se is debatable and this is likely because the definition of SIBO is still being worked out, meaning do we cut off the time at 120 minutes or 80 or 90 minutes and what values do we consider positive? And that's likely why they say we can't quite say it's SIBO per se because there's not a lot of agreement in the data in terms of what exactly we're calling SIBO and what exactly we're not calling SIBO. But clearly we see this pattern of altered fermentation on the breath testing that indicates bacteria and bacterial overgrowth play a role in SIBO. And we also see a number of papers showing that SIBO treatments lead to improvements in breath testing and improvements in patient symptoms. So to say SIBO is not a real condition is it's laughable because there is no highly credible scientific evidence that points in that direction. There may be a paper or two or three that are challenging the condition but if you look at the body of evidence at large there is no good summative piece of information that's coming to that conclusion. And then to the point of Rhafaxamine, Rhafaxamine is a viable treatment for small intestinal bacterial overgrowth. And Rhafaxamine I believe has a number needed to treat of, I believe it's 11. And in my article I comprised a number needed to treat table looking at different therapies and you see that natural therapies actually seem to, for the most part outperformed drug therapy but it doesn't mean that Rhafaxamine isn't a viable therapy. And Rhafaxamine has shown, I believe it's anywhere from a 50 to a 70% response rate when you look at some of the meta-analyses is it a perfect treatment? No. Are the studies using Rhafaxamine perfect? No, because they only use Rhafaxamine. They use Rhafaxamine as a monotherapy meaning no dietary changes, no lifestyle changes, no post-treatment pro-kinetics, no probiotics. So we can of course have a much better extended effect theoretically anyway when using Rhafaxamine in conjunction of a more holistic and global plan. Also in that paper, in one of the recent criticisms, hypnotherapy was mentioned to be more effective than the little FODMAP diet. And that's a very intellectually dishonest statement because there's something known as positive selection bias, meaning when you're first studying a treatment, the studies showing that that treatment was effective are more likely to get published, right? So if something is new, there's more of the selection pressure for studies that have shown to be effective. So the less studies there are, the more risk there is a bias that kind of overestimates the effectiveness of the therapy. So we have one trial in hypnotherapy, whereas we have about 80 or 90 studies in probiotics and even more than that with Rhafaxamine. So again, it's intellectually dishonest and incredibly scientifically ill-informed and naive to think that you can take a one study and compare it to a meta-analysis of 80 studies and say that you have an equal effectiveness. So hypnotherapy was shown in the short term to be slightly more effective than the low FODMAP diet and the longer term, the low FODMAP diet was shown to be more effective. We have one study on hypnotherapy, we have 11 studies, I believe, randomized clinical trials in the low FODMAP diet and the number needed to treat for hypnotherapy, or I'm sorry, so there's another issue here which was bringing up peppermint as a treatment. I'm sorry if I'm kind of monologuing, but... I know, that's what we're talking about. Peppermint oil was shown to have a number needed to treat of I believe 2.2, whereas the low FODMAP diet had a number needed to treat of about two to three and then probiotics had a number needed to treat of about eight to nine and the number needed to treat means you have to treat this many patients until one has a positive response. So for every 2.2 people you treat with the low FODMAP diet, you'll have one person who responds. For every two to three people you treat with peppermint oil, you'll have one person who positively responds and for every eight to nine people you treat with probiotics, you'll have one person who positively responds. But again, this is where understanding how science works is very helpful because there have been I think four trials with peppermint oil where again, there's been 80 to 90 trials with probiotics. So we see that positive selection biased with peppermint oil and that would mislead one to think that peppermint oil is more effective than probiotics. But I can tell you clearly in my clinical experience and I have for the past several months been giving patients alone peppermint oil and then later having them go on probiotics so I can kind of compare just to see if this shakes out the way it should shake out which is we should see probiotics outperforming peppermint oil even though probiotics have a less favorable number needed to treat, that's been a more studied condition so that removes the biased in making probiotics look more effective than they actually are which has not been done for peppermint because there's only been four studies and clearly probiotics are more effective in clinical practice than peppermint is for IBS. Peppermint can certainly be helpful but to say that something like peppermint oil and hypnotherapy are going to be better than a low phobomethiate in probiotics is it's really irritating. I have to admit it's just irritating when people who have platforms make these comments in an area where they don't have a level of expertise in the particular body of literature and again I'd have no problem if these things were written in a constructive, conservative, inquisitive way but when they're couched in language that's absolute it causes more damage than it does help people and that was evident by the plethora of emails I received by people freaking out that this person is now saying that SIBO is not a real condition. So I mean there's so much I could say and sorry for the monologue but those are just a few things that come right to my head. It really was irritating wasn't it? And the person, we don't mean to be mysterious but nor do we also want to give like extra energy to the sensationalism of this but that person has a good reputation I thought online as being somebody who is very well schooled. I don't know, I don't know him personally but I do know you and I do know what an expert you are and how, where your heart is and where your mind and soul are so that's why I trust you so much and why so many other people trust you as well including your colleagues, Dr. C. Becker and the like. So somebody's maybe new, small intestinal bacterial overgrowth, I've just gotten a diagnosis or a suspicion of it being SIBO. It is real, there are studies as well as thousands and thousands of clinical experiences by professionals so it's worth investigating. There are studies you can go, what's the best place to go find some studies? We'll put the link for your article here as well but let's say somebody wants to like be totally neutral and do their own digging which is gonna be a lot of their time because I know this even took you so long but is PubMed the place to go? Yeah, I think PubMed is a good place to go. I would start with my article because I try to showcase both sides of the evidence when there is substantial evidence that's critical of a certain point in the article I wrote, I'd make a point and then I'd follow that point by saying but not all the data here agree and then I'd cite the studies looking at the other side and that I think is very important if you're not gonna go directly to PubMed which if you're not a scientist that's gonna be a very slow boat to China because it'll take you a very long time to figure out what the broader body of literature says. It's like trying to navigate from East Coast to the West Coast looking through a magnifying glass. You need to have a broader understanding of the issue but you could go to PubMed and there are several links to PubMed in my article. I would start there because again I lay out many of the meta-analyses and what a meta-analysis does is it summarizes a body of data and so it's very hard to cherry pick with meta-analyses because meta-analyses, their nature is to be a summarizing study. So if you wanted a cherry pick you take one study that shows something misleading but a meta-analysis will include that as well as all the other relevant data and then give you a summary in terms of what the trend in the data is showing. But yeah, PubMed is a very good place to start if someone wanted to do a direct dive. Okay and then I've also put the link right now up on the screen as well as in the comment area of this Facebook Live and also I'm gonna be sending this out to our entire CBOeSOS.com community in an email. I'll also get you a copy of this video so you can share it with your community and Dr. Sebecker is gonna be sharing it with hers as well. So we've got the studies, we've got the experience. Were there any points in that article that you felt were like, I've never thought about it like that. That's a really good point. Did that happen at all? That didn't happen but there were some points that I thought were valid criticisms. And so this is to play to the other side of the coin which are that CBOe is over-tested and over-diagnosed and there's excessive fear surrounding the condition of CBOe. And so that's very important to understand and those I think are valid criticisms. And that part I liked, I agreed with and I stated that as such in my article. I said, here's the points I agree with. There is over-diagnosis, over-treatment and too much fear regarding CBOe. And some of this comes down to the simple fact that in my opinion, which is a reflection of what the research literature shows, you should never be using a CBOeBreat test as your only guiding factor in making any treatment decision. I do not think we have strong enough data there. I do not think that's what the consensus of the literature shows. I like the approach of testing at baseline to establish if you have CBOe on the chessboard or not and then treating until you obtain a positive response. And if you look at the Rome consensus and if you look at the North American consensus, the Rome consensus recommends conservative use of the test, the North American consensus recommends the liberal use of the test and I'm kind of in between those two where I'm a little bit more liberal than Rome but I'm a bit more conservative in the North American consensus. But I think this in clinical practice ends up being a very effective method, meaning you have some data to help you but you're not going to hinder yourself with serial repeat lab testing that uses up time and money. But it's also important to remember that not every positive on a CBOeBreat test means someone actually has CBOe. And this does not mean it's an inaccurate test. Many tests suffer from a degree of false positives or false negatives, meaning the test shows positive but you don't actually have the condition or the test shows negative and you actually have the condition. So that happens in some testing. So the CBOe testing is not perfect but many tests are not perfect. But this is why it's important not to only look at a CBOeBreat test and say someone has a positive CBOeBreat test but they're feeling generally very well and they're healthy but now they're gonna be inundated with fear and anguish because the CBOeBreat test says that they're still positive. It's a very, very important point to make. And then also there seems to be a degree of fear about CBOe that is far in excess to what is justifiable. And I think that's another criticism that is valid. And I think that comes from the fact that people who obtain benefit after treating CBO don't typically hang out on CBO message boards and chat groups and what have you. So there's this confirmation bias or the selection bias where the most challenging cases are the ones that are the most vocal. So that makes the sound like CBOe is worse than it actually is. And you combine that with the fact really unfortunately that people are trying to yell louder and louder to try to grab the consumer's attention that now you have people making more and more drastic claims. It's almost like advertising in a town. If no one puts up bright flashing signs the first person to put up a bright flashing shine is gonna get a lot of attention but then everyone starts doing that. So then you have to go a level higher and put up a billboard that's a bright shining sign. That's five times the size of the original sign. So what's happening I think on the internet is people are yelling louder and louder and making stronger and stronger claims trying to capture your attention. And I think that's a huge mistake because that misleads people in the thinking that CBO is far worse than it is. So those were a couple of the criticisms that I thought were valid and important for us all to be aware of. I love that you're making such a great like psychological observation as well because that is the way we behave. And there's this very strange combination of a little bit of hysteria. And if you have it, which I have since I was probably five years old, I get that. And then I also understand that there might be like a backlash of like resentment about that. I mean, it's the whole thing. The bottom line is guys work with your practitioners learn from people like Dr. Ruchio, Dr. Seebecker learn from the, you know, summits and you know, all these great opportunities that I've been personally busting my butt to get out to everybody. And everybody's been so gracious in supporting that because, you know, as they say, the truth is out there. And that's what we want to do is we want to get it out there. So how much more time do you have Dr. Ruchio? About five minutes. About five minutes. So I've put the post up. Everybody go look at DrRuchio.com's website, sign up. You're gonna learn so much from him. He does these super recaps of the hottest news in functional health every Friday. If you're a practitioner, you can sign up for these great summaries that he does. And I think, you know, it's a very nominal fee. And I think you can even get some for free. And just if you want reliable information from a very smart, thoughtful source with lots and lots of clinical experience as well as the research and the tests he's doing even in his own practice, please do find Dr. Ruchio. What are your, what is the final thought for us here? I know this was short, but if everybody will just go read that article, which by the way, I'll put in our email as well to our community, what's the final thought? What I would offer people as a final thought is understanding that SIBL-YES is a real condition and it's a very treatable condition. Now, yes, are you gonna have a small pocket of severe cases? Yes, and we could use inflammatory bowel disease as maybe a simple illustration of this concept. The most severe cases of inflammatory bowel disease like Crohn's and ulcerative colitis will be working very hard to stave off surgical removal of part of their intestinal tract, right? That's the most severe, but there are some people who come in with inflammatory bowel disease. We make a small change in their diet and they never have a symptom ever again, right? So it's important to understand that there is a spectrum of disease activity or condition activity and not to automatically lump yourself in with the smallest subset that is the most severe. The importance of that can't be overstated because one's self-perception of their health does manifest in health outcomes. And so if you think you are sick, then you are going to manifest it. This is known as the placebo effect. And this is why it's incredibly important that clinicians are very cautious and deliberate and discerning in the language that they use because you're going to impart a degree of mental anguish on to a person depending on what you tell them that they have or they don't have. So, placebo is a real condition. It's probably not as bad as most people think. It's certainly something to work with because optimizing your gut health can have a wide range of positive health impacts and there's a number of effective treatments out there and it's just important to obtain your education and your information from someone who is dispassionate, who is objective and who is going to try to get you solutions as simply and as easily as possible because unfortunately there's probably 50% of knowing what to do and then 50% of knowing what not to do that's important in successfully navigating this landscape. Excuse me, so those are a few of the things that I think are most relevant to the CBO conversation and I would also say don't lose your grip on your life. Make sure you maintain a life. There's a great quote by Nietzsche to paraphrase it. He who has a why to live can overcome almost anyhow. So you need to have that why. Don't lose grip of your why because if you have nothing else in your life other than your health journey I've seen those people really struggle because there's nothing pulling them out of their health and into something bigger than themselves. And there's a ton of science and treatment options they've done in that article but it's important not to again lose that grip on the other aspect of your life that you're trying to get yourself healthier so that you can bring a more vibrant you to what. Don't lose track of that what. And if you are watching that human longevity I think it's that longevity documentary that's out right now floating around the internet that's one of the big points that they talk about is when people have a purpose to live when people have a social community and family members that they want to care for then they do, they live longer. And it's a beautiful thing. Well, you are a godsend. Thank you so much Dr. Ruchio. We will put the information out there. I'm gonna spell your name right even. It's gonna be awesome. And I'm gonna see you in the masterclass at Sebo SOS the speaker series on March 22nd where you and I are gonna be talking about the masterclass you're doing for an hour on the elemental diet which is one of the most surefire ways to treat Sebo and then also followed by two hours of Q and A. Before you go, we do have one question. What would we say to our doctors when the doctor says your test results are wildly different than they were before and you haven't even treated and then they just go to the conclusion, Sebo's not real. So you're saying that someone has done two tests with no treatment and they have- Wildly different, yeah. They have had time in between but that's Rohan is asking this question but generically when the doctor or your practitioner says I just read something on the internet, Sebo's not real we're gonna send them to your article. I mean, the best thing you could do would be to send them to our article and also to understand that no one anywhere is saying the claim has not been made that Sebo tests are static meaning they're always going to be the same unless you treat them. There will be a fair amount of dynamic shift in the testing and if you know how to interpret the tests and you're able to cut off when you have a true positive in the positive range from being borderline or being into the false positive range if you're diagnosing a true positive in my opinion, the likelihood that you're gonna flip from a true positive to a negative is very slim. But if you don't understand most notably the important cutoff time of 80 to 90 minutes and looking at the levels and if you're screwing right around positive to negative then there's a higher probability that you may flop in between positive and negative as there's a slight shifting in your digestion. But also, if you're looking at Sebo testing conservatively my commentary to someone who had a borderline case would be, well, we show you're just over the cusp showing that you have Sebo and we may or may not need to treat this and we would look at the context of the patient which is exactly what the Rome consensus recommends. So you're never making the Sebo and also as I said earlier you're never treating a Sebo breath test in isolation you're always looking at that in the clinical context of the patient their history, their presentation their response to other treatments and you're using all that information collaboratively. So it's almost a misdirected question to say what if the test shifts because it's again, it's not all about the test it's the test in the greater context and also reading the tests conservatively will give you the highest probability that you'll see a consistent positive or a consistent negative in repeat Sebo breath testing. And by the way, like really good practitioners in the testing world like Gary Stapleton he will say exactly what you just said it's not in a vacuum he always wants to know the rest of the story so more support for your concepts. Thank you so much Dr. Ruchio have a beautiful day. We will see you on May 22nd, five to eight PM East Coast time for that masterclass on the elemental diet. You guys can find out more information about that by emailing us at info at SeboSOS.com and in our SeboSOS virtual summit Facebook group go ahead and if you aren't in it already just like go and say, hey, I wanna join the group and we'll get in there. Okay, Namaste, thank you so much sir. My pleasure. Take care, bye bye, bye bye.