SIBO Recovery and Fecal Microbiota Transplantation (FMT) with Amy Hollenkamp of the SIBO Diaries

Welcome to the very first episode of The Perfect Stool. This is your host, Lindsey Parsons. I'm a gut health experimenter, health coach, and fascinated student of the gut microbiome. I'll be talking with alternative medicine professionals, dietitians, scientists, and people who've tried various cures, especially fecal microbiota transplantation, to heal their gut, to give you the insights scoop on everything you've always wanted to know but were afraid to ask about your gut health so that you too can have the perfect stool.

Hi, this is Lindsey Parsons with The Perfect Stool, and I'm here with Amy Hollenkamp, who is a registered dietitian practicing in Cincinnati, Ohio, and author of The SIBO Diaries. Hey Amy, how you doing?

Good, how are you doing, Lindsey?

Great. So can you tell me first what SIBO stands for and what does it mean? Yeah.

So SIBO stands for small intestinal bacterial overgrowth. So with SIBO, we all hear how, how you're supposed to have good bacteria in your gut. What happens when you have SIBO is that the good bacteria from the large intestines moves into the small intestines and creates issues. Like bloating, malabsorption. It can just really cause a lot of problems because the small intestines is supposed to be rather sterile compared to the large intestine. So we want a lot of good bacteria and diverse bacteria in the large intestines, but it can cause a lot of problems when it moves into the small intestine and inhibits proper digestion and absorption.

Okay. And how do we know why or how it moves into the small intestine?

Yeah, so SIBO is a secondary condition. It's— and sometimes people think it's their root cause, but SIBO is a result of some other problem or breakdown in digestion or motility usually. So there's a number of different root causes, but kind of as a whole, if there's an issue with your digestion, so maybe low stomach acid or poor bile production or bile release, if you have delayed motility, a lot—

meaning you're constipated or your food's just not moving quickly enough through your system.

Yeah, so like a lot of things that can cause delayed motility would be like thyroid issues can delay motility. That can be a root cause of developing SIBO, but also hindrances in your brain-gut axis. So The vagus nerve produces these migrating motor complexes, which are— it's a big word, but they're essentially like these electrical waves that stimulate the smooth muscle to move food, bacteria, and waste like through your GI tract between meals. So you can kind of think of the migrating motor complex or the MMC as like a broom that sweeps the small intestines clean after meals. A lot of people with SIBO have deficiencies in those migrating motor complexes. So these sweeping waves that cleanse the GI tract between meals, and that results in, in fibers and bacteria to sit in the small intestines for too long and kind of eat on the food. That was meant for you and not for bacteria. So it kind of causes a perfect storm environment for bacteria to grow in the small intestines where it doesn't belong. So that's another really big one that is usually a problem in a lot of SIBO patients.

Okay. So tell me about your own gut problems and when and how you were diagnosed.

Yeah.

So I— my gut issues sort of happened after I had mono. When I had the mono, things just sort of didn't feel right from a GI standpoint, and it was bearable. So the mono sort of cleared, and I, and I could still bear to eat the foods that I liked, and life sort of went on. But at some point, things just kept progressing and my symptoms kept getting worse. So I had a lot of bloating, a lot of discomfort, felt just like things weren't moving through as well as they should have. So I went to a GI doc when I was kind of at my wit's end and was told I have IBS because all my tests came back negative.

Okay, and can you just spell out what IBS is?

Yeah, IBS is irritable bowel syndrome, and in my opinion, it's sort of a junk diagnosis. It's sort of— it's a cluster of symptoms. So it's not a disease. It's sort of a cluster of symptoms. And usually it's given to— it's a title or a name that's given to someone who doesn't really have any other— anything else wrong with their GI tract from an anatomical point of view. So they don't have Crohn's, they don't have celiac or ulcers or anything like that. Nothing can be found. But you still have symptoms like constipation or diarrhea or maybe a mix of both. So nothing is anatomically wrong that a GI doctor can see on certain labs, but you still have all these symptoms. So that's kind of what a typical IBS patient looks like, is they're pretty symptomatic, but the conventional medical system lets them down by just kind of giving them an IBS diagnosis and sending them on their way. So that's kind of how I felt when I got diagnosed with IBS.

So, right, what did the doctor say you could do about it, or what kinds of interventions?

Yeah, um, not much, to be honest. He— and I do think that it's not really— they're not really trained to dig to the root cause of issues in the conventional world. So it's not— I think he was well-intentioned, but It's kind of like, oh, try maybe some Metamucil or some fiber supplements, but that's it. Because I was more on the constipation side, which again, like, I had tried all those things and nothing worked, and some even made me a little bit worse. So there really wasn't any answers I was getting from the conventional world. And so then I kind of swung more into the functional medicine I just sort of fell in love with functional medicine, so, because it made more sense.

So did you see a functional medicine doctor then?

I did. I saw a functional medicine doctor after I was kind of fed up with the conventional model. And again, like, I was an analyst, was my job previously, so I was very focused on figuring out the root cause. That was something that always made sense to me as an analyst. So that's kind of what made me shift to the functional medicine model.

Okay.

And really to dig deep about why am I having these symptoms and what can I do about it?

And what did the functional medicine doctors suggest or work through with you?

Yeah. So that at that point I got tested for like large intestine issues. So I did a really comprehensive stool test. And I did a breath test and I was positive.

Can you— sorry, let me just stop you. Can you explain what the breath test is?

Yeah. So the breath test is a diagnostic tool that practitioners use for SIBO. Essentially, you drink this little sugar solution and when, when it's kind of moving through your GI tract and it hits the small intestines. If you have SIBO, an excess of bacteria in your small intestines, those bacteria will feed on the sugary solution and produce a lot of gases. So those gases can be collected in your breath. So the breath test is really just collecting those gases in your breath and measuring them to see if you have SIBO or you don't have SIBO.

And what did your breath test show?

Yeah, so my breath test showed elevated levels of methane gases. It's called SIBO-C, so I was more constipated dominant, but SIBO-C is associated with methane bacteria versus SIBO-D, which is more the diarrhea predominant, is more associated with hydrogen dominant bacteria.

Got it. Okay. And so what did the— what did the doctor want you to do about that?

Yeah. So the doctor wanted me to do a lot of antimicrobials. So that's sort of where we started, which is essentially the plan was to clear that bacteria out and that I'd feel so much better once that bacteria was cleared. So I was like, oh yeah, like, this will be great. So I started doing like an herbal formula for like 5 weeks or so. And I might have noticed a very mild decrease in symptoms, but not much. I didn't get much relief from it at all.

And did you change your diet during that time?

Yeah. So I was on a low FODMAP with an SCD combo diet. It's called the SIBO Specific Diet.

Okay.

Can you spell out what those, those stand for?

FODMAP is a bunch of hard to pronounce words, but they're essentially fibers and it's an acronym for certain fibers and foods that are fermentable for a lot of bacteria. So people that have those overgrowths can sometimes be hyperreactive to certain fibers because the bacteria can feed on them. And then SCD is Specific Carbohydrate Diet, and it sort of eliminates a lot of starchy foods and allows more, in terms of carbs, more carbs that are simple sugars that are digested earlier in the GI tract.

So what kinds of foods can you not eat on that diet?

It's, it's a rough one for sure. So no grains, no starches. In terms of carbs, you're going to be sticking to certain fruits, but certain fruits were eliminated, things like apples, depending on how strict you were doing it. So I was doing it very strict. So you're really kind of limited, limited to a small amount of fruit because the FODMAP eliminates a lot of fruits. And then meats, pretty much most meat is allowed. You have to eliminate a lot of vegetables that are fermentable. So things like onion, garlic are out.

That's got to be tough.

Oh man, if you're cooking, it's rough without onions and garlic.

Yeah. It's the base of almost every recipe.

Yeah, those can be a trigger for a lot of people with SIBO. So even people that don't go all out on the low FODMAP and SCD diet still sort of avoid some of the really big ones because garlic and onions tend to be triggers for a lot of people. But again, with any of these diets, which I didn't really fully understand when I was going through these things, is that They're meant to be very temporary and you need a plan to move out of those diets. And I feel like with a lot of SIBO people, they don't necessarily have a clear path of like, this is the 4 weeks or the 2 weeks or however long you're doing a really strict diet that I'm gonna be on SIBO-specific, but what is my plan to move off of this diet? 'Cause people kind of get stuck in the rut and feel like they can't add more foods back in 'cause then they're reacting to tons of foods the longer they are eliminating them. So, right.

So how long did you stay on the diet?

Yeah, yeah, I stayed on the diet for about 4 months. I didn't really have much benefit from it, and I feel like, um, I actually got worse just because I wasn't someone that did well on a lower carb diet. It really messed up my hormones. I think I started developing a lot of nutrient deficiencies from it.

How could you tell it messed up your hormones?

Well, my thyroid hormones were low. I never really had issues with that in the past when I had been tested.

Mm-hmm.

And my cortisol levels were really high. So I don't know if like that changed because I didn't have testing prior to doing the diet, so there's no baseline measure, but kind of from a understanding how a low-carb diet can affect hormones at this point, I would guess that going as low-carb as I did really drove my cortisol levels up higher than they were before. And plus, I was having an increase in symptoms, like my hair wasn't falling out, I was getting some increased skin issues, feeling a lot of fatigue and energy issues.

What kinds of skin issues?

Um, mainly like acne on my face, like hormonal acne, a lot of acne like around my chin area. But yeah, it just, it was definitely not the right fit for the— and especially not to have extended it for that long a period of time. So like 4 months is a pretty long period to be on that diet. A lot of people go on these diets for like years, so I at least kind of got out a little bit better than some people do, but it's again then becomes hard to add stuff back in when you've been on a diet like that.

Right. So then what did you do after that didn't seem to work for you?

Yeah, so I didn't mention this either, but I had lost a ton of weight and some of it was due to malabsorption. So like even prior to going on the SIBO-specific diet, I just wasn't absorbing food well, but the SIBO-specific diet really exacerbated my weight So like I had dropped maybe 25, 30 pounds in a 3-month, 4-month period.

And you were thin to begin with?

Yeah, I was definitely more— I've always been like muscular. So I feel like I definitely lost a lot of muscle mass.

Okay.

And like my friends and family were like, whoa, what's up? Because again, like I was losing all this weight and I couldn't maintain it very well with such a restricted diet. So that was another huge problem. So after kind of going on the herbals, for a little bit and nothing changing, I was like, well, let's find a new strategy. And my doctor was like, well, let's just try pharmaceutical antibiotic— antibiotics, because it seems like you're going to need a little bit of extra help. But the pharmaceutical antibiotics kind of made me horrible. Like, they— that was my lowest point ever in my whole journey was after I took pharmaceutical antibiotics.

Was that Rifaximin?

No. So back when I was doing all this, I— there was no— my insurance wouldn't cover Rifaximin. It was kind of before Rifaximin was being used for IBS. Like, I think later I was able to get Rifaximin and I did use it one time. But early on, like, you know, 4 or 5 years ago, a lot of insurances weren't covering Rifaximin at all for IBS.

So you took a broad spectrum antibiotic? Yeah.

And it was— I mean, it was the worst one I could possibly take. So looking back, that's like a huge mistake on my part. Right.

Killing off everything.

Yeah.

Yeah.

I took Cipro, which is like the worst antibiotic you could take. Like it's black label. That's my biggest regret, probably taking that Cipro because I think it really set me back in terms of it didn't help my symptoms. It made my large intestine, I think, a lot worse because when I tested my stool after the Cipro, I had more pathogenic growth of certain bacteria. There was a lot more imbalances in my large intestine bacteria. And I think part of that is going low FODMAP too. So it was kind of the double whammy of going too restrictive on my diet and starving all the bacteria in my GI tract, but then also hitting it with something really powerful like Cipro.

Okay. So when did you first start considering an FMT or fecal microbiota transplantation?

Yeah, I, I heard a podcast with a microbiologist that runs the K-Mount Clinic where I actually ended up getting my FMT. And so it was always something in the back of my mind, like, as an option, but I wanted to try a couple things because again, it is expensive and it's like a big commitment to do. So, I mean, there was probably— after the Cipro, it was a good year or so, even a little over a year, that I was just really focused on gaining weight and like getting my weight back where it needed to be, broadening my diet. But I wasn't really focused that much on anything specific in terms of treating the SIBO. Like, I would try some things, but it was never like a really intense regimen. I had gone to a new doctor, so I switched doctors just because I wasn't getting better and feeling much worse. So her big focus was like, oh, we need to expand your diet. And I thank God that I switched because it allowed me to start gaining my weight back, and it really took like a good year and a half to sort of gain the weight that I had lost and to gain my strength back. And along the way, I tested here or there. My thyroid function was low, and that was something that we kept working on.

And my—

I had done maybe another stool test in there, and things were still kind of off and out of balance. So kind of the longer I thought about it, the more I was just like, I think I want to do FMT. To just really be more like a quicker fix to get my large intestine in balance so that then I could focus on other things that could be wrong.

Can you explain briefly what FMT is?

Yeah. So FMT is fecal microbiota transplantation or transplants. It's essentially where they take bacteria from a healthy donor and implant it. Yeah, from their stool. So they take bacteria from their poop and they implant it into someone with dysbiotic or imbalanced gut bacteria into their colon. And it can be done both through, through your bum or through your mouth, depending on the, the sort of way you're doing it. There's pill form too, but I did the through the butt. Right.

So, so presumably those pills are enterocoded so they don't open up too soon. Okay.

Okay.

So tell me about when you finally decided to pull the trigger and like, what did your family think? What did your friends think when you said, I'm going to go to do this, do this FMT? Yeah.

I mean, the first thing I did was talk to my doctor just to get her take on everything and I was kind of a mess. So she was like, well, if you can first afford it and if you can get over there and have support from your family, like she was totally for it. So she was like, I think this would be a good for you to try. We've tried a lot of other things. Let's simply—

you've been trying probiotics and things like that.

Yeah, exactly. So I tried, you know, probiotics. Looking back, I'm, I'm wondering how I would have done if I tried more prebiotics, which like for SIBO patients like scares the crap out— scares the— can scare the crap out of them thinking about prebiotics. But at that point, I didn't have a positive SIBO test, so I'm wondering how, looking back, how I would have done if I would have added some prebiotics in to help with the growth of healthy bacteria. But yeah, I mean, at that point I just, I just was ready to try something new and my parents were pretty on board with it. My mom actually had a good friend whose husband has cancer and he got C. diff at the hospital and they did an F, like a fecal transplant with him and he like had a huge turnaround from it. So my mom had already seen the positive effects of it. So she, and she had sort of seen me struggling. So again, like it made sense to my family because I feel like they had seen it before, but I do think it would have been a lot harder to explain it if they were just totally not aware of it. And again, like maybe it would have just taken a little bit of extra pushing and educating, but it makes it easier when you have someone that they've seen at work for, for sure.

Right, right. And so tell, tell me about where you had it done.

Yeah, so like I said before, I really liked that microbiologist from the Tame Out Clinic. They have just a really cool procedure of how they extract the bacteria, and I really just trusted that clinic, so I wanted to go to the Tame Out. But there's Lindsey Parsons.

And where's that located?

Um, the headquarters or like the main clinic is in, I think it's right outside of London, but it's in the UK. And, but I went to the affiliate in the Bahamas that does it just because it was easier. It was December, so it was going to be warm. But I also know that they opened one in Canada, I believe. I'm not sure exactly where it is, but I know they opened another location in Canada, which is interesting.

And can you explain why you had to go to another country to do this?

Yeah, so FMT is only FDA approved for, I think it's like non-responsive to antibiotic C. diff infections.

Right.

So like it's very hard to get approval to do it in terms of the laws. And so although I had a lot of imbalances in my testing of my gut flora and my gut, I didn't qualify to have this procedure done based off the laws in the US.

Right.

But the laws in the UK and a lot of European places are a lot looser and you can pretty much get FMT for a lot of different reasons.

So. Okay. So how long after all this started did you go in and have the FMT done?

Oh man. Trying to think. I was having a lot of issues I think it was the fall of 2014. Maybe it was the fall of 2015. I feel like it was like 2 years or so.

Okay. And so you took the plunge, you signed up for it. Tell me about what it involved.

Yeah. So the whole process was pretty easy. Um, you just had to do an initial consult with a nurse and then you did one other consult with a doctor and they just kind of reviewed your case and to see if you were a good fit. A lot of times if you have other conditions, especially autoimmune conditions, that can be a lot trickier. So if you have like ulcerative colitis or Crohn's, they can still find ways to be successful. Like they're still kind of learning how to implement FMT with those autoimmune conditions, but you have to be kind of careful the timing of the implantation or the implantation of the transplant and you have to do it longer term. So you'll buy like top offs when you leave. But if you don't have a lot of conditions that are super inflammatory, it's a lot easier. So like for me, it seemed like a lot of my, my issues in my gut were just a lot of imbalance, not any crazy inflammatory issues going on in terms of like I had no autoimmunity or anything like that.

Right.

Okay.

And so, so all the consults were over the phone?

Yeah, the consults were over the phone. I don't even think they were super long. Like I sent them all my labs and stuff. I think the first one, I mean, they were probably less than an hour, but they were all really helpful. I love the nurses down there and the doctor was really nice too.

Okay. So tell me about the procedure.

So in terms of the procedure, it was kind of like the first day you kind of come and get checked out. The doctor sees you, so it's a little bit longer, but usually the procedure, you're in and out of there within 45 minutes to an hour. And what they do is you just kind of like get into a medical robe and they have a little tube that they put a little like ointment on and they stick it up your bum. And they just sort of have a little syringe with the implant in it. They'll inject that in and then they'll do a water flush to make sure that the, that the bacteria kind of travel the length of your colon. So it's not just kind of sitting in one spot.

And you're fully awake and not anesthetized?

Yeah. Yeah.

And it doesn't hurt. Like, it's super easy. Like, you might feel a little bit uncomfortable, but it's It's like an enema. Yeah, exactly. It's, it's very, very, very manageable and super easy. Like, I was almost surprised about how easy it was. But—

and how long did it take?

Well, the actual putting it in and doing that takes like 2 minutes. It's super fast. But what takes longer is that you get into different positions to help the bacteria travel the length of the colon. So you'll get in a position where like your feet are up high and your back's down low so that the bacteria travels down your colon, and then you flip over to where you're laying on your side, so then that bacteria is traveling across your colon. And then you kind of sit up and you let the bacteria travel back down the other part of your colon. And that process, you're in each position for 10 minutes. So you're in these different positions for 10 minutes. And then you get to leave and kind of go about your day. You want to take it easy and not like work out, but you're still allowed to kind of move around and sightsee if you're in the Bahamas. Like, it's not— you're not, you know, down for the count or anything like that.

And how many times did you do this?

So I did the 2-week treatment. So it was 10 FMT treatments and each weekday I would come in and have it done in the morning. And again, it would take like 45 minutes and then I would just go about my day.

And was that an option? Did they offer, well, we can do it for 5 days or we can do it for 10 days and 10 days would be more effective? Or did they say this is it for your condition?

Yeah, so I remember that they offered like a 5-day for C. diff. So they've done a lot of research on C. diff and have found— they found that like with the 5-day course, they can cure C. diff like 100%. But it took them a while to figure out like how many they needed. And I think when I've heard them talk, or heard the lead microbiologist talk, he said that's 5 days. So usually 5 days of FMT is enough to heal from C. diff. So I know they have like a C. diff program that's 5 days, but for more extensive cases, they like to do a little bit longer. So like Who knows, maybe 5 days would have been enough for me, but it was kind of like, why not? If I'm going to the Bahamas, why not do 2 weeks? Yeah, but I do think with more autoimmune type conditions, 2 weeks and then, and then some. So a lot of times the autoimmune conditions need even more than, than the 2 weeks. So it really just depends on the case.

Got it. And so how did you feel during and after the FMTs?

Yeah, so when I was doing the FMT, it— you have a lot of— a lot of people call it die-off type reactions. As the bacteria is shifting around in there and settling down, a lot of bacteria die and a lot of bacteria start growing. So you just have a lot of things changing in your gut environment. And so I did have a lot of fatigue, especially in like the 2 or 3 hours after I would have it done. I would like lay down and just kind of rest. I had trouble sleeping too. There's a lot of connections between sleep and gut issues, so like I think it was just a lot of change going on in my gut environment to where I was just struggling to sleep a little bit, and I'd have kind of weird dreams, which they said they, they've heard before. So I don't know if that's a common thing, but something that happened to me. But I didn't really feel super great in in terms of energy levels or anything like that. I wasn't having like crazy, like an intense increase in gut symptoms or anything like that. My gut felt like things were shifting around, but I didn't really notice anything like improvements while I was there, I would say.

Okay. So would you say though, after, after time that it had solved your gut problems?

Yeah.

So one thing that they explained to me when I was there was that when they put this bacteria in, it takes like 3 to 6 months for everything to settle and for those bacteria to, to develop a really cohesive and robust community. So it takes a while for everything to just settle down a little bit. And so I like noticed more positive effects later, and they said sometimes, you know, people, it'll be like 6 months after and they're like, oh my gosh, I'm so much better. Sometimes it's 3 months, sometimes it's right away. It just really depends on the person. You really don't know, and they tell you that before you go into it, you really don't know when positive effects will come. So you're not really expecting it, you know, day 1 or day 2, right?

So when did you first see positive effects?

Yeah, I would say probably around the month mark.

Okay, and what were they?

Just better gut function mainly, so like less bloating. I felt like my bowel movements were a lot better, right?

Well, actually, that is— that's the million-dollar question, right? So the name of our podcast is The Perfect Stool. So did your FMT get you to the point of having Having perfect stools.

Exactly.

Yeah.

I mean, my FMT definitely got me way better stools. So I do think that I had other issues that were influencing my gut function that were outside of just specifically the bacteria. So I think I still had some things to work on, but I would say gut function and my stools and everything like that overall improved about like 60%.

So do you feel like it was a good choice to do it?

I definitely feel like for me it was a really good choice because it helped more quickly fix my imbalances and bacteria so that I could focus on other areas. So again, like I could focus on hormones and focus on some of these other areas, lifestyle areas that I needed to work on to help with gut function. So it sort of was a really good push in the right direction that allowed me to sort of ride on that momentum, and I could build off that momentum, if that makes sense.

Yeah. And so now this, this prompted a whole career change for you. Do you want to just briefly talk about that?

Yeah, so I was an analyst prior, um, but what kind of analyst? A marketing analyst. So I did a lot of sales analytics and things like that, but my whole career, like I mentioned before, was like really breaking down complex processes and complex business problems so that we could fix them and, you know, help my company make money. And so when I wasn't really getting the help I needed in the conventional world, it really kind of prompted me to be like, well, I could use my gifts, my analytical talents in a way where I help others break down what issues they're having in their gut and maybe hormone dysfunction and other things that can create health issues. How can I? I just felt like I could use my analytical talents to help humans instead of helping companies. So it brought me to quit my job, and then I went back to school and did 3 years of school to get my RD, and I've been an RD for about 4 months or so. So—

oh, just 4 months now?

Yeah, I'm fresh out of, out of school and out of, you know, working, working on getting my RD. So, okay, great.

Yeah, tell me about your current practice. Do you— you help people with SIBO?

I do help people with SIBO, so that's kind of my bread and butter at this point, just because I write about it so much. But I really— IBS and SIBO, even large intestine issues, I feel like I can help people. I think again, like, with SIBO, a lot of people get caught in the clearance phase like I did, where they're kind of stuck clearing, and then it comes back, and then they have to clear it with antimicrobials, and then it comes back because they're not addressing the why that bacteria is getting stuck in there. So like how their digestion is working or how their motility is or how their MMCs are. So it really kind of takes digging to the root and developing a really multifaceted treatment approach to help someone heal from SIBO.

And so do you recommend FMT to your patients?

Yeah, I mean, it really depends. So I think if you're dealing with an active case of SIBO, FMT might not be the best option. Just because you kind of want to knock it down and then do FMT. So if you're, if you've treated the SIBO, then I would say FMT would be a great option because it helps rebalance the large intestine bacteria, which helps with all the things that can prevent SIBO from developing. So again, it can help with the brain-gut axis. Issues in the migrating motor complex function. So it can help those sweeping waves if your large intestine bacteria is well balanced. And then it helps with digestion, it helps with absorption, it helps with inflammation. Like, all these things are super helpful to keep SIBO at bay. So again, like, if you clear the SIBO and then you get FMT, it could be helpful. Again, there are people with IC valve issues that might not do well with FMT. So if they're— if the valve between their large intestine and small intestine tends to be stuck open, then you might need to figure out a way to get that under control to do well with FMT, and maybe not at all. Like, you wouldn't do well with FMT if you can't get that ICI valve.

Yeah. And then the cost of the FMT at Tameont was how much?

Yeah, so the FMT at— in the Bahamas was close to $10,000, which is a lot of money. And I was very—

presumably not covered by insurance.

No, no, no, no. Yeah, not covered by insurance. So it was definitely— I was very lucky that I had some support and help in terms of how to pay for that because I couldn't have afforded that right on my own.

And presumably most of your patients can't afford that, I imagine.

Yeah, exactly. And I do think that You 100% can fix the large intestine without doing FMT. It just sometimes is going to take longer, you know. It's just something that's going to take longer and some due diligence and figuring out, you know, what prebiotics might be helpful, what foods need to be eaten to help create a really diverse microbiome. So it just takes more time to, to get the shifts that you can get with an FMT. Rather quickly.

And probiotics too, I assume?

Yeah, and probiotics for sure. So again, finding the right probiotic and prebiotic can be really helpful to, to shift the balance. Um, but again, like I said, it just probably takes a little bit longer, which I mean is okay. It's just, it's just gonna be, be a little bit longer of a journey, that's all.

So what is your typical protocol for someone who comes to you with SIBO?

Yeah, I mean, that's hard because with SIBO Everybody's case is so different. So I don't really have one protocol that I just go to if someone has SIBO. It really depends on where they're at in their journey. A lot of times what I feel like I have to do first is get the diet right where I think it needs to be. So sometimes people are unintentionally undereating because their diet's too restrictive, or they need to address other areas like sleep, like exercise or movement. It doesn't really have to be exercise, any type of movement's good, making sure their hormones are balanced. So it really kind of takes a diverse strategy, and it takes kind of knowing what the person's root causes are. So maybe you're someone that has a lot of thyroid dysfunction from undereating, which I see a lot. Unless you fix that, no matter how many antimicrobials you take or how many foods you restrict, you're always going to have problems.

So I'm curious about this undereating, since that doesn't seem to be a problem I see a lot around me. Overeating is usually the problem you see a lot more. So, so what does under eating look like and why are people doing it?

Yeah, I mean, under eating, a lot of times it can be hard to pinpoint with gut patients because again, if someone's losing weight, it's usually a result of two things. One is they're not absorbing their food and nutrients properly, which is a huge problem for someone with SIBO. But then also A lot of times when they're on these super restrictive diets, they're going from like more of a standard American diet that's rich in carbs, that's rich in a lot more calorically dense foods. And if they're not careful and they jump on a SIBO-specific protocol like I did, it can be easy for them to just cut out carbs completely and not add in the fats that they need. To sustain where they need to be calorically. So I see that as a huge issue. A lot of times people just like underestimate how much whole foods they need to eat to sustain themselves. It can be like, I think we're pre-programmed to think like, oh, low calorie is good, because like you're saying, most people do overeat. But in a lot of the gut health world, a lot of people under-eat because they just get too restrictive.

Mm-hmm. So what kind of a diet would you recommend for somebody with SIBO?

Yeah, so I like moving from a really broad approach to a more narrow approach if we have to. So usually if I had a patient come to me with SIBO, I would try to be as broad as possible in the context of a whole foods nutrient-dense diet. So I would— the one thing that I would say is would be they probably need to avoid gluten for a little bit. So that's usually a more universal thing that I recommend.

But not forever.

Not forever. And again, it depends on the person. Some people can cheat a little bit and be fine, but it's just like it helps calm down inflammation. So that's really the focus of the diet recommendations, is just how can we eliminate inflammation and symptoms. And so with a whole foods nutrient-dense diet, maybe without gluten, and then maybe other trigger foods that they're having, how can we— you might need to avoid those too. So most people know their triggers. Sometimes they don't, and that makes it a little bit harder. But if you know your triggers and we avoid maybe gluten and your triggers, and let's see where your symptoms are then. And if you're still having symptoms, then I might say, let's try something a little bit more strict. Let's maybe remove dairy or something like that. So it's kind of like I'm trying to keep it as broad as possible without increasing any symptoms or inflammation.

And that's while simultaneously giving them antimicrobials, or—

yeah, I mean, it's— again, it depends on where they're at. So I get a lot of people kind of at the end of their rope with SIBO, where they've treated a ton of times with antimicrobials. So, but if they haven't treated it before, then of course I would antimicrobials to help get the bacterial number down.

And then those are non-prescription, right?

Yeah, so I really like— there's a product, GI Microbax. I like that product a lot, but there's a lot of different herbal formulations you can use that are effective. I don't think it's like one over the other. You need to develop a good strategy with someone that you're working with to knock the bacteria down a little bit. So so you can, at the same time, working on diet and working on your root causes.

Right. So what do you think of a ketogenic diet for someone in that situation?

Yeah, for keto, with keto, I think some people could possibly have success on keto, but I think that it's something that would cause more stress on a person just Like, cutting out carbs can raise cortisol levels just because to produce glucose in the blood, which your brain needs, your body has to make glucose from protein, and that process requires cortisol. So when cortisol raises, your gut can become a lot more dysfunctional. So a lot of times people on keto diets have higher cortisol levels, and that can cause gut issues. I do think that sometimes their thyroid starts to malfunction as well because you're not— you need carbs and insulin to convert the inactive thyroid hormone into the active form.

And the ketones that are produced on a ketogenic diet can't do that?

Uh, in terms of the thyroid?

In terms of any use of glucose in the body. My understanding was on a ketogenic diet that ketones are what become your fuel.

Well, And ketones do fuel the brain somewhat, but the brain still needs some, some glucose. So because your, your blood needs some glucose in it, so that has to come from something. So if you're not eating it in the diet, then, then your body's going to create it.

Got it.

Through a process called gluconeogenesis. So it's sort of like, I just see a lot of people going too low carb, it hurting their hormones, it hurting their gut bacteria, because again, if you're cutting out lots of carbs, especially starchy carbs, have a lot of good things like resistant starch, a lot of soluble fibers. You have imbalances in the gut start to form because your large intestine bacteria are not getting any fermentable fibers for food.

And is there a way that one can do the ketogenic diet and just add in those fibers, like taking fiber supplements, for example?

I think it's very hard to do just because there's so many different types of fibers in food and every bacteria has a different favorite food. So it's like, if you think about it, like, it's just kind of interesting. The diversity of your plate yields the diversity in the gut. And I think if you're using supplementation, you're— you can only supplement so many fibers and there's just like a plethora in your food that maybe even fibers we don't even know about and studied, you know. So I think it's really hard to manufacture the diversity in fibers using supplementation versus eating real food.

Right. So now you're— how far out from your FMT are you at this point?

Almost 2 years.

So 2 years, okay.

Yeah, it's been a little, it's been a little while. So I think it'll be 2 years in December. So I went, I think, the 6th of December in 2016. So yeah, it's been 2 years.

And how is your gut health and your health in general now?

Yeah, my gut health is definitely way better. I would say I'm at like 90, 95% in terms of gut health. I think the big thing that I needed to do to really help the remainder of my symptoms after FMT involved a lot of lifestyle changes, managing my stress, working on hormone issues. So it was kind of like, it helped with my gut, but it, it wasn't like this magic bullet. Like, some people think of FMT as like, oh, I'm gonna take it and all my problems are gonna go away. And again, a lot of problems might improve, which it did in my case, but I still had to work and do some other things. Again, continuing to eat a diverse diet following the FMT can be really important. And then again, working on things like hormonal issues, correcting nutrient deficiencies. I did a lot of meditation. So again, like certain things that are still crucial to maintain gut health and overall health, I still had to be doing to sort of get where I am now. Right.

Well, I'm glad that you're doing so much better. And thank you so much for sharing all this great information with us.

Of course, it was awesome being here. I'm, I'm glad I was able to come on.

And can you tell our listeners where they can find you online?

Yeah, you can find me online at sibodiaries.com. You can follow me on Facebook as well at The SIBO Diaries.

Okay, great. Well, thank you so much, Amy.

Thank you.

I hope you enjoyed the first episode of The Perfect Stool. If you liked it, please press subscribe so you won't miss future episodes. You can find links to Amy's website and mine in the show notes. You can find me online at HighDesertHealthCoaching.com. I specialize in helping women lose weight without dieting or counting calories so that they can keep it off for life, as well as helping women overcome autoimmune and digestive issues naturally. I see clients in person in Tucson, Arizona, or via phone or video chat. If you're struggling with the yo-yo of dieting and you need a new plan, support, and accountability, don't hesitate to sign up for a free Total Weight and Health Transformation discovery session with me. That's 45 to 60 minutes of time devoted to listening to you and helping you find a plan to solve your problems. I promise it will give you some valuable insights into your situation, and you can decide if health coaching is the right solution for resolving your health and weight concerns. You can do that at HighDesertHealthCoaching.com or check the show notes for a link. You can also follow me on Facebook at High Desert Health. Thanks for listening.