The Root Cause Medicine Podcast

Dr. Cheryl Burdette, clinician and educator who created the Hormonal Matrix course, argues for viewing thyroid, adrenal, and reproductive systems as an interdependent network. She highlights four-point cortisol rhythms, sensitive estradiol/FSH measures, comprehensive thyroid panels, gut–thyroid links, and practical interventions like probiotics, nutrients, and botanicals. Short, systems-focused thinking replaces isolated lab chasing.

Are your patients putting Salmonella in their morning smoothie?That’s essentially what happened recently when people added what they believed was a safe, antioxidant-packed greens powder to their daily routine.The ingredient? Moringa.Moringa leaf powder is often marketed as a nutrient-dense botanical containing vitamins, minerals, antioxidants, and plant compounds that may support general wellness (Bibi et al., 2024; Camilleri & Blundell, 2024). For many people, it feels like an easy health habit: add a scoop to a smoothie and start the day feeling proactive about nutrition.But recently, moringa powder was linked to Salmonella infections that resulted in hospitalizations.So what happened?In this episode, Jeff and I walk through how contamination can occur and how practitioners can protect their patients from a similar fate.This story ultimately isn’t about moringa.It’s about why manufacturing quality and supply chain oversight are critical when evaluating dietary supplements.Clinical Takeaways from This EpisodeBotanical powders can carry microbial risk if supply chain controls failPlant-derived supplements are grown in open agricultural environments where contamination from soil, water, or wildlife can occur. Without appropriate processing and testing, pathogens such as Salmonella may persist (Lin et al., 2024).Salmonella can survive in dry foods for long periodsLow-moisture products—including spices, flour, and powdered botanicals—can allow Salmonella to remain viable for extended periods despite appearing shelf-stable (Lin et al., 2024; Flock et al., 2022).Manufacturing standards are a key safeguard in supplement safetySystems such as supplier verification, microbial testing, pathogen-reduction steps, and lot traceability—required under Current Good Manufacturing Practices (cGMP)—are designed to reduce contamination risk in dietary supplements (Bailey, 2020; Ma et al., 2025).Guest Introduction: Jeff Gladd, MD is the Chief Medical Officer at Fullscript, where he helps guide clinical strategy and stays current on emerging research, safety developments, and regulatory changes across the supplement and integrative health industries. In this role, he reviews scientific evidence, manufacturing practices, and industry trends to support clinicians using professional-grade supplement solutions. Dr. Gladd is also a practicing physician at GladdMD, where he focuses on integrative and functional approaches to patient care. His work bridges clinical medicine, nutritional science, and supplement safety—helping clinicians evaluate dietary supplements within everyday practice.Clinician FAQIs Salmonella infection from supplements common?Salmonella is one of the most common causes of foodborne illness globally, though infections linked to dietary supplements are relatively uncommon compared with traditional foods (Shane et al., 2017). However, outbreaks involving powdered foods and botanical ingredients have been documented.What symptoms should clinicians watch for?Symptoms typically begin 6 hours to 3 days after exposure and may include diarrhea, abdominal cramps, fever, nausea, and vomiting (Eikmeier et al., 2018; Butt et al., 2004). Most healthy adults recover within several days without antibioticsHow can clinicians help patients choose safer supplements?Encourage patients to choose products from manufacturers that follow Current Good Manufacturing Practices (cGMP), perform microbial testing, and maintain transparent sourcing and quality control systems (Bailey, 2020).Episode Sponsor: This episode is sponsored by Fullscript, a comprehensive care delivery platform designed to support whole-person, integrative healthcare. Fullscript allows clinicians to streamline supplement dispensing, lab ordering, and patient education in one free, centralized system—helping reduce administrative burden while supporting clinical decision-making. For practitioners, Fullscript offers access to professional-grade supplements, evidence-informed protocols, and lab integrations that can support more efficient planning and follow-up. For patients, it provides a clear, organized way to receive recommendations, manage refills, and stay engaged in their care. The goal is not to replace clinical judgment, but to make it easier for clinicians to focus on what matters most: thoughtful, individualized patient care.Disclaimer: The views expressed on this podcast are those of the hosts and guests and don’t necessarily reflect those of Fullscript or any affiliated organizations. This podcast is for informational and educational purposes only and is not intended to be medical advice. For your safety, always check with your doctor or healthcare provider before making changes to your health routine.ReferencesBibi N, Rahman N, Ali MQ, Ahmad N, Sarwar F. Nutritional value and therapeutic potential of Moringa oleifera: a short overview of current research. Nat Prod Res. 2024;38(23):4261-4279. doi:10.1080/14786419.2023.2284862Camilleri E, Blundell R. A comprehensive review of the phytochemicals, health benefits, pharmacological safety and medicinal prospects of Moringa oleifera. Heliyon. 2024;10(6):e27807. doi:10.1016/j.heliyon.2024.e27807Lin Z, Jiang S, Zwe YH, Zhang K, Li D. Glycogen plays a key role in survival of Salmonella Typhimurium on dry surfaces and in low-moisture foods. Food Res Int. 2024;175:113714. doi:10.1016/j.foodres.2023.113714Flock G, Richardson M, Pacitto-Reilly D, et al. Survival of Salmonella enterica in military low-moisture food products during long-term storage at 4, 25, and 40°C. J Food Prot. 2022;85(4):544-552. doi:10.4315/JFP-21-321Bailey RL. Current regulatory guidelines and resources to support research of dietary supplements in the United States. Crit Rev Food Sci Nutr. 2020;60(2):298-309. doi:10.1080/10408398.2018.1524364Ma C, Monagas M, Bronstein L, Cadwallader A, Goldman V. Dietary supplement adulteration: laboratory approaches to risk mitigation. J Nat Prod. 2025. doi:10.1021/acs.jnatprod.5c00456Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea. Clin Infect Dis. 2017;65(12):e45-e80. doi:10.1093/cid/cix669Eikmeier D, Medus C, Smith K. Incubation period for outbreak-associated, non-typhoidal salmonellosis cases, Minnesota, 2000–2015. Epidemiol Infect. 2018;146(4):423-429. doi:10.1017/S0950268818000079Butt AA, Aldridge KE, Sanders CV. Infections related to the ingestion of seafood: part I—viral and bacterial infections. Lancet Infect Dis. 2004;4(4):201-212. doi:10.1016/S1473-3099(04)00969-7Marchello CS, Birkhold M, Crump JA; Vacc-iNTS Consortium Collaborators. Complications and mortality of non-typhoidal Salmonella invasive disease: a global systematic review and meta-analysis. Lancet Infect Dis. 2022;22(5):692-705. doi:10.1016/S1473-3099(21)00615-0Falowo AB, Mukumbo FE, Idamokoro EM, et al. Multi-functional application of Moringa oleifera Lam. in nutrition and animal food products: a review. Food Res Int. 2018;106:317-334. doi:10.1016/j.foodres.2017.12.079Fernandes Â, Bancessi A, Pinela J, et al. Nutritional and phytochemical profiles and biological activities of Moringa oleifera Lam. edible parts from Guinea-Bissau (West Africa). Food Chem. 2021;341(pt 1):128229. doi:10.1016/j.foodchem.2020.128229Hassan MA, Xu T, Tian Y, et al. Health benefits and phenolic compounds of Moringa oleifera leaves: a comprehensive review. Phytomedicine. 2021;93:153771. doi:10.1016/j.phymed.2021.153771Ramesh B, Chauhan R, Don PMU, et al. Moringa oleifera: a comprehensive review of its nutritional benefits, functional applications, and future potential in food science. J Sci Food Agric. 2025. doi:10.1002/jsfa.7038

When Labels Lie: The St. John’s Wort ReportA recent analysis of 22 St. John’s Wort supplements purchased online found that only one actually matched its label for the key compound hypericin. Several products contained little to none of the active ingredient, and some appeared to use synthetic dyes to mimic the color of hypericin, potentially misleading simple testing methods (Now, 2025). Why does this matter? Because when a supplement doesn’t contain the ingredient it claims, patients may not receive the support they expect. That can lead to wasted money, confusing clinical outcomes, and lost trust in integrative care. In this episode of the Root Cause Medicine Podcast, we’re joined by Dr. Eric Viegas, Medical Product Manager at Fullscript, to unpack what this report means for clinicians and patients. We discuss how ingredient discrepancies can happen—from plant sourcing and manufacturing to risks in online marketplaces—and how practitioners can help protect patients from misleading products. We also explore what clinicians should look for when choosing supplements, including validated testing methods, Certificates of Analysis, and quality standards that help ensure products contain what the label promises.Clinical Takeaways from This EpisodeSupplement quality directly affects clinical decision-makingIf a product does not contain the labeled ingredient or dose, clinicians may struggle to determine whether a therapy is supporting patient outcomes.Botanical supplements can vary widely in active compoundsFactors such as plant sourcing, harvest timing, and extraction methods may influence the concentration of active constituents like hypericin (Butterweck, 2007).Quality verification systems help reduce riskThird-party cGMP certification, validated laboratory testing, and transparent supply chains may help clinicians identify supplements with stronger quality controls (FDA, 2024).Guest IntroductionDr. Eric Viegas is a Medical Product Manager at Fullscript specializing in supplement quality assurance and ingredient verification. His work focuses on evaluating nutraceutical ingredients, reviewing manufacturing standards, and supporting clinicians who use professional-grade supplements as part of integrative care.Labs, Nutrition, and Lifestyle SupportUnderstanding St. John’s Wort standardizationExtracts are commonly standardized to 0.3% hypericin, a marker used to estimate potency.Supplement quality indicators clinicians may reviewCertificates of Analysis (COAs) verifying ingredient identity and potencyThird-party cGMP certification for manufacturing facilitiesTesting for contaminants such as heavy metals, pesticides, microbes, and solventsAnalytical methods used to confirm botanical ingredientsHigh-performance liquid chromatography (HPLC)High-performance thin-layer chromatography (HPTLC)These analytical techniques help verify the presence and concentration of botanical compounds.Key Moments00:00 — When supplement labels don’t match what’s inside the bottleWhy ingredient accuracy matters for patient care.02:23 — The St. John’s Wort investigation explainedA breakdown of the analysis showing that only one product matched its hypericin label claim (NOW, 2025).05:20 — Why missing active ingredients affect outcomesHow inaccurate potency may influence patient expectations and treatment evaluation.07:10 — Why botanicals are especially vulnerable to variabilityHow growing conditions, plant parts, and extraction methods influence active compounds (Butterweck, 2007).10:54 — How quality verification works behind the scenesWhat manufacturers and distributors may do to verify supplement quality.16:01 — Why this issue extends beyond St. John’s WortOther botanicals may also vary in potency depending on sourcing and manufacturing.DisclaimerThe views expressed on this podcast are those of the hosts and guests and don’t necessarily reflect those of Fullscript or any affiliated organizations. This podcast is for informational and educational purposes only and is not intended to be medical advice. For your safety, always check with your doctor or healthcare provider before making changes to your health routine.CitationsButterweck V, Schmidt M. St. John's wort: role of active compounds for its mechanism of action and efficacy. Wien Med Wochenschr. 2007;157(13-14):356-61. doi: 10.1007/s10354-007-0440-8. PMID: 17704987.Barnes J, Anderson LA, Phillipson JD. St John's wort (Hypericum perforatum L.): a review of its chemistry, pharmacology and clinical properties. J Pharm Pharmacol. 2001 May;53(5):583-600. doi: 10.1211/0022357011775910. PMID: 11370698. Izzo AA. Interactions between herbs and conventional drugs: overview of the clinical data. Med Princ Pract. 2012;21(5):404-28. doi: 10.1159/000334488. Epub 2012 Jan 11. PMID: 22236736.NOW Tests St. John’s Wort Supplements Sold on Amazon. NOWFoods.com October 29, 2025. https://www.nowfoods.com/healthy-living/articles/now-tests-st-johns-wort-supplements-sold-amazonUSFDA. Current Good Manufacturing Practices (CGMPs) for Food and Dietary Supplements. Published 04/24/2024. https://www.fda.gov/food/guidance-regulation-food-and-dietary-supplements/current-good-manufacturing-practices-cgmps-food-and-dietary-supplements 

Anyone Can Order Labs Now: Who's Interpreting Them?In this episode of the Root Cause Medicine Podcast, we explore a growing clinical reality: patients now have immediate access to advanced bloodwork but not necessarily interpretation with a clinician. In this conversation, we introduce Fullscript Journeys, the provider-led answer to direct-to-consumer lab platforms. With lab testing, AI-supported interpretations and wellness plans, and seamless follow-ups, Journeys empowers providers to deliver a modern patient experience — without compromising clinical guidance.What is Fullscript Journeys?Fullscript Journeys is a provider-led lab-to-plan solution that enables clinicians to deliver a modern, digital care experience while maintaining clinical oversight and individualized judgment.Patients can:Order labs through a branded storefront curated by their providerComplete a simple intake to power a personalized wellness planSchedule a blood drawAccess structured, provider-reviewed labs resultsReceive a personalized wellness plan from their clinicianStay on track with retesting and follow-upsProviders can:Choose or customize lab panels (including 20 ready-made templates)Launch and share a Journeys storefront to grow their practiceKeep current patients engaged by adding a Journey to their care planReview and edit AI-assisted draft interpretations before releaseApprove and personalize wellness plansMonitor lab orders, results, and follow-ups within one dashboardFullscript Journeys is designed to reduce repetitive administrative work – such as creating first drafts of interpretations and coordinating follow-up lab orders – while preserving provider authority, individualized care planning, and appropriate clinical review.  Importantly, Journeys functions as clinical decision support. It does not replace medical judgment, diagnosis, or individualized patient assessment.Key Episode ThemesMore patients have lab results in hand—but not clear answers. The bottleneck is interpretation, not access.AI can help draft and organize information, but it supports clinical judgment—it doesn’t replace it.Preventive, long-term care can scale with better systems—while keeping trust and the provider–patient relationship at the center.Fullscript Journeys gives providers a scalable way to deliver personalized care that keeps patients engaged and under their guidance between appointments. Patients order labs through a personalized storefront, receive AI-powered interpretations, and follow a wellness plan built around their results. Automated follow-ups keep patients engaged over time, and providers stay in control of every care decision without taking on additional administrative work.Guest Information:Dr. Cheng Ruan, MD, Physician Transformation InstituteDr. Emlah Tubuo, PharmD, Powell PharmacyLiz Mckinney, MS, CNS, LDN, NutrisenseJosh Walters, Head of Product at FullscriptDisclaimer: The views expressed on this podcast are those of the hosts and guests and don’t necessarily reflect those of Fullscript or any affiliated organizations. This podcast is for informational and educational purposes only and is not intended to be medical advice. For your safety, always check with your doctor or healthcare provider before making changes to your health routine.

Dr. Emlah Tubuo, an integrative pharmacist and entrepreneur who founded Powell Pharmacy, blends whole-person pharmacotherapy with practical clinic systems. She discusses creating 45-minute med + supplement reviews, drug–nutrient depletion and counseling, biomarker-driven risk testing, and clinic pillars like nutrition, movement, and inner alignment. Practical workflows and tools for scaling integrative pharmacy are highlighted.

Jeff Gladd, MD, an integrative physician and Fullscript CMO who turns nutrition research into practical clinical guidance. He discusses how creatine works in growing bodies. They cover who might benefit, links to lean mass and bone health, safety data in healthy youth, monitoring for kidney concerns, and tips for choosing high-quality creatine products.

SummaryIn this Root Cause Medicine podcast episode, Dr. Kate Kresge is joined by Dr. Eric Viegas, quality and safety lead at Fullscript, to explore emerging concerns around ashwagandha-associated drug-induced liver injury (DILI). While ashwagandha remains one of the most widely used adaptogens in integrative medicine, recent international case reports have highlighted rare but clinically meaningful hepatic adverse events. This episode equips clinicians with a mechanistic understanding of potential risk factors, withanolide content that may increase vulnerability, and practical strategies for patient screening, education, and monitoring—without dismissing the therapeutic value of this foundational herb.Clinical Takeaways from This EpisodeAshwagandha-Associated Drug-Induced Liver Injury (DILI) Is Rare but DocumentedCase reports from Japan, Iceland, and the U.S. describe hepatocellular injury typically occurring within 2–12 weeks of initiation, often resolving after discontinuation (Björnsson, 2020).Withanone and Oxidative Stress as a Proposed MechanismThe withanolide withanone may contribute to genotoxic and oxidative stress, particularly in states of depleted glutathione, potentially impairing hepatic detoxification capacity (Siddiqui, 2021).Withanolide Concentration MattersProducts standardized to high withanolide content may pose greater theoretical risk compared to traditional whole-root or aqueous preparations (Björnsson, 2020).Patient Vulnerability Influences Risk ProfileIndividuals with pre-existing liver concerns, polypharmacy, high oxidative stress burden, or impaired phase II detoxification may warrant closer consideration and monitoring (Siddiqui, 2021).Clinical-Grade Supply Chains Support Risk MitigationPractitioner-dispensed platforms with transparent sourcing, certificates of analysis, and clear extract documentation may help reduce exposure to adulterated or mischaracterized products.Patient Education and Monitoring Remain Frontline ToolsCounseling on symptom awareness and considering baseline and follow-up liver enzymes may support safer use when ashwagandha is clinically appropriate.Guest IntroductionDr. Eric Viegas is a quality expert at Fullscript, where he oversees supplement quality programs, supply chain integrity, and clinical-grade standards. With expertise in pharmacology, toxicology, and nutraceutical regulation, Dr. Viegas supports practitioners in making evidence-informed decisions around supplement sourcing, formulation, and patient safety. Learn more: https://fullscript.comLabs, Nutrition, and Lifestyle SupportLiver Function and Safety Monitoring LabsComprehensive Metabolic Panel (CMP)ALTASTTotal and direct bilirubinAlkaline phosphatase, as clinically indicated  (Björnsson, 2020)Nutritional Considerations for Hepatic ResilienceAdequate dietary protein to support glutathione synthesis (Siddiqui, 2021)Lifestyle and Integrative Support StrategiesReview of total supplement and medication load with attention to polypharmacyPatient education on early symptoms of liver stress such as fatigue, pruritus, dark urine, and jaundice (Björnsson, 2020)All strategies are intended for educational support and clinical consideration and should be applied within the context of individualized care.SponsorThis episode is sponsored by Fullscript, a comprehensive care delivery platform designed to support whole-person, integrative healthcare. Fullscript allows clinicians to streamline supplement dispensing, lab ordering, and patient education in one free, centralized system—helping reduce administrative burden while supporting clinical decision-making. For practitioners, Fullscript offers access to professional-grade supplements, evidence-informed protocols, and lab integrations that can support more efficient treatment planning and follow-up. For patients, it provides a clear, organized way to receive recommendations, manage refills, and stay engaged in their care. The goal is not to replace clinical judgment, but to make it easier for clinicians to focus on what matters most: thoughtful, individualized patient care.FAQs1) Can ashwagandha cause liver injury?Yes, but it appears to be rare. Published case series and reports describe ashwagandha-associated drug-induced liver injury (DILI) with symptom onset most often within weeks (commonly ~2–12 weeks) after starting, and improvement typically occurring after stopping the product. Clinicians should treat this as an uncommon, but plausible, idiosyncratic adverse event rather than a predictable toxicity for all users (Björnsson et al., 2020).2) What are the typical symptoms of ashwagandha-related liver injury?Reported presentations resemble other forms of DILI and may include fatigue, pruritus, dark urine, and jaundice; some patients may have nonspecific malaise before overt cholestatic or hepatocellular patterns are recognized on labs. Educate patients to discontinue the product and seek evaluation promptly if these symptoms occur (Björnsson et al., 2020).3) How long after starting ashwagandha might liver injury show up?In published cases, liver injury has typically appeared within 2 to 12 weeks after initiation (though individual variability exists, as with other DILI phenotypes). This timing supports a practical monitoring window for higher-risk patients, especially early in therapy (Björnsson et al., 2020).4) Who is at higher risk for ashwagandha-associated DILI?Risk appears to be influenced by host vulnerability and context, including pre-existing liver disease or prior liver injury, significant polypharmacy, and higher oxidative stress burden. Because DILI is often idiosyncratic, risk stratification is imperfect; however, these factors justify a more conservative approach and closer follow-up (Siddiqui et al., 2021; Björnsson et al., 2020).5) What is the safest way to use ashwagandha clinically?A clinically cautious approach is to:Prefer transparent, clinically vetted supply chains with clear extract specifications and quality documentation.Screen for liver history and medication/supplement load.Educate patients on early warning symptoms.Consider baseline and follow-up liver enzymes (e.g., ALT, AST, bilirubin) in higher-risk individuals or if symptoms develop.This framing supports safer use without implying the product is universally unsafe or “detoxifying,” and keeps claims within educational and clinical-monitoring boundaries (Björnsson et al., 2020; Siddiqui et al., 2021).CitationsBjörnsson HK, Björnsson ES, Avula B, Khan IA, Jonasson JG, Ghabril M, Hayashi PH, Navarro V. Ashwagandha-induced liver injury: A case series from Iceland and the US Drug-Induced Liver Injury Network. Liver Int. 2020 Apr;40(4):825-829. doi: 10.1111/liv.14393. Epub 2020 Feb 11. PMID: 31991029; PMCID: PMC8041491. Siddiqui S, Ahmed N, Goswami M, Chakrabarty A, Chowdhury G. DNA damage by Withanone as a potential cause of liver toxicity observed for herbal products of Withania somnifera (Ashwagandha). Curr Res Toxicol. 2021;2:72-81. Published 2021 Feb 16. doi:10.1016/j.crtox.2021.02.002

Dr. Linda Dahl, MD, a board-certified otolaryngologist and integrative voice specialist, connects subtle vocal changes to whole-person health. She discusses using the voice as a clinical window. Topics include mucosal inflammation and microbiome links, reflux and failed PPI treatments, yeast-related coughs, hormonal and autonomic effects on voice, posture and breath mechanics, and practical low-cost voice care tips.

In part two of our SIBO series,  we’re joined again by Dr. Allison Siebecker to focus on 2 key pillars that can influence whether patients stabilize or relapse: nutritional management and supportive care during and after SIBO treatment. We explore how to use prokinetics to support migrating motor complex function, when digestive aids like bile acids and enzymes may be appropriate, and how to apply SIBO dietary frameworks as personalized, flexible tools—not rigid rules. We also cover practical approaches to suspected yeast/dysbiosis overlap, how to support gut barrier integrity without worsening fermentation, and the key myths that can derail outcomes. This episode helps clinicians move from “eradication mode” to sustainable, integrative SIBO care.Clinical Takeaways from This EpisodeHow do prokinetics help to prevent SIBO relapse and support the migrating motor complex?Dr. Siebecker frames prokinetics as a core strategy to support upper GI motility and migrating motor complex activity, particularly between treatment rounds and for maintenance after major symptom improvement, individualized to relapse risk and underlying drivers. Prokinetics help to accomplish roles that the migrating motor complex and motilin typically perform in the GI tract, including the routine out-movement of foodstuffs, resulting in less time for bacteria to ferment specific carbohydrates (Deloose, 2015).Can you use prokinetics in diarrhea-predominant patients, or are they basically laxatives?They’re not laxatives by definition. Prokinetics are intended to support coordinated GI motility (often esophagus, stomach, small intestine) and may still be considered in diarrhea-predominant cases when small intestine motility impairment is part of the picture; dose and individual tolerance matter (Camilleri, 2021).Should clinicians use restrictive SIBO diets during treatment, and can diet “cure” SIBO?Food based diets are best positioned as symptom support, not a standalone cure. Low-fermentable carbohydrate approaches may reduce gas-related symptoms and improve adherence during treatment, and clinical experience shared here suggests improvement can still occur even when diets are quite restricted. Food is distinct from the elemental diet, where patients only intake a supplement for 2 weeks, discussed part of the series (Knez, 2024).How should clinicians approach SIBO diet personalization and food reintroduction after treatment?Dr. Siebecker recommends using established dietary frameworks (low FODMAP, SCD, hybrid approaches like the SIBO-specific guide/biphasic structure) as starting points, then customizing based on symptom response. Food reintroduction can be gradual, sometimes using “micro-dosing” exposures, with repeat trials to reduce confounding factors. Not everyone with the same subtype of SIBO will be able to tolerate the same foods.What supportive care is commonly missed in complex or relapsing SIBO cases?Commonly missed supports discussed by Dr. Siebecker include: physical medicine for for structural contributors, thoughtful use of digestive support (enzymes, bile acids when clinically indicated), and careful selection of gut barrier supports—noting that some mucopolysaccharide-rich “leaky gut” agents may aggravate symptoms in active SIBO for some patients.Guest IntroductionDr. Alison Siebecker is a clinician and educator recognized for her work in SIBO subtyping, breath test interpretation, treatment sequencing, and relapse prevention strategies. She provides practitioner education, patient resources, and community learning through siboinfo.com Labs, Nutrition, and Lifestyle Support MentionedMotility support: prokinetics (pharma and botanical options discussed)When used: between rounds and for remission maintenance (often at least ~3 months, individualized).Options discussed: prucalopride, low-dose erythromycin, LDN (adjunct), ginger and ginger-based blends, Iberis amara–containing multi-herbal combinations.Digestive support: bile acids and enzymes (individualized)Bile support may be considered when clinical suspicion of low bile flow exists; enzymes may support digestion during symptom management and re-expansion.Yeast/dysbiosis overlap: testing optionsStool testing (colonic yeast), urine organic acids (yeast metabolites), Candida immune markers (reactivity patterns), and symptom questionnaires as pragmatic adjuncts.Gut barrier support during active SIBO: choose lower-fermentation options firstTrial cautiously: marshmallow, aloe, comfrey (may aggravate symptoms for some).Often better tolerated options discussed: IgG/colostrum, zinc carnosine, non-fermentable anti-inflammatory supports.Integrative lifestyle medicine and structural supportPhysical medicine, acupuncture, chiropractic when appropriate.Key Moments03:30 – Why some physical medicine modalities may improve outcomes in complex SIBO04:45 – Prokinetics explained: migrating motor complex support vs laxative misconceptions06:45 – Timing between treatment rounds and how practice scheduling impacts success14:31 – Foods for symptom relief: why diet alone may not resolve relapse drivers23:00 – Leaky gut support during active SIBO: what may aggravate symptoms vs better-tolerated options27:06 – Biphasic/SIBO-specific dietary frameworks and personalization principles30:26 – Common SIBO myths that derail care and patient confidence31:40 – Clinical hope message: troubleshooting why patients aren’t improvingWant to elevate your practice? This episode is sponsored by Fullscript, a comprehensive care delivery platform designed to support whole-person, integrative healthcare. Fullscript allows clinicians to streamline supplement dispensing, lab ordering, and patient education in one free, centralized system—helping reduce administrative burden while supporting clinical decision-making. For practitioners, Fullscript offers access to professional-grade supplements, evidence-informed protocols, and lab integrations that can support more efficient treatment planning and follow-up. For patients, it provides a clear, organized way to receive recommendations, manage refills, and stay engaged in their care. The goal is not to replace clinical judgment, but to make it easier for clinicians to focus on what matters most: thoughtful, individualized patient care.DisclaimerThe views expressed on this podcast are those of the hosts and guests and don’t necessarily reflect those of Fullscript or any affiliated organizations. This podcast is for informational and educational purposes only and is not intended to be medical advice. For your safety, always check with your doctor or healthcare provider before making changes to your health routine.CitationsCamilleri M, Atieh J. New Developments in Prokinetic Therapy for Gastric Motility Disorders. Front Pharmacol. 2021;12:711500. Published 2021 Aug 24. doi:10.3389/fphar.2021.711500Deloose E, Janssen P, Depoortere I, Tack J. Redefining the functional roles of the gastrointestinal migrating motor complex and motilin in small bacterial overgrowth and hunger signaling. Am J Physiol Gastrointest Liver Physiol. 2015;309(9):G649-G661.Knez E, Kadac-Czapska K, Grembecka M. The importance of food quality, gut motility, and microbiome in SIBO development and treatment. Nutrition. 2024 Aug;124:112464. doi: 10.1016/j.nut.2024.112464. Epub 2024 Apr 5. PMID: 38657418.

The research around SIBO is evolving, and 2026 has brought more subtypes, testing and treatment options than ever before. Our guest this week, Dr. Allison Siebecker, is an expert in conventional and natural approaches to SIBO, helped to open one of the first integrative SIBO centers in the nation, and frequently teaches physicians about how to effectively treat even the toughest cases of SIBO, ISO, IMO and more. Today, we explore how hydrogen, methane (IMO), and hydrogen sulfide–associated (ISO) pattern-typing can help us choose treatment options that help to decrease SIBO symptoms effectively. We discuss how impaired motility - particularly dysfunction of the migrating motor complex - can impact symptom persistence and relapse in addition to microbial type and load, and why we should address it in treatment plans. Dr. Siebecker also reviews the newest advances in SIBO testing, breath test interpretation, and how long to test depending on what you’re looking to discover. If SIBO has felt like a guessing game in your practice, or if you’re just looking to stay on the leading edge, this episode offers a clearer, physiology-driven framework grounded in education that will help your clients get and stay well. Timestamps00:00 - Introduction to the episode and guest03:45 - What SIBO is and how it’s currently defined (including ICD-10 update)06:50 - Differentiating hydrogen, methane, and hydrogen sulfide subtypes08:40 - Key symptoms: bloating, IBS symptoms, mood, fatigue10:54 - Why gas types matter and how they affect motility15:00 - Primary causes and risk factors: infections, meds, mold, structural changes18:40 - Mold and mycotoxin impact on gut motility21:59 - How to test: glucose vs. lactulose, two-hour vs. three-hour tests24:14 - Choosing a testing method and interpreting flatlines29:01 - Cost, access, and why testing saves time and money long term31:03 - Choosing treatment based on gas type and severity36:32 - Understanding treatment rounds and when to stop or switch protocols38:59 - Why methane and hydrogen sulfide SIBO are more difficult to treat43:26 - Nystatin, yeast overgrowth, and when to co-treat for CIFO47:55 - Rifaximin as a eubiotic and why it’s well tolerated49:46 - Preview of Part 2: Nutrition, prokinetics, supportive therapiesClinician Questions & Evidence-Informed TakeawaysHow is SIBO defined and what testing is recommended?SIBO is best understood as a clinical syndrome requiring both characteristic gastrointestinal symptoms and objective evidence of microbial overgrowth in the small intestine. Breath testing may support diagnostic clarity, subtype identification, and treatment planning, particularly in patients with IBS or recurrent digestive disorders (Pimentel, 2020).What are the differences between hydrogen-, methane-, and hydrogen sulfide–associated SIBO patterns?Hydrogen-predominant SIBO typically reflects small intestinal fermentation, whereas methane-associated IMO and hydrogen sulfide patterns may involve both the small intestine and colon. Hydrogen predominant types are also usually caused by bacterial overgrowth, while methane and sulfide-predominant types can involve overgrowth of archaea. These distinctions influence motility, symptom expression, and selection of appropriate treatment options (Pimentel, 2020).How does impaired gas handling contribute to SIBO and IBS symptoms?Symptom severity may be driven by reduced clearance of gas rather than gas volume alone. Dysfunction of the migrating motor complex and altered neuromuscular signaling can result in significant bloating, distension, and pain even with modest gas elevations. Helping patients restore normal gas-clearing abilities can help to alleviate symptoms, according to Dr. Siebecker (Serra, 2001).How does methane slow intestinal transit and result in constipation-predominant presentations?Methane functions as a gasotransmitter that interacts with the enteric nervous system and may slow gut motility. This provides a physiologic explanation for constipation-predominant IBS patterns and the increased treatment complexity seen in methane-associated cases (Park, 2017).Which breath test substrate provides the most clinically useful data for SIBO evaluation?There are multiple non-invasive tests available for the detection of SIBO that contain a carbohydrate drink and containers designed to collect breath samples at regular intervals (Losurdo 2020).Lactulose is preferred by Dr. Siebecker in clinical practice because it traverses the full length of the small intestine and into the colon, potentially reducing false-negative results associated with early glucose absorption that can occur in some patients. Dr. Siebecker recommends tests that are at least 3 hours in duration for most patients. (Pimentel, 2020)How does breath test duration impact the detection of methane and hydrogen sulfide patterns?Shortened testing protocols may fail to capture later-rising methane or persistently low hydrogen and methane patterns. According to Dr. Siebecker, extended collection windows can improve detection of methane-associated IMO and suspected hydrogen sulfide physiology. It could also help to capture patients with SIBO who also have impaired motility and transit time (Tansel, 2023).What is the clinical interpretation of a flatline hydrogen and methane breath test for SIBO?A flatline pattern (i.e. low and relatively stable hydrogen and methane values) could give clues to abnormal function in symptomatic patients. Dr. Siebecker suggests that in appropriate clinical contexts, abnormal patterns like flatline may suggest hydrogen sulfide overproduction or altered microbial metabolism of gases (Lakhoo, 2018).How should breath test severity inform SIBO treatment sequencing and prognosis?In Dr. Siebecker’s experience, higher gas levels may justify consideration of strategies with greater average reduction potential, such as elemental diet, while lower or moderate elevations may be approached with pharmaceutical or herbal treatment options. Severity-based planning can improve timelines and patient expectations.If patients relapse after SIBO treatment, what does that mean?Symptom recurrence shortly after treatment more often reflects incomplete microbial reduction or the existence of undertreated root causes rather than true relapse. This distinction supports staged treatment approaches with reassessment rather than premature abandonment of therapy. Patients with incomplete resolution can also be evaluated for other disorders like pancreatic exocrine insufficiency, bile acid malabsorption, lactose intolerance, etc. (Rao, 2019).Under what circumstances should coexisting fungal overgrowth be considered in SIBO patients?Dr. Siebecker explains that small intestinal fungal overgrowth (SIFO) testing could be considered in patients with prior candidiasis, repeated antibiotic exposure, or persistent symptoms despite improving SIBO markers. Evaluation is typically individualized rather than routine (Soliman, 2025). What is the role of prokinetics in long-term SIBO management?Prokinetics support the migrating motor complex and may help maintain treatment gains following antimicrobial therapy. Addressing motility is central to relapse prevention and sustained gut health (Kim, 2023).What factors should be reassessed in patients with recurrent or refractory SIBO?Persistent or relapsing SIBO warrants reassessment of medications (particularly opioids), structural contributors, metabolic and neurologic conditions, immune dysfunction, environmental exposures, and lifestyle factors influencing gut physiology (Rao, 2019 and Pimentel, 2020).Guest Dr. Alison Siebecker, ND is a naturopathic physician, internationally recognized SIBO expert, and educator whose work has shaped how clinicians understand small intestine overgrowth, breath testing, and integrative treatment options. She is known for her clear clinical algorithms, deep expertise in SIBO subtypes, and commitment to practitioner education. Her ongoing collaboration and dialogue with leading researchers—including Dr. Mark Pimentel’s research group—continues to advance the field. You can learn more about her at https://www.siboinfo.com/SIBO TestingLearn more about Optimizing SIBO Diagnosis with Testing Order SIBO testing for patients through Rupa Health and Fullscript with a free accountWant to elevate your practice? This episode is sponsored by Fullscript, a comprehensive care delivery platform designed to support whole-person, integrative healthcare. Fullscript allows clinicians to streamline supplement dispensing, lab ordering, and patient education in one free, centralized system—helping reduce administrative burden while supporting clinical decision-making. For practitioners, Fullscript offers access to professional-grade supplements, evidence-informed protocols, and lab integrations that can support more efficient treatment planning and follow-up. For patients, it provides a clear, organized way to receive recommendations, manage refills, and stay engaged in their care. The goal is not to replace clinical judgment, but to make it easier for clinicians to focus on what matters most: thoughtful, individualized patient care.DisclaimerThe views expressed on this podcast are those of the hosts and guests and don’t necessarily reflect those of Fullscript or any affiliated organizations. This podcast is for informational and educational purposes only and is not intended to be medical advice. For your safety, always check with your doctor or healthcare provider before making changes to your health routine.CitationsPimentel M, Saad RJ, Long MD, Rao SSC. ACG Clinical Guideline: Small Intestinal Bacterial Overgrowth. Am J Gastroenterol. 2020;115(2):165-178.Rezaie A, Buresi M, Lembo A, et al. Hydrogen and Methane-Based Breath Testing in Gastrointestinal Disorders: The North American Consensus. Am J Gastroenterol. 2017;112(5):775-784. Serra J, Azpiroz F, Malagelada JR. Impaired transit and tolerance of intestinal gas in the irritable bowel syndrome. Gut. 2001;48(1):14-19. Park H, Lee K, Park S, et al. The effects and mechanism of action of methane on ileal motor function. Neurogastroenterol Motil. 2017;29(9):e13067. Losurdo G, Leandro G, Ierardi E, Perri F, Barone M, Di Leo A. Breath Tests for the Non-invasive Diagnosis of Small Intestinal Bacterial Overgrowth: A Systematic Review With Meta-analysis. J Neurogastroenterol Motil. 2020;26(1):16-28.Tansel A, Levinthal DJ. Understanding Our Tests: Hydrogen-Methane Breath Testing to Diagnose Small Intestinal Bacterial Overgrowth. Clin Transl Gastroenterol. 2023;14(4):e00567. Published 2023 Apr 1. doi:10.14309/ctg.0000000000000567Birg A, Hu S, Lin HC, et al. Reevaluating our understanding of lactulose breath tests by incorporating hydrogen sulfide measurements. JGH Open. 2019;3(2):228-233.Lakhoo, Krutika MD1; Liu, Xiaochen MSc1; Lentz, Greg2; Lin, Eugenia BS1; Chang, Bianca W. MD3; Pimentel, Mark MD1; Pichetshote, Nipaporn MD1; Rezaie, Ali MD, MSc1. Phenotype and Antibiotic Response in Patients With Flat Line Breath Test Results: A Large Scale Database Analysis: 448. American Journal of Gastroenterology 113():p S261, October 2018. Soliman N, Kruithoff C, San Valentin EM, Gamal A, McCormick TS, Ghannoum M. Small Intestinal Bacterial and Fungal Overgrowth: Health Implications and Management Perspectives. Nutrients. 2025;17(8):1365. Published 2025 Apr 17. doi:10.3390/nu17081365 Rao, Satish & Bhagatwala, Jigar. (2019). Small Intestinal Bacterial Overgrowth: Clinical Features and Therapeutic Management. Clinical and Translational Gastroenterology. 10. e00078. 10.14309/ctg.0000000000000078. Kim YJ, Jo IH, Paik CN, Lee JM. Efficacies of prokinetics and rifaximin on the positivity of a glucose breath test in patients with functional dyspepsia: a randomized trial. Rev Esp Enferm Dig. 2023 Mar;115(3):121-127. doi: 10.17235/reed.2022.8735/2022. PMID: 35748472.