Intersection of IBS, SIBO & the Low FODMAP Diet

Hey Friends.

Today’s post includes a bit of “alphabet soup”: SIBO, IBS & FODMAPs. I will start with a brief introduction of SIBO and commonly asked questions about this disorder.  I will then provide a few low FODMAP diet updates too!

Let’s start with SIBO, shall we?

What is SIBO?  SIBO is a condition where both aerobic and anaerobic bacteria over grow in the small intestine. Typically, the small intestine contains low levels of bacteria unlike the large intestine which harbors a diverse ecosystem of microbes. Our gut microbes play a role in health and disease. Important positive functions of microbes include: degrading carbohydrates for fuel, creating vitamins for good health and maintaining normal function of our immune system.

What are the symptoms of SIBO? Symptoms mimic those found in irritable bowel syndrome including: bloating, abdominal distention, gas, pain, fullness after eating, and alteration of  bowel habit (constipation, diarrhea or alternating).

When SIBO occurs are we full of ‘bad bacteria’? SIBO occurs when we have bacteria in the wrong place versus having too many of the wrong kind of microbes. Though it is possible that certain microbes vs. others are more problematic (cause more symptoms) in the small bowel. More research is needed!

Dysbiosis is a condition where there is an imbalance of microbes. Dysbiosis may present with an abundance of potentially pathogenic (disease causing) bacteria versus probiotic (health promoting) microbes. This can occur in your colon or small intestine. We all have our own personal gut microbial fingerprint which makes navigating this science a bit trickier.

Are SIBO and IBS related? I  think of SIBO as IBS on steroids. SIBO and IBS could be separate conditions or perhaps a disorder on the same spectrum. IBS and SIBO present with similar symptoms though I find in my clinical practice SIBO patients experience symptoms of greater severity. I asked William Chey, MD, a leading US gastroenterologist and world-renowned authority on food intolerance from University of Michigan to weigh in on this discussion w/ me.

Kate: Do you think SIBO and IBS are really the same disease on a spectrum?

Dr. Chey: I have a somewhat different view. IBS is a symptom based condition consisting of abdominal pain and altered bowel habits. I believe that there are likely a number of “diseases” for which we don’t currently have biomarkers, which present with symptoms that are consistent with the diagnosis of IBS. Consider this, 20 years ago, we didn’t understand that a small percentage of “IBS” patients actually have Celiac disease or microscopic colitis or dyssynergic defecation. Now it is widely recognized that all of these diseases can mimic IBS. I believe that SIBO is another IBS mimic. I also believe that even in the absence of a formal diagnosis of SIBO (>10×5 CFU/ml), quantitative or qualitative alterations in the gut microbiome can cause IBS symptoms.

Kate: What are some clinical features you assess in your patients that would prompt you to order a SIBO breath test?

Dr. Chey: Risk factors like diabetes, scleroderma, immune deficiency disorders, neuromuscular disorders, etc. make me consider SIBO early in the work up of a patient with pain, cramping, bloating, flatulence or diarrhea.

Kate: Do you have a dietary approach you recommend for your SIBO patients and why?

Dr. Chey: My primary approach to the treatment of SIBO is a course of antibiotics. To reduce systemic side effects and the development of antibiotic resistant extra-intestinal bacteria, I prefer to use non-absorbed antibiotics like rifaximin. I often use adjunctive dietary therapy following antibiotics – I focus on the low FODMAP diet. Though this is not an evidence based strategy for SIBO, I do think there is a biologically plausible reason this the diet may offer clinical benefits and increase the durability of response to a course of antibiotics for SIBO. We know that the low FODMAP diet offers clinical benefits to the symptoms of IBS which are often indistinguishable from SIBO. Further, we also know that FODMAPs are important prebiotics for a wide range of bacteria. Thus, it is reasonable to hypothesize that reducing dietary FODMAPs might slow recurrence of SIBO. Of course, this remains to be proven is methodologically rigorous clinical trials.

I appreciate these very thoughtful answers from Dr. Chey and fully agree with them. Let’s continue with other questions that arise frequently about SIBO.

Where can I find accurate and evidenced based resources for SIBO? To be honest, I get pretty worked up about the misinformation that abounds on the Internet about SIBO and the overall lack of research in this area. With this, I feel terribly sorry for the SIBO sufferers out there trying find treatments to feel better. Unfortunately,  there is a lack of consensus amongst GI docs and other healthcare professionals when it comes to the testing, diagnosis and the treatment of SIBO. This leaves patients stumbling to find answers on their own.  I follow Mark Pimentel’s research (he’s active on Twitter @MarkPimentelMD), attend key GI conferences such as Digestive Disease Week to learn about evidence based research in this area, and gather as much science-based research via Pub Med  I can get my hands on. When working with your healthcare provider, ask about their treatment approach. Their answer should include: determine cause of SIBO, treat with non-absorbed antibiotics (there is some evidence for herbal therapies too and/or an elimination diet), and adjust diet to the patient’s personal tolerance often with a reduction in fermentable carbohydrates. Also, any supplement recommendations should have science to support their use. Be wary of practitioners that want to sell you $$$ worth of supplements. When doing any online research (sometimes this just adds to your stress– so limit your time online!), be sure the site is reputable and science-based.

How do you get tested for SIBO? I understand the often arduous process it takes to get a diagnosis for SIBO. I was diagnosed with this condition back in 2003, 10 years after an intestinal resection and was very miserable for almost 2 years prior to getting treatment.  Getting the diagnosis took firing a couple GI docs and finding a new one that would listen and understood SIBO. If you have SIBO or think you might have SIBO…the best thing you can do is find a gastroenterologist that understands this condition.

Should you take probiotics when you are taking antibiotics for SIBO? A recent study published in 2017 conducted a meta-analysis (a statistical analysis that combines the results of multiple studies) and systematic review of current evidence to assess the efficacy of probiotics in preventing or treating small intestinal bacterial overgrowth (SIBO).  The results showed that the probiotics group showed a significantly higher SIBO decontamination rate than the non-probiotic group (RR=1.61; 95% CI, 1.19-2.17; P<0.05). The hydrogen gas level was significantly reduced among probiotic users too. Probiotics were associated with a reduction in abdominal pain scores but they have little effect on daily stool frequency. Given the review of this meta-analysis, I have started to recommend probiotics supplements during rifaximin therapy. But, of course, each individual should follow the recommendations of their personal health care provider.  The study can be found here.

What diet should you follow when you have SIBO? This is the million dollar question and honestly, there is little research in this area. However, given the majority of SIBO sufferers fulfill the diagnosis of IBS –and the low FODMAP diet is an evidenced based therapy for IBS, the low FODMAP diet is my first line therapy for SIBO.  I await research in this area. Any diet that restricts poorly absorbed or short chain carbs that small intestinal bacteria will gain easy access to, ferment and allow them to grow –will likely contribute to symptom benefit. Diet should be individualized and should be the least restrictive to maintain quality of life and adequate nutrition. There are many VERY restrictive diets recommended for SIBO and I do not feel the majority of individuals need to highly restrictive with the diet.  In my experience working with thousands of patients with SIBO, the bulk of them improved on the low FODMAP diet. I have had a handful of patients that had difficulty with starches and fibers. Working with a dietitian to guide diet therapy is a must. Additionally, remember diet is one part of the solution for SIBO. Many SIBO patients put so much pressure on themselves and on the importance of diet that their stress level prohibits them from attaining good health. Treating SIBO requires (in my opinion) a multi-faceted treatment plan. More on this to follow.

What test should you undertake for SIBO–glucose or lactulose?  Glucose offers greater accuracy per a couple papers: Saad, R  2014 Dec;12(12):1964-72. Rana, SV Digestion 2012;85:243–247

But…I thought I would ask Dr. Mark Pimentel from Cedars Sinai as he is the true expert on breath testing in my opinion.

Kate: I am reviewing the literature and most papers I am reading favor the glucose breath test over lactulose saying it is the most accurate. Yet,  I realize that the glucose can miss distal sibo. Are you still in favor of lactulose testing for this reason?  

Mark Pimentel: “The recently published north American Consensus of experts suggest lactulose because it is more likely not to miss SIBO.”  The North American Consensus paper Dr. Pimentel is referring can be accessed here.

In my opinion, I often favor the glucose test for my patients with a very sensitive tummy, who tend to have rapid onset of symptoms post eating and are diarrhea predominant. I encourage glucose testing for these patients to avoid the laxative effect of lactulose (it speed intestinal transit & functions as a laxative).

What is the best treatment for SIBO? Antibiotic (pharmaceutical, herbal or elemental diet) to induce remission. Identify underlying cause of SIBO (when possible) and treat (ie–identify celiac, treat issues such as fecal loading or severe constipation), and maintaining remission w/ discrete meal times & spacing, motility medications, adequate bowel regimen or elimination habits –constipation or fecal loading reduce movements in small intestine and likely contribute to relapse. Correcting any nutritional deficiencies is important too. I typically encourage testing Vitamin D (fat malabsorption often occurs with SIBO), B12, ferritin, zinc for starters and supplement as needed. Individualized therapy is key!

Rifaximin, a poorly absorbed  drug with unique properties is typically the first line therapy for SIBO with a positive hydrogen test. When methane gas is elevated, a combo of rifaximin and neomycin, may have greater efficacy as noted in the study noted here.

Rifaximin is active against pathogenic and non-pathogenic bacteria in the bile-rich small bowel (it’s soluble in bile) and its low water solubility makes it active only against highly susceptible bacteria, primarily anaerobes, in the water filled colon.

Rifaximin may also impart some anti-inflammatory effects in the gut or the function of the gut microbes (ie gut microbe metabolism, adherence and/or virulence). We are still learning more about how this particular medicine helps SIBO patients.

What if my SIBO test is negative but I felt miserable during the test? Discuss with your doctor whether you should be treated empiraclly with antibiotics or consider further work-up.

What symptoms are associated with methane + sibo?  Those who are methane + sibo are more than 5 times more likely to be constipated, the more methane gas, the more severe the symptoms, and treatment may require dual antibiotics. One study found here revealed better eradication of methane + sibo with neomycin + rifaximin. Other resources for methane:

  • Rezaie, A How to Test and Treat Small Intestinal Bacterial Overgrowth An Evidenced-based Approach. et al Curr Gastroenterol Rep 2016; 18: 8.
  • Kunkel D et al. Methane on breath testing is associated with constipation: a systematic review and meta-analysis. Dig Dis Sci. 2011;56:1612–8.

What about hydrogen sulfide gas? Can microbes make hydrogen sulfide gas? Yes, they can! You may find in individuals with hydrogen sulfide production that the breath results are completely flat-lined (meaning zeros on both hydrogen and methane levels throughout the 90 minute testing time). The microbes that make hydrogen sulfide gas use up all the hydrogen to make hydrogen sulfide so the hydrogen expelled from the lungs during the test is undetectable. I asked Dr. Pimentel a few questions about hydrogen sulfide…

Kate: Hydrogen Sulfide gas.  Would love you to  provide some info to my blog followers. Do you think testing for this is coming soon to the consumer? 

Dr. Pimentel: “While H2S is really exciting there is no device to measure this commercially yet. We are working to get one out there but not for at least a year.” 

In a recent abstract presented at the DDW meeting in Chicago in May 2017, elevations in hydrogen sulfide gas were associated with diarrhea and fatigue.  More to come as the research evolves in the gut microbiome, health/disease and diet research!

Okay…if you are still with me…

FODMAP updates: I updated my low and high FODMAP checklists. Why? Because, sadly bananas were re-tested at Monash University and found to be high FODMAP for the full ripe banana.  You can eat an unripe banana (not too many of my clients are psyched about that) BUT you can still have up to 1/3 of a ripe banana–so I added that to my updated list. Updated checklists can be printed for personal use….but if you are a FODMAP newbie–try to work with a registered dietitian knowledgeable in the low FODMAP diet to guide you. The diet is most effective when adhered to correctly.  If you are a low FODMAP diet follower or health professional seeking low FODMAP educational handouts check out my free resources here.

Oyster mushrooms tested…and are LOW fodmap…yay, for that! And did you see those little baby canned corn (the kind that you find in Chinese dishes), they are low FODMAP too! I really like the Monash U low FODMAP app to learn the latest food updates. My team at For a Digestive Peace of Mind are also in the background working on new updates for my low FODMAP grocery guide app–the goal is to add more brand name items that appear low FODMAP per ingredients–along with certified low FODMAP foods too. (All proceeds of my app are being used to provide free resources for those with IBS.)

Congratulations if you read all of this! What other science topics would you like me to cover? I am all ears.

 

 

 

51 replies on “Intersection of IBS, SIBO & the Low FODMAP Diet

  • Leslie

    I would be interested in hearing if anyone else has had gallbladder issues that might be related to their IBS/SIBO, or might be an underlying cause of some of the IBS/SIBO issues.

    Reply
    • Terri Sidell

      Leslie I unable to find the article or Dr. name at this time,but there is a Dr. on the East Coast who had found that the gall bladder & liver problems are associaed with Irritalble Bowel problems. He even could preform a surgery to correct the situation. The lady who had IBS and lectured around the Chicago area to Doctors about this problems sold Acacia Fiber to relieve the symptoms. You will have to google a lot,since we moved and can’t find her book or the Dr. who she listed on her site about finding IBS was caused by liver problems. This lady was before Kate’s time, so look for info before 2007 on Acacia Fiber & Irritable Bowel Sydrome.

      Reply
    • Terri Sidell

      Leslie,as soon as I left this site I found the lady I was referring to> Heather’s & Company on Help for IBS. She had an article on her site about a Dr. who found that liver problems caused IBS. She also recomemded the Acacia Fiber. I do not find fiber to help me,but help for my dogs who required fiber without gas. It is an easy to digest fiber. We give fiber to prevent Clostridium in dogs.

      Reply
  • Julie

    Hi Kate, this is timely. I’m just about to start a course of Rifaximin and wonder if you consider a readily available probiotic like Align to be an suitable choice during the treatment or if their are others you’d recommend. Thanks.

    Reply
  • emmie

    Kate, So many thanks for all of the work you do! This poorly understood area of health has long needed someone like you to advocate for us and bring your knowledge and understanding, not to mention recipes, to us in ways we can understand, use, and if need be use as a starting point for discussions with our healthcare providers.
    I do feel a little sad about bananas….;-)

    Reply
  • Sally Wessely

    Thank you for this. I needed to read it today because I have been chasing down symptoms for weeks. Now, where do I go from here? I will question the doctor who diagnosed my SIBO as to how she intends to treat another flare-up. I have taken xifaxan for this before. Thank you so much for your informative posts. I’m printing it out to add to my arsenal so when I talk to my GI doctor I will have a more informative base from which to start.
    Now, what will I eat for breakfast? I was eyeing a banana.

    Reply
  • Jan

    Thank you so much for all this information. I have never liked bananas but after I started fodmap, I tried one. Within 4 hours I was paying for that experiment, so no bananas for me. Your article does verify somethings I was suspicious about ( rapid onset after eating some foods) but now the question is what to do about it. I have an good working relationship with my GI so I suppose I could take this article since it is heavy on science supported theory and research and not just Dr. Google and have a deeper discussion with him regarding testing for SIBO and ABX therapy.
    I long for the days when eating was not such a stressful situation. I recently took a workshop and the host provided lunch. I had explained to her previously of my dietary restrictions. She made a vegetable pilaf with a cherry klafouti for dessert. She couldn’t have hit the mark on the head any better in terms of getting all of the offenders in one bowl. Anyway, I brought my own pretzels and a drink. Still, I can miss the socialization that goes on around food.
    I have a business trip coming up and stress over that as there are group meals every day. I already checked and found a Whole Foods near by so I can go and stock up my room with allowable foods but again, a lot of business networking goes on during meals and being the one who either gets a special meal or chose not to eat casts a pall over business discussions. The very thought of eating followed by meetings is enough to raise the panic levels.
    Yes, I do try to redirect the topic but invariably I find someone who shares they have an issue but didn’t know what it was or what to do about it. I try to at least put them on a path of discovery. Many don’t want to entertain the restrictions. I suppose they still can function with eating whatever they want without debilitating impact ( for now ).
    Thanks again for keeping us aware of options and new research. I appreciate it!

    Reply
    • Kate @ Kate Lives Healthy

      Jan,
      I totally understand the social issues. I feel really isolated over gatherings and events. I travel a lot and Go Macro bars are my go to item. I get the peanut butter ones and will pair it with some pretzels or crackers (rice cakes are a fav) to snack on as a lunch. I also bring canned tuna (wild planet has a pull tops so no can opener) and will pair it with rice or low formal veggies at dinner events if there is no other options at the meal. Go Macro makes their sunflower butter and chocolate bars in a ‘mini’ size and I always have them on hand for snacks as well. I also bring baggies of oats for oatmeal for breakfast. Hope you are able to enjoy your trip!

      Great post Kate. I took a course of Rifraximin for SIBO earlier this year and while it didn’t completely help the symptoms it made a noticeable difference. Thanks for the updates.

      Reply
  • Juanita vidaurri

    Dear Kate, thanks a million for this wonderful information! I have IBS n I’m in the low fod map diet. I’ve als have had Sibo a couple of times since I was diagnosed two yrs ago. The first time I was on xifaxan n the the other one too. I’m seeing a nutritionist. Can you please address the issue on the best probiotics for IBS. I have asked my nutritionist but she just guides me to a website. I would like to know of a specific name of one you recommend for IBS. Thank you! May God bless you as you continue to help people like me.
    Juanita Vidaurri

    Reply
  • Shari Thompson

    Hi Kate,

    Thank you for well researched information including the links and papers; M.D.s like to see references that they may trust. I particularly liked the information on hydrogen sulfide as I tested negative on all of the hydrogen breath tests. This information will go with me to my next G.I. appointment!
    Shari Thompson

    Reply
  • Peg

    Thank you Kate for this information. I’ve always wondered if my IBS diagnosis was correct. I suspect I may in fact have SIBO. I will talk with my Internist about it. Can you give us any tips about living through a colonoscopy! Those of us with either of the above do not look forward to having this exam. In fact my GI person has never been able to get all the way through the large intestine because of tight curves…I don’t want to use the word kink because that would be an entire other problem! Soon to be 74 I understand I will no longer have to go through this procedure. Any info will be appreciated.

    Reply
    • katescarlata

      Hi Peg, Incidence of SIBO increases with age–so definitely discuss w/ your internist! Some patients do have a tortuous colon–with lots of twists and turns–this can make having a colonoscopy a bit tricky for the GI doc and patient.

      Reply
  • Julie

    Your post was really informative and comprehensive! Thank you for writing it! 🙂

    My question: Is SIBO similar to IBS in that it is a chronic illness with intermittent flare ups? Once you have it, do you always have it, though there are times when it is inactive? Or is it more like the flu or other shortened illness that is treated and “cured?” I ask because I have had SIBO in the past and tested positive again for it recently. I’ve been on a modified low FODMAP diet ever since seeing you a few years ago (though I’m far from perfect). There have been no identifiable underlying causes. Is SIBO something that can be a chronic, episodic illness in some people?

    Reply
    • katescarlata

      Hi Julie, Some people (such as me) have untreatable conditions that allow SIBO to re-occur. These may include small bowel diverticula, motility disorders due to a number of conditions, surgical removal of the ileo-cecal valve (that’s what I have)–that may require episodic treatment. Others have more treatable conditions. Some patients learn they have celiac disease–even though initial tests showed they didn’t. They go on a gluten free diet, heal the gut, and the SIBO doesn’t return. There is not just one pathway–each SIBO journey can be very different from another. And try to liberalize your diet if you can.

      Reply
  • Esther

    Absolutely amazing post !
    You make a huge difference in the lives of us who struggle with these issues .. !
    Thank you Kate !

    Reply
  • Anna

    Thank you for this informative update. I tested positive via lactulose breath test, have hydrogen domininant SIBO.

    My doctor wants to start me on Rifaximin — but my insurance company says it is an “experimental” treatment, so they won’t cover it.
    Your thoughts? I want to come back around and challenge their refusal.

    Reply
    • katescarlata

      Anna, Rifaximin is unfortunately not approved by the FDA for SIBO treatment–which seems a bit crazy as it there is science showing it works for SIBO decontamination and is commonly prescribed for this reason –with a fairly low risk profile. It is FDA approved for IBS-D. So…if you have the IBS-D diagnosis–your doctor might be able to put through a request with that diagnosis.

      Reply
      • Anna

        Thank you ! This helps with understanding and opens a way to possibly get coverage. Rifaximin is very expensive. Never been diagnosed with IBS-D. I’ll ask my doctor about it.

        Got giardia several years ago, finished treatment, and since then I’ve had continuing trouble: severe gluten and milk intolerance, and two subsequent GI infections (cryptosporidium and blastocystis). Still having symptoms. Now SIBO.

  • Emily

    Hi Kate,

    Thanks for another great post! In reviewing the updated high/low FODMAP lists, I was wondering if you have any thoughts on, or experience with, dairy-free products based on pea protein (like Ripple milk or Daiya cheese)? The Monash app gives “protein supplement, pea protein” a green light, but peas are red, which is confusing to me…thanks!

    Reply
    • katescarlata

      Hi Emily–I find my clients tolerate most Daiya cheese products. If the product only has pea protein vs. the whole pea–it is likely to be lower in carbs–and hopefully, therefore, lower in FODMAPs. Remember:FODMAPs are carbs NOT protein. It’s a bit of a guessing game, unfortunately, as more foods need to be tested.

      Reply
  • Judy

    Hello Ms Scarlata. This is an excellent article. Thank you. I am new to the world of IBS and SIBO. Currently I do not have access to either a GI doc or dietician in my area that is covered by my insurance. So my MD and I are going this together by ourselves. Insurance willNOT pay for testing either. So, based on my history and what I have read, we are clinically thinking that I have SIBO. Reading this and your links, and eliminating FODMAPS as well as some of the items on the CSD I have found significant improvement of my symptoms after just about two weeks. The refaximin is prohibitive in cost as well. We are going to use the herbal approach (more to my liking anyway, since antibiotics got me into this mess to begin with!). Thank you so much for your blog posts and resources. I’ll be back many times, I am sure!:)

    Reply
  • Judy

    Hi Kate: I like your food list guides.They break the foods down differently and give another piece of information in an easy-to understand format. A couple of questions. Does the designation above the columns of foods to avoid “pulls water into the gut,” mean that food contributes to diarrhea symptoms. (I most definitely have diarrhea, never constipation). Secondly, I have read several of these list. They all are heavy on foods not readily found or used routinely in the No American diet–at least not mine. Such as clementines, durian, or paw paw or starfruit, or jerusalem artichoke. Sure, these are often available in my supermarket, but are super expensive, and rarely look appealing–old and tired. Is there a list anywhere that has a greater emphasis on American fruits and veggies, vs Australian (I understand the origin of the list, never-the-less I would like one that has more familiar foods. Thanks in advance.

    Reply
  • Rhiannon

    Great article — thanks Kate!

    In your future post, if you could help us find an acceptable probiotic that is free of —
    —gluten
    —dairy
    —FODMAPs,
    I would be most grateful.

    Reply
  • Terri Sidell

    Dear Kate,
    Enjoyed your article on Intersection of IBS ,SIBO. I am wondering is the Glucose Breath test preferred by Dr.Mark Pimentel over Lactulose the same Glucose test taken to test for Hypoglcemia??

    Reply
    • katescarlata

      No Terri, the glucose breath test for SIBO does not test for hyper(high)-or hypo (low)-glycemia. This test is evaluating gas produced only by microbes in our gut to assess for overgrowth of microbes in the small bowel.

      Reply
  • Malcolm

    Dear Kate.
    As always, you send out great articles packed with information! Thank you very much! I have never heard of SIBO, but will now read up about it, at least for another understanding of digestive issues. Unfortunately, I read to the bottom of the article and read about bananas. I eat one just about every morning. Although I don’t think they are bothering me, (I follow fodmap pretty religiously) I will try cutting down on them just to see my results. Again, thank you for your time and information!

    Reply
    • katescarlata

      Malcolm—if the bananas are not bothering you…I might consider keeping them in your diet. Work w/ your dietitian (I hope you have one!) to guide you. NO need to make your diet more restrictive than necessary, right?

      Reply
  • Leslie

    Hi Kate! (different Leslie) 🙂
    Thanks for an awesome update!! As usual you explain things in such a way that I can easily convey to my patients, and I feel very prepared with answers to the questions they are likely to ask. Thank you. How close are you to having your low FODMAP grocery guide app available for android phones? I’m one of many who are anxious to use it! Thank you Kate!!! 🙂

    Reply
  • Joy Greenhalgh

    Many thanks for the great article Kate !
    A topic I would be most interested to hear more on is the interaction of different FODMAPS. Is much known on this subject?
    There’s the relation of glucose and fructose with fructose “piggy backing” into the system with glucose.
    I read that sorbitol interferes with fructose absorption ( … making apples a bad combination of FODMAPS )
    I’ve searched for verification on the topic of the effects of sorbitol on fructose absorption but found nothing.
    Hmmmm interesting.
    Another interesting topic is fructans : I am at the re-introduction phase of the FODMAP diet. I am advised by my dietician that the body responds differently to different high fructan foods. So, unlike with the other FODMAPS, high fructan foods have to be tested individually to establish tolerance, as opposed to, for example, fructose where a test with honey will sort out ones fructose tolerance that is applicable across all high fructose foods. Is there any research as to why the body reacts differently to different high fructan foods?

    Cheers, Joy (from the UK)

    Reply
  • Suzanne Begin

    In your blog, you do not indicate who Doctor Chey is… This is essential in order to establish credibility and help me convince my doctor that this condition is real and that I need his help. I want to show the blog interview to him, but without Dr Chey’s credentials, it has much less impact… Please clarify this. I am hoping that Dr Chey is a gastroenterologist (mainstream medicine)…

    Reply
    • katescarlata

      Hi Sue, here is the info in the blog you must have missed: I asked William Chey, MD, a leading US gastroenterologist and world-renowned authority on food intolerance from University of Michigan.

      Reply
  • Aimee

    Thanks for the updates on the fodmap checklists. I have been wondering why lactaid milk and lactose free cottage cheese bother me (bad gas). Have you found that some people don’t tolerate these even though they are low fodmap?
    Also, I’m looking forward to hearing more about probiotics especially which ones are good for constipation vs. diarrhea.
    Thanks!

    Reply
  • Stephanie Sanders

    This is great info, Kate! Thanks so much for your hard work and commitment to all those folks who suffer so…you are a breath of fresh air!

    Have you found any reliable research to support the notion of drinking sixteen pounces of celery juice every morning to rebalance the hydrochloric acid in the stomach is helpful in controlling SIBO? There are some who say this is crucial for those who have not had any success with xifaxin or the xifaxin and neomycin regimens even when they adhere strictly to the low FODMAP diet….

    Would you please address this?

    Thanks in advance…

    Reply
  • Tiffany Cole

    Hi Kate. I am just starting my research on elimination dieting and fodmap to help with my symptoms. Have you ever heard of villous atrophy & possibly any good articles on how to treat it? In addition to my IBS like symptoms, I do not have these cells (villi) on the bottom of my colon to help absorb nutrients & break down certain foods & unfortunately the dr that performed the colonoscopy could not give me a reason as to why they were gone.

    Reply
    • katescarlata

      Tiffany–villi would be found in your small intestine. Have you been ruled out for small intestinal bacterial overgrowth and/or celiac? Your doctor should be able to discuss this further with you.

      Reply
  • John Harrop

    Good article – thanks.

    It would be good to have a review about small gut dysmotility, type-3 Ehlers-Danlos syndrome (hypermobile EDS) & SIBO.

    I probably have this, as does one of my daughters.

    ME: (aged 72y) – regular, sometimes quite severe IBS-type symptoms for several years before. Have had endoscopies and colonoscopies, and capsule endoscopy. Jujunal diverticulosis and colonic diverticulosis. Also developed acute inflammatory arthritis –onset age 55y. Treated with analgesics, some steroid injections, then plus NSAIDs of increasing potency, then plus hydroxychloroquine, then plus methotrexate p.o. , then plus methotrexate sc up to max dose of 25mg weekly. My joint problems were progressively getting slowly worse.
    I was anaemic (Fe and B12 deficiency – so mixed aetiology), and Vit D deficient. Have had occasional Fe infusions, regular B12 injections and oral Vit D replacement therapy.

    Finally on my own initiative about 3 years ago (and advice from my other daughter who happens to be a FODMAP-trained dietician) I started on a low-FODMAP diet. Hey presto! I can report now that my gut symptoms have slowly improved to date, and I have progressively reduced my anti-arthritis medication one-by-one and finally (and on the advice of my rheumatologist) I have now stopped ALL all my arthritis drugs and my joints are fine!
    As long as I keep to the low FODMAP diet my gut is pretty much fine as well!

    I have never had joint hypermobility, but did have POTS-like symptoms when younger. So perhaps a “form-fruste” of EDS type-3?

    YOUNGER DAUGHTER – (aged 44y) – has obvious type-3 EDS with multi-system involvement. Over many year she has seen numerous specialists in many disciplines – finally she now has a firm diagnosis. Much of her symptomatology has also dramatically improved on a low-FODMAP diet.

    – Oh! – I forgot to say that I am a retired medic and my younger daughter is a paediatrician (her 2 daughters also have type-3 EDS). There is a lesson there – all of this is complex, and no wonder it is poorly recognised by most medics!

    Much of our sufferings then have been enormously helped by a low-FODMAP diet – it has probably enabled my daughter to keep going as a busy Dr in acute paediatrics. We are truly amazed by the help that our diets have been to our well-being!
    We assume that we have SIBO due to gut hypomobility/paresis and deficient GI neuroregulation, and that the FODMAP-induced changes in the gut microbiome have had a major effect on our multi-symptomatology. Many of our medical advisors/colleagues (but not all!) agree.

    A piece about EDS / gut dysmotility / SIBO / low-FODMAP from you would help spread thoughts about the inter-relationships of these issues, and perhaps stimulate more research which is sorely needed!

    Sorry this is such a complex story, & perhaps rather boring to many!!

    A big question for us now is concern about the effects of a very long-term, even life-long, low FODMAP diet. I must add we both take supplements (B-100, Vitamin C, Chelated Mg, and Bio-Kult).

    Best Wishes
    John Harrop.

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  • Stephanie

    Kate, did you personally retest for SIBO after your treatment? Or did you just go by symptoms and maintain a low FODMAP diet? I am concerned retesting could provoke a relapse.

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