When I was diagnosed with small intestinal bacterial overgrowth back in 2003, there was very little talk about the condition called, SIBO. SIBO presents with symptoms that mimic IBS, especially upper GI bloating and distention after eating. I am grateful that testing is becoming more available (though, we still have a way to go!) and more importantly that more GI docs are willing to order testing. The research continues to expand in this area.
Experiencing SIBO is not a walk in the park. Like IBS, SIBO can stop you in your tracks. Many sufferers are able to function (barely) but getting through the daily grind can be challenging. Eating exacerbates SIBO symptoms and humans need to eat! This can be a conundrum for the person diagnosed with SIBO. It is easy to be swayed into limiting your diet to a very restrictive diet that results in weight loss and possibly malnutrition…but your body needs good nutrition to heal from the infection and your don’t want to starve ALL the bacteria.
Some patients switch up their diet and consume very little carbohydrate and large quantities of protein. The problem is …protein ferments too —and the by-products of protein breakdown in the intestine may in the end, be more damaging… potentially leading to inflammation in the gut. In animal studies by-products from protein: ammonia, phenols, amines and hydrogen sulfide are associated w/ intestinal permeability, DNA damage, inflammation & cancer. The diet needs some balance!
There is NO one evidenced based diet for treatment of SIBO. Modifying fermentable carbohydrates, our gut microbe’s favorite food source, is generally recommended. This can be achieved in a number of ways. Mark Pimentel’s group uses the low fermentable diet, I tend to recommend the low FODMAP diet and others suggest the specific carbohydrate diet, GAPs and/or paleo.
What diet is best for SIBO? The answer is, we don’t know. In my humble opinion, I feel the diet should be the least restrictive as possible to manage symptoms. I look forward to the time when we have more nutritional research to provide evidenced based nutritional guidelines for SIBO. I do think that the diet may need to be individualized based on the person’s microbiota. Different microbes ferment different food substrates—and we all have our own gut microbial footprint. In clinical practice, I find the low FODMAP diet works well for most, BUT, there is not enough research in this area to prove that diet alterations will prevent SIBO from relapsing.
Addressing and fixing the underlying causes of this condition, when possible, is the goal.
- Did you suffer from food borne illness which may lead to partial small bowel paralysis? You may benefit from a prokinetic therapy such as low dose erythromycin or even the herbal supplement, Iberogast.
- Have you been on long-term PPis? PPis increase the pH (lower acidity) of the small bowel and are associated with slowing down small bowel motility. Is it possible to reduce your dose or discontinue? Of course, work with your gastroenterologist to find what is best for you.
- Are you chronically constipated? Methane producing microbes are associated with slowing down bowel motility, when undergoing breath test for SIBO, be sure both hydrogen and methane gas production is evaluated. Methane gas is associated with constipation and reduction of methane gas improves constipation. (Chatterjee, S et al Am J Gastro 2007;102:837-841;Ghoshal, UC et al J Neurogastroenterol Motil 2011;17: 185-188) Patients with methane +SIBO have better outcomes with dual therapy antibiotics as sometimes using rifaximin alone is often not enough.
- Do you suffer with pancreatic insufficiency? Checking stool elastase to evaluate for insufficient pancreatic enzyme production is a good test to rule this out. Perhaps you may need pancreatic enzymes to help your body digest food.
Want to learn more?
I am excited to speak at the Gut Microbiome Conference in Huntington Beach, California, at the end of September 2016 on food and the gut microbiome! I attended this conference last year and it was fantastic! I look forward to learning again from the other top speakers about the microbes that reside in our gut and how they play a role in SIBO, IBS and other health conditions. One topic that I find very interesting is how alcohol can be created in the gut by our microbes! Also, Mark Pimentel’s group has a Global Outreach SIBO symposium coming in November 2016, click below to register or learn more!
For now, here are a few tools to help you navigate a SIBO diagnosis and upcoming programs to consider attending to learn more:
- A recap from the SIBO conference I attended in Portland, Oregon at the Natural College of Natural Medicine back in 2014. Although this info is 2 years old, it still applies.
- Understanding potential causes of SIBO, one of my past posts .
- My $10 SIBO review of all the information I have gathered which can serve as a great handout for health professional or patient use, purchase here.
- Upcoming programs: 2016 Global Outreach Symposium on IBS & SIBO, register here! and the Gut microbiome conference, click here.
Sherr curtis-cramer
Hi Kate, I’m grateful for your willingness to research and discuss your findings on this blog.
I was really interested in the article regarding (BAD) bile acid diarrhea. I have been diagnosed with IBS-D but can’t help but wonder if BAD is causing my intestinal problems. I was prescribed cholestyramine which seems to help a great deal. Do you know of any long term side effects that can occur as a result of long-term use of this product?
katescarlata
I don’t know of any long term side effects–perhaps you doctor or the pharmacist can weigh in on that. But the potential risks might be far less than having bile lurking in your colon–where it doesn’t belong!
Alison Pounds
Thank you for posting! I was just diagnosed with SIBO. I think I tested positive for both hydrogen & methane. Is that possible? And what does that mean?
katescarlata
Yes, it is quite possible to have overgrowth of microbes that make hydrogen and others that make methane. If the methane is > or equal to 10 PPM during the first 90 minutes–you may need to have dual antibiotic therapy to eradicate the methanogens.
Alison Pounds
Thank you, Kate! My methane was 22 at 90 minutes so I will definitely ask my doctor about dual antibiotic therapy!
Alorie
I have been diagnosed with the methane kind of SIBO. MYgastro put me on Rifaximin for 10 days. I felt better for a while, but all the symptoms came back with a vengeance. When my gut is off, I feel terrible all over. I am now working with a physician at Canyon Ranch (a specialist in digestive issues). She put me on an herbal treatment, but I had a bad reaction to it. I have been on PPTs for acid reflux for some time, which may account for my getting SIBO. I have been working hard to get off Omeprazole, which I have succeded in doing. I am down to 150 mgs of Rinitadine at night and 75 in the morning, plus 2 DGL before each meal. I am taking garlic supplements (odd for someone on the FODMAP diet mostly) and melatonin, which is also supposed to help with digestion. I am feeling better, but I am certainly not SIBO free. I am thinking of the antibiotic combo which might help with everything else I am doing. This is certainly a nasty affliction, and so little is really known. I just have to keep trying.
Sarah
Thanks for this post. Diet can be very confusing when it comes to SIBO. Have you researched the Fast Tract Diet for IBS at all? It limits fermentable carbs. A lot of people seem to find this one more effective than low fodmap. The author claims that it can possibly treat SIBO on it’s own. It sounds great but I am concerned with some of the things you have mentioned above. If you are familiar with it, I am curious as to what your thoughts are on it?
katescarlata
Hi Sarah—I am familiar with the Fast Tract Diet for IBS—and I think the concept of fermentation potential of foods is creative and interesting—but it falls short in some areas–for instance, onions and garlic are big symptom triggers for individuals with IBS and SIBO–though they measure on the low side of fermentation potential as they have relatively low amounts of carbs…but the type of fiber is rapidly fermentable by gut microbes. I think it makes the process of eating more complicated than it needs to be—and although may individuals treat their sibo successfully–be careful of books that make claims… they might not have research to support.
Alison Pounds
Hi Kate,
I just finished my second round of antibiotics (Rifaxan & Flagyl). I felt so much better towards the end of this round of antibiotics but now a few days later my symptoms have all come back. What was your healing process with SIBO like? Is this just normal that my gut could still be off even if the SIBO is gone or is the SIBO probably not gone if all my symptoms have come back? I’m feeling pretty discouraged.
katescarlata
Sorry to hear this, Alison. It could be that the treatment was not long enough. But, also, it is essential to try to determine why the SIBO occurred in the first place. If you are chronically constipated–it will just come back. If you have slow motility of the small bowel–often the case–then you need a prokinetic to keep the small bowel clear of bacteria. Does your GI doc have a good understanding of SIBO? That is so important. Are you spacing your meals every 2-4 hours?
Alison Pounds
I am actually seeing my primary care doctor for SIBO because he is the only one that suggested testing me for it. So, I think he is at least somewhat knowledgeable about it considering all my other doctors hadn’t even heard of it. I am spacing out my meals. I asked him about a prokinetic the last time I saw him & he said he’s hoping one of the other supplements he has me taking will do the same thing. I can ask him about it again when I go back. Are there any other medicines that you know of that could be helpful in getting rid of SIBO?
katescarlata
Alison–prokinectics such as low dose (50 mg) erythromycin can work–or Iberogast—to help motility. But, again–it is essential that the cause(s) of the SIBO are assessed and treated. If you are constipated–you will may need a bowel regimen w/ either magnesium or miralax—and maybe physical therapy. If you have small bowel inflammation–then you would need to identify the cause and treat. I would suggest you see a GI and dietitian to help guide you—-or you will just relapse and not move forward.
Kate
Alison Pounds
Thanks, Kate! Do you know any dietitians to recommend in the Nashville, TN area? The dietitian I was seeing didn’t know anything about SIBO or FODMAPs.
katescarlata
Alison, A colleague provided the names of 2 dietitians in Nashville that might be a good fit for you: Nan Allison or Katherine Fowler–I believe they are both in private practice.
Alison Pounds
Thank you, Kate!
Barbara Horn
Can I use corn starch to thicken broth,I am very new to Fodmap I have crohns for 50 yrs.please I need help.
katescarlata
corn starch is not a FODMAP, Barbara!
Kate Lents
Hi Kate,
I have SIBO and so far cannot take an antibiotic. My insurance has denied Xifaxin and I am in waiting mode for 2 weeks to hear from my GI. He said just do the low Fodmap. I printed your low Fodmap grocery list and have been using it, however, I have found several low Fodmap lists and none are the same. I am eating the Erewhon cereal but found out I cannot have any grains, cereal included. I am at a loss where to go or what to eat. I am also now a Vegan because of a casein allergy. So my only protein is Garden of Life Organic plant formula protein powder that is gluten free, soy free, diary free, sugar free….. I have looked for a nutritionist in the Tampabay area but so far no luck with any that know SIBO. Do you or your contacts have any suggestions in this area for a good nutritionist? Also, I am at a loss at which Fodmap list to use. What is your suggestion? I have had SIBO for a couple of years but was just officially diagnosed from the breath test a month ago. Thank you so much for your help!
katescarlata
Kate, it certainly sounds like you need to be working with a GI dietitian. Check out Gastrogirl.com and see if you can find a dietitian there that could work w/ you remotely.