What is SIBO?
Smal intestinal bacterial overgrowth (SIBO) occurs when there is an abnormal increase in the overall bacterial population in the small intestine — particularly types of bacteria not commonly found in that part of the digestive tract.[1]
This condition should rather be considered a symptom, since everyone with SIBO has a root cause, and solving this root cause is the key for curing SIBO.
- Abdominal surgery
- Structural issues – Intestinal Adhesions, Intestinal Diverticulosis, injury to the small intestine, and an abnormal passageway between two segments of bowel, surgically created blind loops, resection of ileocecal valve, Gastric Resection
- Overuse of antibiotics, which have dysbiotic effects
- Overuse of PPIs
- Food poisoning
- Motility disorders - Gastroparesis, Hypothyroidism, certain medications (opioids, PPIs), IBDs, Celiac Disease, Gastroenteritis, Lyme disease, Ehler's Danlos, history of eating disorders
- Metabolic disorders – Diabetes, Hypochloridria
- Organ System Dysfunction – Cirrhosis, Renal failure, Pancreatitis, Immunodeficiency states, Malnutrition, Radiation Enteritis, Scleroderma, HIV, AIDs
- Altered bile flow and enzyme production
- Insufficient Immunoglobulins in the small intestine
- Stress
Without treating the cause, SIBO will likely recur after treatment.[4]
How do you know if you have SIBO?
While SIBO has many giveaway symptoms, you need to have a lactulose test (which shows you the levels of methane or hydrogen – some cases sulphur) to rule out other conditions, such as Small Intestinal Funghal Overgrowth (SIFO), IBS, ulcerative colitis…
The symptoms include:[5]
- Loss of appetite or increased appetite
- Abdominal pain and cramps
- Nausea
- Diarrhoea or constipation
- Excessive bloating and distention
- Depression, mood swings, headaches, and irritability
- Extreme hunger or cravings
- Recurring urinary tract infections
- Pneumonia
- Weight loss and malnutrition
Bile salts, which are needed to digest fats, are broken down by the excess bacteria in your small intestine, resulting in incomplete digestion of fats and diarrhoea. Bacterial products may also harm the mucous lining of the small intestine, resulting in decreased absorption of carbohydrates and proteins. Bacteria can compete for available food. And compounds produced through the bacterial break-down of stagnant food can also trigger diarrhoea. Together, these effects of bacterial overgrowth result in diarrhoea, malnutrition and weight loss.[6]
- Brain fog
Probiotic use can lead to the development of D-lactic acidosis, which itself has been linked to brain fogginess, among other symptoms, in some patients with short bowel syndrome.[7]
- Autoimmune conditions
The gut microbiota can be considered to be a fully functional organ of the body. Occasionally, the host relationship with the microbial residents of the gut has few defined boundaries. Thus, comes the issue of the commonality of epitopes of the gut residents and the human body. It is possible that under certain conditions, some gut microbes can give rise to autoimmune conditions.[8]
- Vitamin deficiency
As a result of incomplete absorption of fats, your body can't fully absorb the fat- soluble vitamins A, D, E and K. Bacteria in the small intestine synthesize as well as use vitamin B-12, which is essential for the normal functioning of your nervous system and the production of blood cells and DNA. The overgrowth of bacteria can result in B-12 deficiency that can lead to weakness, fatigue, tingling, and numbness in your hands and feet and, in advanced cases, to mental confusion. Damage to your central nervous system resulting from B-12 deficiency may be irreversible. Poor calcium absorption may also eventually result in kidney stones and osteoporosis.[9]
- Insulin resistance and weight gain
SIBO weight gain may be due to inflammation and dysbiosis within the gut, insulin resistance, or dietary preferences due to digestive discomfort.[10]
Methanogens have been shown to affect caloric harvest by increasing the capacity of polysaccharide-eating bacteria to digest polyfructose-containing glycans, which leads to increased weight gain in mice.[11]
It has previously been demonstrated that SIBO was related to diabetes gastrointestinal symptoms and autonomous neuropathy. This study demonstrated that T2DM combined with SIBO patients showed the worst glycaemic control and a lower level of insulin release compared with patients without SIBO. This suggests that the presence of SIBO in T2DM subjects could be associated with the beta-cell function. [12]
Treatment
Treatment options vary from individual to individual, since everyone has a different root cause and different overgrowth. The most common treatment is antibiotic, which have high relapse rates and 50 % efficiency. [13] The most important part of treatment is finding your root cause and fixing it.
Fixing the root cause
1. Low stomach acid (hypochloridria) [14]
Stomach acid plays two important roles in your body: breaking down food and killing harmful microbes that you ingest.
What causes hypochloridria?
- Proton pump inhibitors (PPIs) – medications used for the treatment of heartburn and acid reflux that work by blocking stomach acid production e.g. omeprazole, esomeprazole, lansoprazole, …
- Helicobacter pylori – a type of bacteria which survives in the stomach by secreting an enzyme that neutralises stomach acid. H. pylori infection causes gastritis, which leads to less stomach acid production.
- Autoimmune gastritis – an autoimmune disease where the immune system destroys the acid producing cells in the stomach called parietal cells.
- Thyroid issues – low stomach acid is common in both hypothyroidism and hyperthyroidism. Also, stomach acid is needed for the absorption of the thyroid medication, l-thyroxine.
How to fix it?
- Stopping PPIs (if you can)
- Treating H Pylori
- Apple Cider Vinegar, which has a similar pH to stomach acid of around 2.5. It has proven side effects including oesophageal injury meaning this is a likely unsafe treatment method.
- HCl Acid Tablets
2. Gut Dysmotility
If our digestive system is healthy, the migrating motor complex (MMC), a pattern of gut contraction, moves bacteria from the small intestine into the large intestine during fasting. If MMC function is impaired, bacteria are not cleared from the small intestine correctly, increasing the chances of developing SIBO.
Non addictive options include herbal teas, ginger root or artichoke extract. Popular remedies are Magnesium Citrate, MotilPro or Motility Activator. If these fail to help, prescription medication like prucalopride and itopride are recommended.
3. Altered Bile flow
Bile and enzymes are both needed for food digestion. Proteolytic enzymes and bile acids also have anti-bacterial effects, helping to protect our gut against bacterial overgrowth. Without sufficient enzymes, carbohydrates may not be broken down sufficiently, providing fuel for bacteria to overgrow. Without the protective effects of enzymes and bile acids, there is an increased risk of developing SIBO.
This can be fixed by eating food that promote bile, such as ACV, lemons, limes, bitter herbs, ginger, turmeric, cinnamon, artichokes, radishes, beets, chicory or rocket. Most of the time medication like ox bile, digestive enzymes and TUDCA are beneficial.
4. Insufficient Immunoglobulins
The presence of bacteria associated with SIBO can cause a weakening of the natural defences of the gut lining and Secretory IgA, allowing increased access of the materials present in the gut into the blood stream, including toxins. How can we fix that?
L Glutamine[15]
The gastrointestinal epithelium plays big role in digestion, absorption and secretion. It also works as a barrier to the diffusion of toxins, allergens and pathogens into the interstitial tissue. Barrier disruption and diffusion of noxious substances are known to induce mucosal inflammation and tissue injury. The disruption of gut barrier function plays a crucial role in the pathogenesis of many gastrointestinal diseases such as IBD, IBS, Celiac Disease and Infectious Enterocolitis.
Mucosal protective factors such as growth factors and nutrients preserve the gut barrier integrity and are beneficial in the treatment of various gastrointestinal diseases. L-Glutamine the most abundant amino acid in blood plays a vital role in the maintenance of mucosal integrity. Its consumption in small bowel mucosa exceeds the rate of production during catabolic stress such as trauma, sepsis and post-surgery. In the small bowel mucosa, glutamine is a unique nutrient providing fuel for metabolism, regulating cell proliferation, repair and maintaining the gut barrier functions
Colostrum [16]
Research studied effects of bovine colostrum, egg, or the combination, on bacterial growth. Bovine colostrum overcame the issue of weakened gut lining by strengthening the gut cells and maintaining their natural cell-cell contact proteins, preventing excessive leakage of luminal contents through the layer of the gut lining that act as a natural barrier. Using bovine colostrum on its own was shown to be just as powerful as using it in combination with egg.
Doctor Playford: “While the bovine colostrum did not directly kill the bacteria in this study, it did strengthen the natural gut barrier against the stresses of bacteria. I am hopeful more studies will be conducted to further explore the health benefits of bovine colostrum for SIBO and leaky gut.”
5. Stress
Stress interferes with our digestion and gut motility. When stressed, our body produces less stomach acid, leading to reduced bile secretion and enzyme production, both of which contribute to SIBO. Stress can also weaken the immune system, allowing for overgrowth of bad bacteria.
Stress relieving methods target the vagus nerve, such as yoga, massage, meditation, deep breathing, walking, and focusing on the vagus nerve. When it comes to digestion, the vagus nerve is a big player. It stimulates contractions in your digestive tract, helping move food along smoothly. So, if your vagal nerve tone is healthy and strong, your digestion is likely to much more efficient as well. [17]
6. Surgery
Some digestive system abnormalities, such as a bowel obstruction, Diverticula, or Crohn´s disease can, in some cases, be treated through surgery.
Herbal treatment
Herbal treatment is shown to be at least as effective as antibiotics[18], and due to the rising antibiotic resistance of many bacteria, is has become a popular method. Many companies have created expensive yet effective combinations of various herbs, which are efficient at killing SIBO, such as Candibactin AR/BR, Biocidin, FC Cidal, Dysbiocide…
In a study comparing herbals and antibiotics, 251 of the patients had a positive Lactulose Breath Test (LBT), 165 underwent treatment and 104 had a follow up LBT. Of the 37 patients who received herbal therapy, 17 (46%) had a negative follow-up LBT compared to 23/67 (34%) of rifaximin users. The odds ratio of having a negative LBT after taking herbal therapy as compared to rifaximin was 1.85. Fourteen of the 44 (31.8%) rifaximin non-responders were offered herbal rescue therapy, with 8 of the 14 (57.1%) having a negative LBT after completing the rescue herbal therapy.
Oregano Oil[19]
Oil of oregano possesses remarkable antimicrobial properties, which make it highly effective in limiting bacterial growth. It exhibits inhibitory effects on various bacterial strains, reducing the risk of bacterial infection. It can cause digestive issues, so a slow-release ADP version is recommended.
Studies have shown that oil of oregano has the ability to downregulate the expression of genes involved in biofilm formation and extracellular polysaccharide synthesis. Biofilms are communities of bacteria that are highly resilient to antibiotics and contribute to the persistence of infections. By inhibiting biofilm formation, oil of oregano prevents the spread and growth of bacteria.
Furthermore, research has indicated the significant inhibitory effects of oil of oregano on bacterial strains. At concentrations as low as 1/2 MIC, it can inhibit up to 80.89% of biofilms. At the MIC concentration, it inhibits 89.71% of biofilm formation. These findings highlight the potent antimicrobial potential of oil of oregano against different bacterial strains.
Oregano powder had a mild effect on the microbial cell cultures increasing Enterococcus faecium, rearranging ratios of members in the genus Lactobacillus and significantly reducing the genus Streptococcus. Beneficial short chain fatty acids (SCFA), acetic and butyric acid, were also significantly increased in oregano powder supplemented cultures.[20]
Allicin
Allicin is a biologically active component of garlic which you can buy as a supplement. It has high antimicrobial effects and immune boosting effects which allow the body to fight against the bacterial overgrowth. Make sure you buy a pure form of Allicin without any FODMAPs. What's special about allicin is that this is what treats the methane, methanogenic archaea or in layman's terms - bacteria. These bacteria are tough to kill and need different antimicrobials to kill them.
Berberine complex [21]
Berberine is a compound found in Oregon grape, barberry, goldenseal, and other herbs. Berberine has been shown to reduce the relative abundance of BCAA-producing bacteria, including Clostridiales; the families of Streptococcaceae, Clostridiaceae, the Streptococcus genera, and Prevotella.
Neem extract
Neem is a tropical evergreen tree which can kill many bad bacteria, including gram-positive Staphylococcus aureus and gram-negative E. coli.
Atrantil
Atrantil is a pill which if highly effective against methanogens. It contains 3 components, each targeting different aspects of the digestive health. It contains M. balsemea Wild extract (peppermint) for calming your bowels, Quebracho extract to soak up hydrogen and weaken the bacteria, and Saponin/flavonoid in order to reduce methane production by eliminating the methane producing bacteria. It is important to know that it may take up to 20 days of using the product before seeing the effects.
Other herbs have been rising on their popularity, such as Pau d´arco, Grapefruit Seed Extract, Black Seed Extract, or Turmeric.
Probiotics
Many people with SIBO feel worse because of probiotics, which makes me wonder if it could be a die off reaction. Many probiotics have been shown highly effective against bad bacteria, which cause SIBO. Which bacteria are those?
A study[22] concentrating on people with SIBO detected these bacteria:
-Streptococcus (71%; 6.4 ± 0.8),
-Escherichia coli (69%; 7.2 ± 0.9),
-Staphylococcus (25%; 6.2 ± 0.6),
-Micrococcus (22%; 6.0 ± 0.7),
-Klebsiella (20%; 7.1 ± 0.8),
-Proteus (11%; 6.1 ± 0.8)
for microaerophilic bacteria, and
-Lactobacillus (75%; 6.1 ± 1.1),
-Bacteroides (29%; 6.9 ± 1.3),
-Clostridium (25%; 5.5 ± 1.0),
-Veillonella (25%; 5.3 ± 0.7),
-Fusobacterium (13%; 4.8 ± 0.5),
-Peptostreptococcus (13%; 6.1 ± 0.7)
for anaerobic bacteria.
Other common bacteria include Salmonella, Shigella, Citrobacter, Enterobacter, and Yersinia, archaea are methanobrevibacter. Why is it important to know? Because most of these can be targeted with certain probiotics.
Proteobacteria
To directly target Proteobacteria, you first need to identify the specific bacteria that are overgrown. The most common Proteobacteria overgrowths are Desulfovibrio, Sutterella, Parasutterella, Bilophila, Klebsiella, and Escherichia. In clinical practice, the following therapeutics may lower these bacteria:[23]
Sutterella: berberine, Bacillus subtilitis
Parasutterella: berberine, Bacillus coagulans
Klebsiella: berberine, neem, oregano, thyme
Escherichia: berberine, neem, oregano, thyme
Desulfovibrio: codonopsis, garlic, inulin, Bacillus coagulans
Bilophila: chamomile, garlic, inulin, Lactobacillus rhamnosus GG
Staphylococcus aureus is an opportunistic human pathogen that is infamous for causing community- and hospital-acquired infections. When S. aureus unfolds its pathogenic nature, it can cause many pathologies, including infections of the skin, wounds, soft tissues, bloodstream, bones and lungs. In addition, the contamination of food products with S. aureus may lead to serious cases of gastroenteritis.
From the gut, S. aureus can in principle reach other body sites through translocation across the mucosa and epithelium. This may relate to increased intestinal permeability caused by regular epithelial regeneration, diminished gut health due to inflammatory disorders or infection, or surgery. Alternatively, S. aureus translocation may follow active damage of the epithelium through the secretion of inflammatory compounds, allergens or toxic products. For example, in patients with intestinal bowel disease (IBD), there is an increased intestinal permeability that triggers a cascade of events resulting in increased bacterial growth and risk of sepsis.
Decolonization—eliminating the symptom-free bacteria—could prevent harmful S. aureus infections. Previous decolonization strategies have used topical antibiotics or antiseptics to get rid of S. aureus from the nose or skin. These efforts have had limited success, likely because they don’t affect S. aureus in the gut. Decolonizing the gut would require oral antibiotics. But this risks harming the beneficial gut microbes that usually help prevent infections. It could also lead to more antibiotic resistance.
Bacillus subtilis, secretes molecules that inhibit S. aureus colonization. An oral probiotic containing live B. subtilis spores eliminated S. aureus from the guts of mice. This suggested that probiotics might decolonize S. aureus from the human gut without the risks that go with antibiotics. After four weeks of probiotic treatment, S. aureus in the stool, a proxy for gut S. aureus, declined by 97%. S. aureus in the nose declined by 65%. Between the effects on these two sites, the researchers estimated that probiotic treatment got rid of at least 95% of S. aureus in the human body.
Streptococcus[26]
Streptococcus agalactiae (Group B Streptococcus, GBS) is a Gram-positive bacterial species that causes disease in humans across the lifespan. While antibiotics are used to mitigate GBS infections, it is evident that antibiotics disrupt human microbiomes, and antibiotic resistance in GBS is on the rise.
Studies based on the use of the intestinal probiotics Lactobacillus rhamnosus GG, Lactobacillus reuteri, and Bifidobacterium have each reported achieving reduced levels of Streptococcus mutans.
Specific Probiotic Strains
Bifidobacterium
Control of Klebsiella pneumoniae pulmonary infection and immunomodulation is done by oral treatment with the commensal probiotic Bifidobacterium longum. [27]
Bifidobacterium spp. play an important role in regulating the intestinal immunity and intestinal barrier. Bifidobacterium animalis ssp. lactis HY8002, selected from eight Bifidobacterium strains by in vitro experimentation, had exceptional resistance to digestive tract conditions and high adhesion to intestinal epithelial cells and a positive effect on immunoglobulin A (IgA) secretion by Peyer’s patch cells.[28]
Lactobacillus
Lactobacillus plantarum can reduce the different members of the Enterobacteriaceae family.[29] It competes with pathogenic bacteria for space and it can reduce numbers of Shigella, Enterobacter and Klebsiella.
Lactobacillus reuteri is a probiotic that has shown benefit in reducing the numbers of different members of the Enterobacteriaceae family, parcitulary the strain DSM 17938.
In a study on people with cystic fibrosis, Lactobacillus reuteri managed to reduce Proteobacteria phylum from 32.6% ro 10%.[30] Another study showed a reduction of these bacteria after 1 months of Lactobacilus reuteri:[31]
- Diarrheagenic E. coli
- Salmonella spp.
- Cronobacter sakazakii
- Klebsiella pneumoniae
- Enterobacter aerogenes
- Enterobacter cloacae
- Serratia odorifera
- Hafnia alvei
- Klebsiella oxytoca
The same strain has been shown to significantly reduce methane levels in the gut.[32] With just one month of taking Lactobacillus reuteri methane levels were consistently decreased and constipation was improved in 20 patients,
Lactobacillus Rhamnosus GR-1 can kill E. coli and can disrupt biofilms produced by these microbes.[33]
Bacillus
Bacillus are soil-based probiotics and generally well accepted even with SIBO.
A study[34] using Bacillus clausii to treat SIBO patients had 40 SIBO positive patients. They were given the Bacillus clausii probiotics three times daily for thirty days. One month after the probiotics ended, each patient retested for SIBO using the same glucose breath test. 47% of the patients had cleared the SIBO confirmed by negative, or normal, breath tests.
Bacillus Clausii also helps modulate your immune response, assists in IgA synthesis, is antibiotic resistant and produces bactarin, which fights pathogens.
Bacillus Coagulans helps the good bacteria colonize in your gut and has been studied in people with IBS, Crohn´s and ulcerative colitis.
Bacillus Subtilis supports gut repair by increasing IgA and butyrate AND produces over 12 antibiotics.
Sacharomyces boulardii[35]
This yeast is highly effective in both SIBO and SIFO. A possible role for S. boulardii in managing pathogenic activity was associated with a protective effect of S. boulardii against pathogenic bacteria in yeast-treated mice, although the mode of action is not associated with a reduction of the pathogenic population, as well as with another study which observed a protective effect against Candida albicans in a murine model.
As a yeast, Saccharomyces boulardii can be taken alongside antibiotics and its functioning is unaffected. It has known anti-inflammatory effects in the gut and can inactivate pathogenic toxins and stimulate enterocyte (cells of the intestinal lining) maturation.
In a pilot clinical study[36] of 40 patients diagnosed with SIBO due to the autoimmune condition, systemic sclerosis, the effects of Saccharomyces boulardii on hydrogen production and SIBO eradication was assessed and compared with metronidazole, a common antibiotic used in the treatment of SIBO. The patients were divided into 3 groups; one group were given metronidazole alone for 1 week, another group were given metronidazole with Saccharomyces boulardii for 1 week and the third group were given Saccharomyces boulardii alone for 1 week. Two months later, hydrogen breath tests were repeated. The group that achieved the best results was the metronidazole and Saccharomyces boulardii group, with SIBO eradicated in 55% of participants at 2 months. Saccharomyces boulardii therapy alone eradicated 33% which was better than the group given metronidazole alone with just 25% SIBO eradication.
Elemental Diet[37]
An extreme form of trying to starve the bacteria is the Elemental Diet (ED), which provides you with every nutrient you need, while starving the bacteria and keeping your MMC going. For a period of up to four weeks, meals are replaced with a powdered formula of nutrients in pre-digested, easily absorbed form. It has an eradication rate of 80% and reduces high gas levels in one 2-week course, reducing the need for multiple rounds of antibiotics or herbals.
You can buy pre made EDs, which are very costly, or make your own (https://www.siboinfo.com/uploads/5/4/8/4/5484269/homemade_elemental_diet_options.pdf)
If you buy one, make sure to buy a Dextrose free version, since many people ended up with Candida or increased SIBO levels because of the sugar feeding the bacteria. Some options include:
Elemental Heal Whey Free (Functional Medicine Formulations)
ElementAll - Chocolate (elemental diet)
ElementAll - Pink Lemonade (elemental diet)
Physicians Elemental Diet and Physicians Elemental Diet-Dextrose Free (Integrative Therapeutics)
Elemental Nutrition and Keto-Elemental Nutrition (Vita Aid)
Vivonex Plus (Nestle)
Biofilms
If you´ve had SIBO for a long time, the bacteria likely surrounded themselves with biofilm, a microbialcommunity consisting of bacteria, extremely capable to self-reproduce on biological surfaces. These biofilms are resistant to classical antibacterial treatments and host immune response. You should take biofilm disruptors before and during your treatment to make sure the bacteria doesn’t go into hiding.
A widely used biofilm buster is NAC, N-acetyl-cysteine. One study, for example, showed that NAC, in combination with different antibiotics, significantly promoted their permeability to the deepest layers of the biofilm, overcoming the problem of the resistance to the classic antibacterial therapeutic approach.[38]
Other natural biofilm busters are Tumeric Curcumin, Allicin, ACV, vanilla beans, Oregano Oil, Pomengrate, Cinnamon. Well-known brands of quality biofilm busters are Kirkman Labs Biofilm Deffense, Klaire Labs Interfase, Plus Balance One SerraDefend, Jarrow Formula Lactoferrin or Sovereign Labs Curium.
Dietary Changes
Although almost everyone says you should go on a diet, no studies have been made.
So, what are the options?
Low FODMAP – This diet is designed to help people with IBS and, possibly, SIBO. You eliminate FODMAPS and figure out which foods are problematic and which foods reduce symptoms. FODMAP stands for fermentable oligosaccharides, disaccharides, monosaccharides and polyols, which are short-chain carbohydrates (sugars) that the small intestine absorbs poorly. The Monash University tested many foods and made a safe list. (https://www.ibsdiets.org/fodmap-diet/fodmap-food-list/).
Carnivore – Eating only meat and eggs in an attempt to starve the bacteria. You might end up starving your good bacteria as well. Some attempt to do the carnivore diet, eating nothing but meat and eggs, and get a negative test in a few months. Some need up on square one after months on this diet after eating normal food again. This shows that everyone is different and what works for others may not work for you.
Low Fermentation – Limiting how favorable the gut environment is to bacterial overgrowth. It consists of foods that bacteria aren’t likely to metabolize and ferment—without restricting carbohydrates entirely so that patients can maintain the protocol long-term. (https://goodlfe.com/pages/lfe-sibo-food-list)
SCD - Specific Carbohydrate Diet eliminates carbohydrates from your diet. This eases symptoms of digestive disorders. People who follow a specific carbohydrate diet don’t eat grains or grain products. The diet is also very low in sugar and lactose. (https://www.siboinfo.com/uploads/5/4/8/4/5484269/scd_food-list.pdf)
Some dietary interventions have been used in clinical practice for the treatment of small bowel bacterial overgrowth (SIBO). However, the available evidence to support such approaches is of low quality and scarce. Thus, the treatment of SIBO must be focused on controlling the underlying disease and observing the improvement in symptoms presented by the patient, as so far there is no specific diet for the treatment of SIBO.
A few studies have evaluated diets in the treatment of SIBO. However, the studies are of low methodological quality, making extrapolation of the results to clinical practice unfeasible. Thus, there is still not enough scientific evidence to support a specific type of diet for the treatment of SIBO.[39]
If you look online, every article or blog recommending these diets states they will not cure you. Here are a few examples:
“Foods to Avoid. There's currently not enough evidence to suggest all people with SIBO benefit from excluding specific foods from their diet.”
“There is no perfect SIBO diet, and you may need to experiment. Most diets reduce down fibre to control symptoms. But treatment is key.”
“If you're using a low-FODMAP diet to keep your small intestinal bacterial overgrowth (SIBO) under control, you're not alone.”
Many practitioners have different opinions on what to and not to eat. Dr. McDougall[40], a propagator of a Whole Food Plant Based (WHPB) diet, claims his diet can cure SIBO and SIFO, besides helping you lose weight.
Here is a snippet of his SIBO article, it is worth a read.
“Most people think of bacteria as dangerous and dirty. Our intestinal tracts contain a complex and diverse society of disease-causing (pathogenic) and "friendly" bacteria, referred to as our "microflora." In addition to digesting remnants of our meals and synthesizing vitamins, the helpful bacteria play an important role in the development of the immune system and the production of hormones. In short, "friendly" bacteria prefer to dine on plant-food remnants, and pathogens thrive when the diet is low in plant foods and high in meat, poultry, dairy, eggs and other "junk food."
Therefore, what we choose to eat determines the predominance of the bacteria species that will live in our gut. By switching from a diet based on animal foods and highly processed foods to a whole food, plant-based diet, you can suppress the growth of harmful bacteria and stimulate those that are beneficial. Major alterations in the microflora take place within one to two weeks of changing a person's diet.
Bowel bacteria are fundamental players in the cause of diseases as apparently dissimilar as coronary artery disease and IBD. The intestinal bacteria that grow from a diet of meat, dairy, and eggs contribute to development of atherosclerosis by producing trimethylamine, which is then oxidized into an artery-toxic substance. Both meat and milk have been shown to cause the growth of bacteria that produce toxic sulfur-based compounds that damage the cells of the intestine, causing IBD.”
He goes even further and says restricting carbs is a bad idea.
“Over the past 10 years, diets that restrict foods high in specific carbohydrates (not all carbohydrates) have become popular. The most popular SIBO treatment diets are the Specific Carbohydrate Diet and the Low FODMAP Diet. However, other diets blaming specific sugars for bowel problems are cropping up.
The rules for these diets are very complicated, and thus, they are difficult
to follow. Any benefits achieved, I believe, are simply due to patients paying closer attention to what they eat in general, resulting in the elimination of junk foods, such as cookies, cakes and candies. I would not promote the approaches of restricting specific carbohydrates even if they worked, because these diets continue to promote the consumption of animal foods and vegetable oils, and fail to emphasize the central importance of starch in the prevention and treatment of common Western diseases, including most bowel diseases.
For example, IBS, as discussed above, is "a condition of chronic abdominal pain or discomfort and diarrhea, constipation, or alternating bouts of the two." Consider that cow's milk (the protein) is a very common cause of constipation, and fats and oils themselves can cause severe diarrhea. Both the Specific Carbohydrate and the FODMAP diets allow dairy proteins as well as fats and oils. Plus, these diets promote foods entirely lacking in dietary fibre (animal foods and oils). Fiber, synthesized by plants only, makes up the bulk of a bowel movement. Fiber deficiency results in small, rock-hard marbles that are passed infrequently into the toilet, requiring body-damaging straining.
What we eat and, therefore, send down into our intestine can cause disease not only of this organ, but the entire body. Over the past 35 years, underdeveloped countries, such as Asia (where rice is a staple food) and Central America (where corn and beans are staples), have switched to diets high in meat, dairy, and vegetable oils. These "newly rich" populations have, with a change of their diets, developed epidemics of diabetes, obesity, cancers, and bowel diseases.
One recent study found 92% of people with Crohn's Disease maintained in remission of their disease for two years with a semi-vegetarian, mostly rice, diet. More information on IBS and IBD is found on my website. My experience with more than 6,000 patients in my live-in programs has found that the first organ to respond to a healthy diet is the intestine. Constipation, GERD, and acid indigestion are usually gone within two days.”
It is true that people with IBS often benefit from a WHPB diet. Irritable Bowel Syndrome (IBS) is a chronic condition that affects the large intestine, causing symptoms very similar to SIBO. No wonder that 4% between 70% of people with IBS suffer with undiagnosed SIBO. [41]
In 2018, the American Gut Project released the largest study of the microbiome[42] to date and found that subjects who ate more than 30 different types of plants (including whole grains) in a week had significantly healthier gut microbiomes compared with those who ate 10 or fewer types of plants each week, with more beneficial gut microbes and fewer harmful microbes.
Studies [43]show that compared with people eating an animal-based diet, a plant-based diet increases microbiota diversity in part because it provides more fibre. Fiber is considered a first-line therapy in treatment recommendations for patients with IBS, according to the 2021 American College of Gastroenterology clinical guidelines.
A WFPB diet rich in fibre helps to produce short chain fatty acids, which is the key to building a robust gut microbiome. Fiber adds bulk to stool, speeds up its transit through the colon, and can help regulate bowel movements.
Nutritionist Angela Pifer says that eating FODMAPs does not make SIBO worse.
“I think the problem is that, anytime people eat FODMAPs and see a reaction, especially with SIBO, they think SIBO is getting worse. “ ... but the symptoms are affected, SIBO is not getting worse. On the studies that we look at, three weeks or four weeks, six weeks on a high FODMAP diet, methane does not get worse and hydrogen doesn’t go up. So it’s just the symptoms. The fear is that SIBO is getting worse. They’re going to keep restricting and restricting. At the SIBO Symposium this year, they had a lovely nutrition track. Half that track was around anxiety around food, fear around food, and eating disorders. I’m not saying that everyone that’s on a FODMAP diet has an eating disorder by any means. When you put somebody on that restrictive of a diet, and they get on that for a long period of time, there’s going to be food fear. It’s going to be disordered eating to a degree because of all of the anxiety being bred.”
Dr. Mark Pimentel, professor of medicine and director of the MAST program at Cedar-Sinai in Los Angeles, California, an international expert in SIBO and IMO, says low FODMAP is unhealthy.
“The low FODMAP diet is unhealthy. Now, some of your viewers may not like me saying that. But even those who purport the low FODMAP diet or discover the low FODMAP diet recognize that you have to have a reintroduction phase because it’s going to hurt people over time potentially.
This was presented at the American College of Gastroenterology about a month and a half ago where they showed the people who were sustained on a low FODMAP diet for more than three months started to have measurable nutritional deficiencies. You can’t stay on low FODMAP forever, period.”
Dr. Michael Ruscio has a unique approach and says low FODMAP is nothing to be scared of.
“We learn about how gut bacteria are important, how important it is to feed your gut bacteria and have high levels of diversity. While all that is true, sometimes, what ends up happening is people hear about the low FODMAP diet and how the low FODMAP diet can starve bacteria, and then they get scared that I shouldn’t go on a low FODMAP diet because it’s going to starve my gut bacteria or cause me to lose gut bacteria and they’re supposed to be so healthy. People are very confused about what to do.
To say it very simply, I would not be concerned at all—no, I shouldn’t say “at all.” I would not be very concerned about a low FODMAP diet impact on your gut microbiota. Let me outline a few reasons why that is.
One, there’s been a few studies [that] essentially found that a low FODMAP diet has the ability to help the serotonin cell density—so the number of serotonin cells that you have in the gut—become more like that of healthy controls.
Now, we don’t have any studies yet that have studied the motility effects of the low FODMAP diet. We can’t fully say that this is translated all the way through to a clinical endpoint. However, at least the initial mechanism data that we have is promising that there is reparative utility to the low FODMAP diet.
But not only that, there’s been at least one study that has shown that leaky gut decreases on a low FODMAP diet, and as I mentioned, before another study showing a decrease in histamine on a low FODMAP diet.”
Is the diet needed?
A good approach would be focusing on whole, natural foods, and considering your biggest triggers from high-FODMAP foods that may exacerbate SIBO symptoms.
Bacteria are good at staying alive in worst conditions possible, so they can feed off everything. For example Staphylococcus and Streptococcus feed on glucose from blood,[44] E coli grows by consuming carbon dioxide instead of sugars or other organic molecules, and Klebsiella likes mostly simple starches. Another proof of why diet alone is likely not going to work.
Sources:
[2] https://www.mayoclinic.org/diseases-conditions/small-intestinal-bacterial-overgrowth/symptoms-causes/syc-20370168
[6] [6] https://www.mayoclinic.org/diseases-conditions/small-intestinal-bacterial-overgrowth/symptoms-causes/syc-20370168
[7] https://www.gastroendonews.com/In-the-News/Article/11-18/Probiotics-Linked-to-SIBO-Brain-Fog-/53211?sub=7DAE272E12332BB231CEB25B51BC96728A663097A4796AA32D2E38D7B33BC&enl=true
[9] https://www.mayoclinic.org/diseases-conditions/small-intestinal-bacterial-overgrowth/symptoms-causes/syc-20370168
[19] https://medium.com/@health101/5-things-you-must-know-before-using-oil-of-oregano-for-strep-throat-e6d13287a14d
[25] https://www.nih.gov/news-events/nih-research-matters/probiotic-blocks-staph-bacteria-colonizing-people
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