SIBO: Diet, Testing, and Natural Treatments
What is SIBO?
Small Intestinal Bacterial Overgrowth (SIBO) is a bacterial infection of the small intestine.
Calling it an “infection” can be misleading, because bacteria is always present in the small intestine. The main issue with SIBO is having too much bacteria of a certain species of bacteria, such as normal small intestinal flora, pathogenic bacteria, or normal flora from another bodily region like the large intestines.
SIBO Causes
Stress
Surprisingly stress could be the number one cause of SIBO as one of the biggest inhibitors of SIBO recovery and cause of relapse. Our gut is linked to our brain through the gut-brain axis and is the reason it is often referred to as “the second brain.”
During times of stress our brain sends signals to our gut to basically slow down digestion. Specifically stomach acid production drops and motility (movement of the colon) shuts down. Add stress’s negative effect on immune function and increased inflammation, you literally have the perfect storm for creating and maintaining bacterial overgrowth.
Antibiotic Use
Antibiotics doesn’t just kill pathogenic bacteria but also our healthy normal flora. When antibiotics are taken frequently especially without probiotics bacteria that normally doesn’t reside in our gut has the opportunity to create a new home and overcrowd our normal flora.
A normal healthy gut flora balance prevents invading bacteria through crowding and the release of substances that blocks attachment of harmful bacteria. So when healthy bacteria numbers drop, bad bacteria literally has room to grow leading to SIBO.
Low Stomach acid
Our stomach’s make acid for a reason to break down proteins and absorb B12. The resulting acidic environment serves another purpose; it is unfavorable to the bacteria we don’t want.
When stomach acid decreases whether it is due to stress, age, prolonged vegetarian or vegan diet or use of proton-pump inhibitors, our stomach pH rises allowing bacteria to survive and eventually enter the small intestines leading to SIBO.
Poor Immune Function
Normally the immune system of our gut does an excellent job of keeping out invading bacteria. A healthy immune system will control bacteria in the small intestines by secreting mucus containing immunoglobulins.
If our immune system is compromised due to stress, immune suppressive drugs, nutrient deficiencies, or poor sleep, then the bacteria we don’t want can easily overgrow.
Dysmotility
Another major cause of SIBO is dysmotility, which when the muscles of the digestive system become impaired and are no longer able to empty contents efficiently. This allows contents to get trapped and bacteria to attach to the wall of the small intestines. Basically when you have a large amount of food waste sitting in your small intestines not moving, bacteria can easily proliferate wreaking havoc.
This is why supporting motility is crucial for recovering from SIBO and preventing relapse. Motility is the movement of digestive system controlled by the rhythmic schedule known as the migrating motor complex (MMC) which emits cleansing sweeps along the colon. Dysmotility can be the result of stress, inflammation, and conditions such as hypothyroidism, diabetes, and lupus.
SIBO Symptoms
Classically the symptoms of SIBO can be confused with IBS (irritable bowel syndrome) or other gastrointestinal conditions such as ulcerative colitis and Crohn’s disease. Symptoms of SIBO include:
Constipation
Diarrhea
Acid Reflux
Gas and Bloating
Abdominal pain
Cramps
Hiccups
There are many other symptoms of SIBO that seem unrelated to the gut, including:
Nutrient Malabsorption
Acne, rosacea and other skin conditions
Mood changes: Anxiety and Depression
Restless legs syndrome
Hair loss
Endometriosis and other gynecological conditions
SIBO Treatment
SIBO Natural Treatments
Natural treatment of SIBO includes herbal antibiotic formulas, biofilm disruptors and natural prokinetics. Patients also follow a two part SIBO specific diet for during the eradication and rebuild phases. In some cases, incorporating a 10-14 day elemental diet may be necessary.
SIBO Supplements
Herbal antibiotics have been shown to be as effective in eliminating SIBO as conventional antibiotic treatment. These herbal antibiotics are not just as effective but also have fewer side effects and relapse rates.
The most commonly used herbs used for SIBO include: garlic, berberine (from Oregan Grape), neem, wormwood, blackwalnut, olive leaf and oregano.
There is one thing to note about garlic, especially to those concerned about FODMAPS (Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols). The compound of garlic used is allicin which besides being a very potent antimicrobial does not ferment so it can be tolerated even on a low FODMAPS diet.
Biofilms formed by bacteria as a protective shield must also be broken up by using specific enzymes and chelating agents. A natural prokinetic formula is added to support motility. Some of the main ingredients of these formulas include ginger, 5-HTP, magnesium, artichoke, jujube, chamomile, greater celadine and milk thistle.
SIBO Diet
Normally a combination of the Low FODMAPs diet and Specific Carbohydrate Diet (SCD) Diet is considered best while treating SIBO. The low FODMAPS diet which was originally developed as the dietary treatment of IBS restricts the amount of fermentable sugars/sugar alcohol containing foods, thus reducing intestinal fermentation.
The SCD limits complex carbs (disaccharides and polysaccharides), lactose, sucrose and artificial ingredients. These ingredients are harmful to the digestive system and lead to yeast overgrowth, bacteria overgrowth, and inflammation.
This diet strategy is important because it decreases the amount of fermentable foods which cause unfavorable bacteria to not only proliferate but to produce the gases which make SIBO so problematic.
In some cases however, an elemental diet may be necessary for complete recovery from SIBO. The elemental diet alone without supplements or antibiotics can sometimes be enough to bring about cure. Basically the elemental diet is a bowel reset diet in which only predigested nutrients are consumed in liquid form. This prevents the body from starving while the bacteria is starved off. Patients can use either pre-made physician grade formulas or make their own.
Foods To Avoid
Seed oils including sunflower, sesame seed and canola
Starchy vegetables
Dried fruit and fruit juice
Animal dairy products
Sweeteners (artificial and natural including cane, agave, maple syrup, etc)
Grains
Beans and lentils
Most vegetables and fruits are to be consumed at specific limited quantities as per practitioner recommendations
Testing/Diagnosing SIBO
Despite what you might have heard, stool testing cannot diagnose SIBO because the results of this rest mostly reflects the large intestine, and not the small intestine. A stool test can suggest whether there is a bacterial overgrowth in the large intestine and help to fat malabsorption due to SIBO.
The gold standard for diagnosing SIBO is the 3 hour lactulose breath test and must include both hydrogen and methane. It has to be 3 hours because it takes time for hydrogen and methane to travel through the gastrointestinal tract, into the blood and eventually out the lungs as breath. Lactulose must be used rather than glucose in order to diagnose SIBO in the last 17 feet of small intestine since glucose is not absorbed in this region.
SIBO Hydrogen Breath Test
Any breath test that only includes hydrogen without methane is not complete and could easily result in a false negative. As many as 8-27% of people with SIBO will not have detectable levels of hydrogen.
Archaea bacteria which happen to be abundant in many people who suffer from IBS-C (IBS with constipation), actually feed off of hydrogen and produce methane as a byproduct. Then there are some bacteria like Staphylococcus aureus, Streptococcus viridans, Enterococci, Serratia, and Pseudomonas that produce methane instead of hydrogen.
Antibiotics for SIBO
Rifaximin (generic: Xifaxan) and Neomycin (added in addition to Rifaximin in the case of methane-dominant SIBO) are the most common antibiotics used to treat SIBO as they are non-systemic, meaning they are not absorbed in the bloodstream and remain in the gut.
The normal course of antibiotic treatment is 10-14 days. Unfortunately, a single round of antibiotics is not enough to cure SIBO and many patients will require as much as 4 rounds.
A huge draw back of antibiotic treatment for SIBO is the high recurrence rate. This is often due to a failure in identifying the root cause of SIBO, lack of prokinetic for motility during and post treatment, and not starting the correct probiotic and gut healing after care following treatment.
SIBO Risk Factors
Stress
History of antibiotic use
Use of proton pump inhibitors(PPIs) and other acid reflux medications
Some anxiolytic (anti-anxiety) and antipsychotic medications
Diabetes
Parkinson’s Disease
Thyroid disorders
Lupus
Hormonal Birth control
Book an appointment
At Simplicity Health Associates in New York City, we help many patients with SIBO.
Click here to book an appointment online or call (646) 470-8458. You can also email us here.
Is Naturopathic Telemedicine effective for my SIBO?
Absolutely! Even before the pandemic Dr Ivy has offered virtual appointments to patients for various reasons including international and out-of-state patients, patients with small children, patients with mobility or transportation issues and patients preferring the convenience of having their appointments from their home or office. These patients have been able to achieve the same results as Dr Ivy’s in-office patients as Dr Ivy uses:
A HIPAA compliant electronic medical records system called CHARM
Patients can upload past diagnostic and blood work as well as recommend additional testing including the DUTCH test for review.
Uses a private and secure version of Zoom.
An online Dispensary for patients to easily order physician grade herbs and nutrients that are quickly delivered to the patient.