Improvements In Sibo Research
You know, to be honest, this was a bad year 2020 was a bad year for COVID and all the other things everybodys experiencing. So obviously, to your listeners, I wish everybody well. But on the SIBO front, this has been a fantastic year because we had the SIBO guidelines in February. We have the huge paper from the Australian group summarizing that patients have SIBO. Full-stop, definitive 25-page study meta-analysis, and that really has been a major factor in swaying the medical community again.
We had the cover of a journal article. Im not boasting about our particular findings, but we finally know what the small bowel microbiome looks like. And this was over the summer that made the cover of the journal because its such a provocative first-time-ever finding of what is the small bowel microbiome. And then this all helps with the development of new drugs. So knowing what bugs were talking about and where theyre located is a game-changer for how we develop the drugs of the future. And were working on that right now. I cant give you pie in the sky promises yet because were just doing some clinical trials and we dont know until we know. But Im very optimistic for next year. I think were making amazing progress now.
Chris Kresser: So the idea with that new drug development is to make the drugs both more selective and more effective as a result?
Chris Kresser: All right, take care.
Better supplementation. Fewer supplements.
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On To The Food And Diet Related Questions
First, I have to say that many people asked great questions during the Cedars IBS Chat. So many that Dr. Pimentel did not get to answer all of them . However, he did answer over twenty-five questions and provided us a lot of great info in the process.
Because some of the questions covered information already known, Ill only be recapping those questions that I felt provided new or especially interesting info. But Id encourage you to go back and read all the responses if you have time. Ive also broken this recap up into several posts, because there is just too much information to digest in one post .
Digestion-related puns aside, lets get started
Vegetarian Sibo Bi Phasic Diet By Dr Nirala Jacobi And Anne Criner
Following many requests to develop a vegetarian version of the SIBO Bi Phasic Diet, Dr Nirala Jacobi joined forces with nutritionist Anne Criner to develop a vegetarian version of the protocol. Using soaked and sprouted grains and legumes, this diet also includes some soy products, such as tofu and tempeh to provide non-animal protein sources for vegetarians and vegans.
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What Is The Sibo Specific Diet
It is a combination of the Specific Carbohydrate Diet otherwise known as SCD, and Low FODMAPS diet. SCD was developed by Elaine Gottschall, a biochemist and a biologist who wrote the book Breaking the Viscous Cycle. She developed the diet for treatment of Crohns disease, ulcerative colitis, celiac disease, diverticulitis, cystic fibrosis and chronic diarrhea. FODMAP stands for Fermentable, Oligo-, Di-, Mono-saccharides And Polyols. This diet was developed by Gibbson and Sheppard at Monash University for treatment of Irritable Bowel Syndrome.
The Specific Carbohydrate Diet Was Created Over 100 Years Ago
for use in treating ulcerative colitis, Crohns disease, and celiac disease . But, it was made popular in the 1980s by Elaine Gottschalls book Breaking the Vicious Cycle. The theory behind the SCD diet is that particular types of carbohydrates promote inflammation and increase the number of bad gut bacteria. This then causes nutrients and vitamins not to be absorbed. This sounds similar to the process seen in SIBO, hence the thought behind using it to treat SIBO..
The SCD eliminates most carbohydrates to starve the displaced bacteria in the small intestine. The SCD diet excludes many foods, including rice, potatoes, quinoa, and legumes. It also removes processed meats and added sugars.
On the SCD, the recommended foods to eat are most fruits, vegetables, eggs, fermented dairy, and meats. There is a precise protocol to follow that does not allow for flexibility.
In a recent double-blinded study comparing the Low-FODMAP diet to the SCD diet in IBS patients, participants following the low-FODMAP had a greater reduction in symptoms . No studies are looking specifically at using the SCD diet for SIBO.
In my opinion, this diet is tough for people to follow, very restrictive, and time-consuming. Does it help some people in my experience? Yes, but I would not typically recommend it as a starting point. In addition, if it is used, it should be done under guidance to assure nutritional balance.
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There Are Literally Hundreds Of Different Diets Recommended For Small Intestine Bacterial Overgrowth
which means it can be really overwhelming and confusing to get started.
Should you try low-FODMAP or Elemental? Gluten-free or low-fermentation? Vegan or all meat? Should we be eating to feed the gut bugs or starve them? Are apples allowed or are they forbidden?!? HELP!
People ask me about this all the time, so today I want to help cut through all the clutter and talk about the Big 6 diets for SIBO these are the diets that I hear recommended from the top practitioners most often.
Here are the diets Im going to cover:
Before I dig into the diets themselves, Ill briefly talk about what diet can and cant do, and why diet is used in SIBO treatment.
What Is The Low Fermentation Diet
The low fermentation diet has been designed to reduce symptoms of SIBO through changes in meal timings and avoidance of fermentable foods.
Foods which are low in fermentable carbohydrates are easy for our gut to digest and do not create excess gas. In contrast, when we eat fermentable carbohydrates, bacteria breaks them down in a process known as fermentation, producing excess gas.
Below are some examples of foods allowed and should be avoided on the diet .
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What Is A Sibo Diet
The purpose of a SIBO diet is to temporarily reduce the amount of fermentable carbohydrates in your diet to help improve your SIBO symptoms. By its very nature, a SIBO diet should not be followed long-term and most doctors recommend the maximum amount of time spent on a SIBO diet plan should be 6 months.
To understand how a SIBO diet plan can be useful at calming down your painful and embarrassing SIBO symptoms, lets look at what happens when you eat food and how the bacteria in your small intestine interact with it.
Sibo Specific Food Guide By Dr Allison Siebecker
The SIBO specific food guide was developed by leading SIBO practitioner Dr Allison Siebecker for her patients after years of clinical experience treating thousands of SIBO patients.
Combining the Low FODMAP Diet and Specific Carbohydrate Diet, Dr Siebecker uses a traffic light system to segment foods that are low , moderate and high in fermentable carbohydrates. As this diet was designed specifically for SIBO patients, it can be beneficial for those who are currently suffering from moderate to severe symptoms. It restricts both foods and quantities of foods .
However, the green, yellow/amber and red colour code system and words legal and illegal can be triggering for people who are disordered with food. Plus, it requires people to self-regulate and decide when to move onto higher fermentable foods. SIBO patients can get stuck in the green column for too long, causing further damage to their microbiome. Dr Siebecker hasnt updated the diet since its inception, so doesnt include current practises around some food groups.
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Will My Sibo Come Back
Unfortunately, our understanding of SIBO and how to effectively treat it is still evolving. Even with effective treatment, SIBO has a recurrence rate of 44%. Again, I believe this dismal statistic has a lot to do with the fact that killing overgrowths has been the almost exclusive approach to SIBO until more recently.
To reduce the risk of recurrence, its important to use antibiotics and antimicrobials judiciously, to use SIBO specific antibiotics when needed, address the more global gut dysfunctions listed above, and to eat a plant rich diet that feeds a diverse microbiome.
Steps to Reduce Risk of SIBO Recurrence
The Specific Criteria Of What Counts As Paleo Varies
The paleo diet is less well-defined than low-FODMAP or SCD diets. In general, the paleo diet eliminates grains, dairy, and processed foods. It also limits sugars. There are no studies looking at the paleo diet as a SIBO intervention. But, it does limit carbohydrate intake significantly and many patients with SIBO say they feel better on a paleo diet.
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Sibo Bi Phasic Diet By Dr Nirala Jacobi
Australia’s leading SIBO specialist, Dr Nirala Jacobi, took the SIBO Specific Food Guide and divided it into two phases, hence the name ‘Bi-Phasic’, as she wanted more structure and guidance on what to eat and when to eat it for her patients. SIBO diet Phase 1 is the most restrictive, and is used to help calm digestive symptoms. This phase is used prior to treatment commencing. Phase 2 introduces more fermentable carbohydrates and allows for greater quantities of certain foods, and is used in conjunction with antibiotic or herbal antimicrobial treatment. This is the protocol my SIBO Cookbooks are based on. This protocol works well for people who prefer structure and rules to their treatment plan, and who like to be told what to do.
One risk is that SIBO patients can stay in Phase 1 for too long, which can be damaging to the broader microbiome. The strict rules around this SIBO diet plan can also be triggering for anyone with disordered eating. It is a meat-heavy protocol, so is not suitable for vegetarians and vegans.
Histamine Sibo Bi Phasic Diet By Dr Nirala Jacobi And Heidi Turner
For many people with SIBO, histamine intolerance is also part of their healthcare puzzle. Dr Nirala Jacobi and Dietician Heidi Turner joined forces to create a low histamine version of the SIBO Bi Phasic Diet. This protocol is intended to be used short-term to help calm down a histamine flare and is very restrictive.
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How To Use Dietary Treatments For Sibo
- As the main treatment for SIBO, without antibiotics or other treatment. Diet alone may provide enough symptom relief that no other treatment is desired. However if malabsorption or leaky gut is present, other treatment is advised. Diet will likely be needed to long-term with this approach.
- In combination with antibiotics or herbal antibiotics, for symptomatic relief and added benefit.
- As a therapy to allow the damaged SI lining to heal after eradication with antimicrobial treatment. The lining may need time to repair from the damage of SIBO before it can properly digest all foods. 1 month is the recommendation for this purpose.
- As relapse prevention to stop the overgrowth from recurring. In this case, ongoing use is encouraged, but diet can be more expanded.
Low Fodmap Diet By Monash University
The Low FODMAP Diet was developed by Dr. Sue Shepherd and Dr. Gibson from Monash University as a dietary treatment for people suffering from Irritable Bowel Syndrome . It restricts certain types of carbohydrates: Fermentable Oligosaccharides, Disaccharides, Monosaccharides And Polyols . They are found naturally in many foods and are a collection of short-chain fatty carbohydrates that are not absorbed easily in the gut, which can trigger symptoms.
While not designed specifically for SIBO, it can be used successfully by SIBO patients who have mild symptoms, as it is less restrictive than the other SIBO diet plans. It does still include starches, resistant starches and fibre though, which can be problematic and symptom-inducing for SIBO patients. It is a great diet for vegetarians and vegans, as there are plenty of options for them to eat.
Monash University have released a Low FODMAP app, which contains the most current and accurate information on the diet protocol. There is a fee to download the app, but it is worth the investment to ensure you have the most current information.
The app uses a traffic light system to show low, moderate and high levels of Fructose, Lactose, Mannitol, Sorbitol, GOS and Fructans by serving size. This is handy when determining how large a portion size needs to be, or if you need to avoid only one of these carbohydrates.
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Sibo And Low Fermentation Diets: Yes Or No
I read an interesting paper about using a low-fermentation diet for SIBO. This diet comes out of a laboratory at Cedars-Sinai Medical Center.
I dont agree with all of the recommendations out of this diet. For example, it recommends against yogurt, and yet, in my experience, yogurt is one of the best foods to help clean up the gut. Of course, Im talking about high-quality, sour, Greek yogurt, not the artificially sweetened industrial type that fills the supermarkets. The yogurt I eat contains plenty of beneficial bacteria. Most of the lactose has already been digested by bacteria.
Ive yet to meet a sick person whose gut cant tolerate a teaspoon of yogurt. Ill often start with that dose. If even that amount is hard to tolerate, well work on cleaning up the diet in a different way.
The low-fermentation diet describes rice, potatoes, and sweet potatoes as the best carbohydrates for SIBO. Thats true but they should also clarify that it is best to cook these carbs first and then bake or fry them the next day. This allows the starch to become more digestible. If you have a gut issue, baked rather than boiled or mashed potatoes are much more tolerable.
Further readings:
Although chocolate is deemed acceptable on the low-fermentation diet , I disagree. Dark chocolate is fine for healthy people, but if your gut is giving you any trouble, Id stay away.
Treatment Considerations For H2s
Chris Kresser: Great. Okay, so what about treatment considerations for hydrogen sulfide? You mentioned that with hydrogen, we now know its mostly E. coli and thats leading to some drug discovery and ideas about other options aside from rifaximin that might be useful. Do we know anything about that with hydrogen sulfide? Does it require a different approach? Or are you just using rifaximin and the typical approach with hydrogen so far?
So we dont know exactly how to treat hydrogen sulfide yet. We know from the historical literature that hydrogen sulfide could reduce, for example, with bismuth. So there are people who are trying bismuth or other therapies with some success. But I cant give you a conclusive answer on whats the ideal treatment for hydrogen sulfide yet. Were working on that. And hopefully, well have some answers again in the coming weeks or months, because were avidly treating these patients and trying to see what works.
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I Have Sibo How Do I Treat It
The most important thing to keep in mind is that SIBO isnt just a single infection needing a single treatment. So just taking antibiotics and going back to living your life will not work in most cases.
SIBO is an imbalance that likely developed over months or years due to multiple factors. And, if you want lasting relief, youll need to devote several months to addressing all of the contributors in a holistic way using a combination of the diet, supplements, lifestyle, and medications outlined below.
Conventional Medical Treatments for SIBO:
Antibiotics, two in particular, have shown to have great results in the treatment of SIBO. These appear to be more effective in the small intestine, have less collateral damage in other parts of the gut, and to be less likely to promote antibiotic resistance like traditional antibiotics do.
- Rifaximin for Hydrogen-predominant SIBO
- Rifaximin + Neomycin combination for Methane-predominant SIBO
- Treatment for Hydrogen Sulfide SIBO hasnt been well established, but a combination of the above plus bismuth seem to be the most promising medication approach to date.
Prokinetic agents are often given alongside antibiotics to help move things through the gut more quickly and reduce risk of feeding the bacteria.
Natural Therapies for SIBO:
First and foremost, dont jump right to killing microbes!
- A diet rich in a variety of plant fibers as well as animal foods with limited sugar and processed foods
- Stress management
Popular SIBO Diets :
Getting A Dietician Can Be Just As Good As Low Fodmap Diet
This one is really interesting. The BMJ Study the participant mentions gave IBS patients a diet tailored to the individual patients food sensitivities as measured by a leucocyte activation test. The control group followed a fake elimination diet not tailored to the patients results. After four weeks, the patients with individually tailored diets reported statistically significant improvements in their IBS symptoms. Its worthwhile to note that the control group also saw reductions in symptoms but not to the extent of the individually tailored diet group.
An individually tailored diet allows you to hopefully eat a wider range of food than the standard low FODMAP diet allows. The more foods youre allowed to eat, the better for your general health. Also, if you know what youre actually reacting to, youre more likely to reduce your symptoms. Win-win. Working with a knowledgable dietician can make a real difference.
Dr. Pimentel doesnt say this in his tweet, but the other takeaway is that testing for food sensitivities can also be helpful. The study mentions that some food the patients reacted to were low FODMAP foods! So its important to actually know what youre reacting to because otherwise youll needlessly restrict yourself.
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