I know the title looks like alphabet soup, but this is really important stuff. I’d go so far as to say that this could be the missing link for many GPers when it comes to improving symptom management. So if you feel like you’re “doing everything right” and you’re still struggling with symptoms, please read on.
What is SIBO?
SIBO stands for small intestinal bacterial overgrowth. It’s also sometimes called small bowel bacterial overgrowth or SBBO. It all means the same thing: there are bacteria in your small intestine that are not supposed to be there.
What causes SIBO?
One of the biggest risk factors for SIBO is… slow gut motility. Muscular contractions within the gut are supposed to sweep things, both food and bacteria, through the GI tract. When it doesn’t, bacteria can take hold and multiply in places where they don’t belong. This is bad news for GPers, of course, and even worse if you’re chronically constipated, as bacteria may migrate upward from the colon to the small intestine, as well.
What’s more, it’s thought that protein pump inhibitors (PPIs), which many GPers are immediately prescribed, may encourage the growth of bacteria by limiting (or even eliminating) the anti-bacterial effects of acid in the stomach.
What symptoms does SIBO cause?
Gut bacteria has been found to play a role in everything from allergies to mood disorders to obesity, but the GI symptoms of SIBO are largely a result of the gas that bacteria produces when it “eats.” (See below for more about how what you’re eating affects bacteria.) Bloating, distention, burping, and passing gas are common symptoms.
Bowel changes, either diarrhea or constipation, as well as malabsorption and unintentional weight loss may also result. For people with functional disorders like GP or hypersensitivity, the excess gas in the GI tract can also cause abdominal pain or cramping.
(Lots of people have asked me why GP causes so much bloating and distention. I’ve wondered this myself many, many times. I’ve never had a good answer, but I think I have one now… maybe it’s not so much the delayed emptying as the bacterial overgrowth that results from delayed emptying.)
How is SIBO diagnosed?
The most widely available test for SIBO is a Hydrogen Breath Test. At the beginning of the test, you drink a solution that will “feed” bacteria if they are present, causing them to release gases. Your breath is measured for these gases over the course of several hours (usually 3). That’s it! The drawback is that this test is not 100% accurate and may be even less so for those delayed gastric emptying, as the test counts on the solution being in the small intestine after 3 hours.
I also recently learned that a high level of folate in your blood may indicate bacterial overgrowth. (Mine was very high; hence the breath testing today!)
Some doctors will treat SIBO empirically, meaning based on symptoms and presentation alone. If symptoms improve with treatment, it’s likely that SIBO was an issue.
How is SIBO treated?
Most of the time bacterial overgrowth is treated with antibiotics, preferably Xifaxin (rifaximin), which works only in the intestine and therefore has fewer potential side effects. There is also an herbal protocol for the treatment of SIBO, which was developed by Dr. Gerad Mullin at Johns Hopkins.
Aside from medical treatment, dietary changes are an important part of managing bacterial overgrowth. If the underlying cause of the overgrowth, slow motility, for example, isn’t resolved, then the bacteria may regrow. Eating foods that feed bacteria will make this more likely.
How do FODMAPs fit in?
FODMAPs are fermentable carbohydrates that are often malabsorbed. When we consume FODMAPs, they become fast food for bacteria exacerbating symptoms like bloating, gas, pain, etc. You may notice a reduction in your symptoms just by reducing the FODMAPs in your diet. After treatment for SIBO, a low-FODMAP diet will help to prevent a regrowth of bacteria.
Unfortunately some of the foods highest in FODMAPs are the ones that many people think of as GP-friendly staples. The things your doctor probably told you to eat when you were first diagnosed. Low-fiber wheat products (white bread, crackers, pasta, cereal, pancakes, etc.), applesauce, pears, and dairy products like skim milk, low-fat yogurt, and frozen yogurt. Many of the meal replacement drinks also contain FODMAPs in the form of FOS, inulin, or chicory root.
Is it possible to follow a low-FODMAP GP-friendly diet?
It takes some extra effort and attention, but it is possible to follow a GP-friendly diet that’s also low in FODMAPs. The good news is this will force you to ditch the “white stuff” that I’ve warned against before. What’s more, addressing SIBO and reducing the FODMAPs in your diet may actually reduce your overall symptoms and allow to eat a wider variety of foods.
Do all GPers have SIBO and/or need to follow a low-FODMAP diet?
No. If your comprehensive management plan is working for you and you’re feeling good, then it’s probably not something you have to worry about. But if you feel like you’re doing everything “right” in terms of managing your GP but your symptoms remain — or continue to get worse — an overgrowth of bacteria and a diet that continues to feed them may be to blame.
I recently recorded a Q&A with Kate Scarlata, Registered Dietitian and FODMAP expert. This will help you better understand which foods may be problematic and how to start reducing FODMAPs in your diet.
To download the FODMAP Q&A with Kate Scarlata click the button below (it’s free!).