The SIBO Saga: Part 4

sibo4Disclaimer:  As I have said in the past, I’m not a research blogger.  I’m here to mix “data with soul” and give you useful info, but only in the context of my real, human experience.  That is not to say that citation on my part and proper follow-up on your part are not important.  Everything I wrote about in this blog was presented by Dr. Allison Siebecker, ND at the SIBO Symposium during January 2014 and you can pay to have access to those presentations through the National College of Natural Medicine’s website.

We are almost done with the SIBO series this week (just one more to go).  I’m writing about diet for SIBO today.  This particular subject is pretty much the heart of the series for me.  I think it is the thing folks most want to know about (next to antibiotic treatment) & thanks to Dr. Allison Siebecker, one of the most straight forward subjects under the SIBO umbrella.  If your GI Specialist does not talk about diet while treating you for SIBO, frankly, I think you should find a new doc.  At very least, you should put yourself on a food regimen while being treated, since diet can have an enormous impact on symptom reduction.

Dr. Siebecker did an awesome job with this presentation at the symposium.  She was very well-organized and detailed, while still being concise.  Have I mentioned that she’s my SIBO heroine?  Okay, enough with the gushing, let me get to the info!  She started by addressing reasons patients would use diet for SIBO in the first place.  First, along with a prokinetic (when indicated), the right diet is essential to recurrence prevention.  Second, diet can be used during treatment to manage symptoms.  Finally, diet can be used to decrease extra-intestinal symptoms (symptoms that are outside the digestive system, like brain fog) and improve overall health.

She next went on to re-emphasize that her experience shows diet alone will not treat SIBO in adults.  I think this point is really important, because I hear from so many people that don’t want to use medications and think they will kill the overgrowth simply by starving it.  The problem here is that the person may very well starve themselves before they starve the bacteria.  One encouraging piece of information from Dr. Siebecker is that she has seen success using diet alone to treat SIBO in infants and children.  She did not say why it was more effective for the young ones, but my guess is that the overgrowth has simply had less time to hang around and perhaps their GI tracts have had less opportunities to “go awry” (no valve issues, no diverticulitis, general mistreatment, etc.).

Why is diet useful in SIBO if it is not effective in eradicating it?  Diet is useful, because it addresses two main problems that occur in SIBO.  The first is that bacteria feed on and then ferment the sugars found in carbohydrates.  These sugars are monosaccharides (one sugar), disaccharides (two sugars), oligosaccharides (3-10 sugars), and polysaccharides (10+ sugars).  The second is that this fermentation process leads to gas.  It is the gas produced that causes symptoms in the patient.  Bloating, distention, pain from muscles contracting against the gas (the intestines are sensitive to pressure), burping and farting from the gas exiting, and GERD and nausea which is caused by gas back pressure or reverse motility in some methane-dominant cases.

Fiber, a non-starch oligiosaccharide or polysaccharide, is indigestible by humans.  However, bacteria have enzymes that can break the bonds.  Fiber is a prebiotic that can feed bacteria (both our good and bad bacteria).  Fiber is in all plant food, therefore ANY SIBO diet has to allow for some compromise in order to allow for proper nutrition and also our psychological well-being.  I thought this was an excellent point by Dr. Siebecker, since again, I hear from alot of folks that frankly have gone too far in dietary exclusion attempting to deal with SIBO.

Dr. Siebecker also emphasized as a key point that some prebiotic carbohydrates that humans should be able to digest can become food for the bacteria in SIBO.  She talked about starch, a polysaccharide (think white, i.e. rice, potatoes, bread, pasta), lactose and sucrose, disaccharides, (milk and table sugar), and fructose, a monosacchride.  The degree to which these carbohydrate sources fed bacteria and caused symptoms for patients varied by individual, which she felt was an indication of where the bacteria had overgrown in the digestive tract.  She has found that 85-95% of her patients tolerate starch, 95% can tolerate milk, and about a 1/3 tolerate fructose.  She also noted, very interestingly, that most of her patients tolerate table sugar, unless there is ALSO a yeast overgrowth.  The most dire situations are normally found with severe cases of SIBO with diarrhea where a patient is no longer able to tolerate ANY plant material.

So, what about the diets themselves?  Dr. Siebecker uses five different diets:  SCD, Low FODMAP, SCD+Low FODMAP, GAPS, and the Cedar-Sinai diet.  She stressed that there is not one perfect SIBO diet and a patient must customize through trial and error to figure out which approach is best for them.  There is also no test to determine which diet will work for an individual, although some carbohydrate malabsorption tests can be performed (fructose, lactose, sucrose, and polyol, which is sugar alcohol).  She pointed out that viewing these diets as religions is counter-productive, since trial and error for individual customization is what yields results.  I loved that she encouraged viewing any diet as a template.  (I am a HUGE fan of personal responsibility in determining what is best for you based on the “diet as template” rather than “religion” idea.)

In her clinic, Dr. Siebecker sees 60-75% symptom relief with SCD.  A key benefit of SCD being that the 3-5 day intro mimics an elemental diet and kills alot of bacteria.  She also said that 100% of pediatric Crohn’s patients had relief after three months on SCD, which is amazing.  The Low FODMAP diet lead to 86% overall symptom relief and was really successful with bloating in particular.  She sees a benefit of Low FODMAP being that it is not low carb, which can be a problem for underweight patients (most of her SIBO patients are underweight) and that it is not a “yes or no” diet, but a “how much” diet.  In other words, it helps patients determine how much of certain foods they can tolerate.  She sees the greatest success with a combination of SCD and Low FODMAP, where up to 95% of patients have symptom relief.  She likes this diet, because of the progression of SCD mixed with the “how much” of Low FODMAP.

Dr. Siebecker stated that they use GAPS in the clinic when SIBO is combined with mood or brain disorders, although they modify it and remove cartilage based bone broth (which is fermentable!  consider marrow or meat broths instead).  Finally, Cedar-Sinai has the benefit of emphasizing timing, 4-5 hours between meals, which is best for the migrating motor complex and the easiest diet for people who can not or will not do the other more restrictive diets.  Although, the timing aspect may not be suitable for hypoglycemic patients, who need to eat more often.

The following is her basic breakdown:

Active SIBO

  • SCD+Low FODMAP
  • SCD
  • GAPS (modified to remove avocado, onion, & cartilage bone broth)

Prevention (after SIBO treatment)

  • Low FODMAP
  • Cedar-Sinai

I absolutely loved all the information presented in this talk.  It helped me understand so much about how to approach diet when tackling SIBO.  My personal experience has been to use AIP + Low FODMAP.  Dr. Siebecker did not talk about AIP, but I think this is a great & valid option, since AIP can help manage autoimmunity and autoimmunity and SIBO often go hand-in-hand.  The pro of AIP + Low FODMAP for me, was that it is not excessively low carb, which is a serious problem for me as I am underweight.  At this point, I can tolerate most FODMAP foods again or I have clearly discovered what quantity is acceptable before I have uncomfortable symptoms.  The con . . . restriction in general.  Dr. Siebecker spoke alot about how psychologically challenging any of these diets are for patients.  They are difficult, because they make a person feel “out of synch” with the world around them and require intense commitment.  Naturally, since so much of my focus at Alt-Ternative Autoimmune is the emotional journey, I really appreciated Dr. Siebecker’s acknowledgement of this issue in her patient population.

What about you?  Have you experimented with diet as part of your SIBO path?

You can find Part 5 of the SIBO series here.

About Angie Alt

Angie Alt is part of the blogging duo behind Autoimmune Wellness. She helps others take charge of their health the same way she took charge of her own after suffering with Celiac and other autoimmune diseases; one creative, nutritious meal at a time. Her special focus is on mixing “data with soul” by looking at the honest heart of the autoimmune journey (which sometimes includes curse words). She’s also a world traveler who has been medically evacuated from two foreign countries. Strategizing worst-case scenarios is now something of a hobby. She is a Certified Health Coach through the Institute for Integrative Nutrition and author of The Alternative Autoimmune Cookbook: Eating for All Phases of the Paleo Autoimmune Protocol. You can also find her on Instagram.

21 comments

  • […] SIBO Saga:  Part 4 can now be found HERE, at Autoimmune Paleo, where I and my blog partner, Mickey Trescott, now blog.  Thanks for […]

  • Heather Burkhardt says

    I went low fodmap AIP, with white rice added in and it changed my life. I am waiting for my primary to get my test kit. I really appreciate this series. I have a couple of autoimmune diseases I am working diligently to put in remission. I started AIP in February 2013, and have had great improvement, but no full remission yet. Also, full AIP pre thyroid meds gave me some intestinal issues I never had before, (very rough constipation which I believe triggered diverticulitis), so now I am trying to manage that and heal my gut….I also deal with low blood sugar as well, so your blog is very on point for me. Thanks,
    .

    • Angie Alt says

      I’m really glad you found this series helpful Heather!

  • […] You can find Part 4 of the SIBO series here. […]

  • Nicky Moore says

    Have you heard of Norman Robillard, PhD? He apparently just came out with a book on SIBO. I just saw a link from someone that was commenting on PaleoMom’s SIBO article about his Fast Track Diet. Sarah’s article seems a little dated because she is saying to combine SCD or GAPS with AIP. I commented to her staff today that they might want to have her update that article since she had written it back in 2012 and more research has emerged on the issue since. And on top of that, you and/or MIckey just wrote an article about this exact subject and said NOT to”layer SCD or GAPS with AIP”. Having two prominent AIP websites displaying conflicting information is very frustrating.

    Anyways, I’m on AIP + Low FODMAP, but I still have issues and will be seeing a doc shortly. My concern is that for me, I need an exact list that shows what is Highly Fermentable because that seems to be what is most important regarding SIBO, according to all the articles I have read. Dr. Siebecker’s list combines SCD with Low Fodmap and has a downloadable list, but these lists are way too restrictive for me to maintain thyroid balance and blood sugar levels. The same can be said about GAPS, at least for me. Even Chris Kresser says this in an interview that was posted as a link on your website most recently. http://chriskresser.com/top-4-mistakes-people-make-when-treating-candida-overgrowth. As you know, he talks about how many people mistake just having yeast overgrowth through self-diagnosis, when in reality, most cases overlap with SIBO and/or parasites and/or dysbiosis.

    So back to the diet comments- On the other hand, AIP is great but then everybody has got a different set list of FODMAPS which is very frustrating and there is no advice on “how much” starchy vegetable is safe without feeding the bacteria with starches such as Yucca, Taro, Sweet Potato, etc. and I need these to function. I know Plantain and Tiger Nuts are out because of resistant starch which really stinks!

    So with all that being said, this is what has lead me to be intrigued by Norman Robillard’s book. Do you know of him?

    • Angie Alt says

      Hi Nicky-
      I think the most comprehensive, accurate list you can find is through Monash University in Australia. They have a very helpful downloadable app that gives specifics about serving sizes to keep things in the low FODMAP range. I don’t know about Norman Robillard’s book, but in general, I would say that AIP + Low FODMAP (w/ the low FODMAP component only needing to be maintained for about 3 months post SIBO treatment) kind of takes some self-experimentation. You need to patiently take time to figure out which foods you can tolerate & in what quantities, the longer you are following the low FODMAP, the more likely you should be to start tolerating some of the higher FODMAP foods again. Keep working on it! You can beat SIBO!

  • Cubby says

    Thanks so much for this SIBO series, Angie! I’m finding it to be very helpful. I’m going to take your advice and get the FODMAP app from Monash University. I had read about it before and after reading your SIBO series, and especially this particular post, I think I need to get it. It will help me a lot with the low FODMAP diet that I’m currently following.

    • Angie Alt says

      You are welcome Cubby! The Monash app is so worth it! Best of luck!

  • […] diet is a viable options for treatment of SIBO. Angie Alt of Autoimmune Paleo suggests that SIBO cannot be treated with diet alone. She references Dr. Alison Siebecker’s research to support this […]

  • Barbara says

    Hi, Thanks for doing this series on SIBO.

    I’m particularly interested in the comments by Dr. Siebecker that cartilage based bone broths should not be eaten because they are fermentable.

    Does this mean that other fermented foods like sauerkraut and kombucha should be avoided? I thought that these were supposed to be good for the gut and helped to heal any bacterial imbalances.

    • Betsy says

      I would love more clarity on the bone broth topic as well. We have been working our family of 5 through the GAPS intro diet for the past 6 weeks and are still having trouble with recurrent symptoms in our chronically ill 20 month old. But after reading this series I feel like we are barking up the wrong tree. With GAPS you focus on bone broth and fermentable foods- and this info seems to contradict that. I am glad to have found this website and look forward to reading up on all this information. A lot to process, but over all we are better for having the option to learn!

      • Angie Alt says

        Betsy, basically many bone broth recipes use bones w/ cartilage. Cartilage contains glucosaminoglycans which are polysaccharides (a fermented sugar that is a problem if you have SIBO) and are released during cooking. There is a way around this & that is to concentrate on meat based broths and skip the bones until SIBO is healed. Hope that helps!

  • Renee says

    WOWO, WOW, WOW!! Thank you Angie!!

    I have done GAPS for my SIBO (really helped but now I know was missing key aspects!), turned out I’m high histamine, a bit of oxalate, transulfuration pathway problem so high poly phenols are reduced – I don’t seem to have a problem with salicylates like my ADHD daughter. Definitely autoimmune so aspects of AIP right – this is complicated!!

    Still don’t know what to do about transsulfuration pathway problem -will study Metabolic Healing Methylation Course next. Any ideas meanwhile anyone?

    Thank you so much for this article – along with Chris Kresser and Dr Siebecker, Angie you are a hero! Mickey too!

    Please keep up everything there are so many that need help – I’m in southern Mexico and tons of people here have SIBO and don’t even know it…I deep down feel I’ getting prepared to help them!

    Yes the question of fermented veggies – right now I still stay away because of the histamine which is getting better fast! Then to balance what Chris said about the lack of beneficial yeast – where can I get these other than Sac B.? Are there some sort of ferment that would get beneficial yeast?

    This was just a quickie of 100 more questions…got to get to bed!
    Renee Terrell
    FDN Practitioner in training

    • Angie Alt says

      You are so welcome Renee! As to S. Boulardii, I like the supplement you can find online from Biotics Research.

  • Ava says

    Great info! I was curious, if your SIBO is resolved after treatment do you have to be on the low fodmap diet for the rest of your life? I know you said you can now eat some fodmap foods. With those foods did you do the reintroduction steps people normally do with the AIP? Thanks!

    • Angie Alt says

      Ava-
      Yes, you can eventually tolerate a higher FODMAP diet again, although you may need to take it slow & figure out what quantities work best for you. And you are spot-on! A great way to do this is the same reintro process you use w/ AIP, although you might notice reactions quicker w/ FODMAPs.

  • Amber says

    Hey angie!! Thanks for this series on sibo. I was just diagnosed methane based sibo. I’m soooo anti medications but was told to treat with rifaxamin-flagyl 2weeks then another 2 weeks if not relieved. I have been treating with botanicals the past 4 weeks with minor improvements…do you think the antibiotic route is the better option? Uggghh all this sibo stuff is so overwhelming as there are so many individual opinions-treatments ect. I also tried Atrantil a few days but felt awful on it. Just FULL and belching no appetite. Anyway sorry for winded message but any advice would be sooo appreciated! Thanks for all your blogs 🙂

    • Angie Alt says

      Amber-
      It is really up to your doctors and what is best for you individually, that said, I tend to favor an antibiotic route because I see it work more often.

  • Raymond Toboni says

    Helo Angie,

    I’ve discovered the attached chicken broth recipe on the Monash Fodmap facebook site which uses Chicken bones. Has there been new information regarding stocks/broths made from cartilage bones that make them low fodmap? I’ve attached the link. I’ve reached out to Monash through Facebook but have not heard back. Thanks for your insight on this.

    http://fodmapmonash.blogspot.com/2016/09/low-fodmap-chicken-stock.html

    Raymond

  • Katherine Olenjack says

    Hey Angie-

    Excellent series. I’m planning on getting a Sibo breath test soon because even though I diligently follow AIP and Low fodmap, I’m still crazy constipated! ugh. You mentioned you are a bit underweight, as am I! Did you gain any weight back once you beat your Sibo?

    Katherine

    • Angie Alt says

      Yes Katherine! I did regain some weight. It made an impact for sure. Glad you love the series & wishing you luck!

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