Disclaimer: 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:
- SCD+Low FODMAP
- GAPS (modified to remove avocado, onion, & cartilage bone broth)
Prevention (after SIBO treatment)
- Low FODMAP
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.