What is SIBO you might ask?

Small intestinal bacterial overgrowth aka SIBO, is an emerging clinical concern and numerous studies are coming out about the causes and possible treatments around SIBO.

SIBO is defined as an abnormal increase in bacteria in the upper part of the small intestine (4). When the good bacteria get to a high level in the intestines, they can start to have negative effects on digestion. They include excessive fermentation and inflammation (the bacteria are feeding and producing toxins) that cause abdominal pain, bloating, gas, and heartburn. This inflammation in the gut can also contribute to nutrient malabsorption and weight loss.

What causes SIBO?

SIBO is thought to be caused by several mechanisms. The first is low stomach acid (hypochlorhydria), primarily linked with prolonged proton pump inhibitor (PPI) use (1). PPIs are often prescribed for the treatment of symptoms of GERD. The job of PPIs are to neutralize the stomach acid to reduce symptoms associated with GERD like heartburn. However, when the normal pH of the stomach is altered, nutrients and carbohydrates can not be properly absorbed. There has been several reports that changes in stomach pH due to PPI use has linked to bacteria overgrowth in small intestine (Lo).

Another mechanism of what leads to SIBO is thought to be caused by carbohydrate malabsorption in the small intestine. The bacteria in our digestive system (yes, even the “good” bacteria) use carbohydrates as their energy source. However, there are specific carbohydrates, fructose oligosaccharides, that are not properly absorbed in the small intestine. Since the carbohydrate cannot be absorbed, the bacteria break it down to use as their own energy source, and in doing so causes fermentation of the carbohydrate products. This fermentation produces excess intestinal gas and pressure which has been shown to also relax the LES muscle leading to reflux of stomach acid into the esophagus causing heartburn symptoms. The carbohydrates that have been found to be the hardest to digest are: fructose, lactose, sugar alcohols, and high fermentable fiber sources.

It is estimated that about half of GERD patients taking PPIs were shown to have SIBO. It can be seen as this vicious cycle, not knowing what came first the heartburn symptoms or the SIBO.

Here are some useful hints on how “not fuel the SIBO”:

The key is to limit the fuel source of the overgrown bacteria…carbohydrates!

There are several diet options. Most center around the theme of limiting carbohydrates that are hard to digest and foods with high fermentation probability. These diets are: low FODMAP diet, Paleo, GAPS, and Fast Tract Diet.

Some diet tips:

• Recent studies have shown that gluten-free grains are the way to go (but limit white rice):
  • Consume more brown rice, sticky rice or jasmine rice.
  • For pastas stick with rice based pastas over wheat based pastas.
• Avoidance of dairy: consider soy or coconut milk as alternatives or lactose-free dairy products
• Stick with meals centered around protein and veggies: meat/fish/chicken/eggs
• Limit high fructose and sucrose fruits: these include bananas, apples, pears. Fruits that have low fermentation potential are strawberries and cantaloupe.
• Hydration! Try and get 8-8oz glasses of water a day
• Limiting soda and alcohol (which can make SIBO worse).
• Antimicrobial herbs such as oil of oregano and Berberine can help to treat SIBO

Treating SIBO may seem overwhelming but getting the proper diagnosis and treatment will provide the greatest results. With guidance from your naturopathic doctor to get you on the right diet and herbal/supplemental regimen to treat SIBO, you will see the most effective results. 

References:

1. Freedberg DE. The impact of proton pump inhibitors on the human gastrointestinal micro biome. Clin Lab Med 34 (2014): 771-785.

2. Lo WK. et al. Proton pump inhibitor use and the risk of small intestinal bacterial overgrowth: A meta-analysis. Clin Gastroenterology and Hepatology 11 (2013): 5: 483-490.

3. Nachman F. et al. Gastroesophageal reflux symptoms in patients with Celiac disease and the effects of a gluten-free diet. Clinical Gastroenterology and Hepatology 9 (2011): 214-219.

4. Robillard N. Fast Tract Digestion: Heartburn. Self Health Publishing (2012).

5. Trikha A, et al. Development of food allergies in patients with gastroesophageal reflux disease treated with gastric acid suppressive medications. Pediatric Allergy and Immunology 24 (2013): 582-588.

6. https://www.siboinfo.com/diet.html