Millions of Americans suffer from gastrointestinal symptoms and distress each year. Diagnoses of leaky gut syndrome, Crohn’s and celiac disease, and irritable bowel syndrome (IBS) continue to grow, and researchers still can’t quite put their fingers on why our digestive systems are under attack.
Recently, researchers have started to acknowledge there’s another digestive disorder lurking: small intestinal bacterial overgrowth, or SIBO. It’s more prevalent than previously believed, and it occurs in many people suffering from IBS and certain other underlying conditions. (1)
What Is SIBO?
SIBO is the acronym for “small intestinal bacterial overgrowth,” defined as excessive bacteria in the small intestine, or small bowel. While bacteria naturally occurs throughout the digestive tract, in a healthy system, the small intestine has relatively low levels of bacteria; it’s supposed to be at highest concentrations in the colon.
The small intestine is the longest section of the digestive tract. This is where the food intermingles with digestive juices, and the nutrients are absorbed into the bloodstream. If SIBO is indicated, malabsorption of nutrients, particularly fat-soluble vitamins and iron, can quickly become a problem.
When in proper balance, the bacteria in the colon helps digest foods and the body absorb essential nutrients. However, when bacteria invades and takes over the small intestine, it can lead to poor nutrient absorption, symptoms commonly associated with IBS, and may even lead to damage of the stomach lining.
When you have SIBO, as food passes through the small intestine, the bacterial overgrowth interferes with the healthy digestive and absorption process. The bacterium associated with SIBO actually consumes some of the foods and nutrients, leading to unpleasant SIBO symptoms, including gas, bloating and pain.
Even when treating small intestinal bacterial overgrowth with antibiotics, relapse rate is high. This is a chronic condition that can be cured, but it takes patience, perseverance and a change in diet. In fact, SIBO treatment includes a healing diet, and some foods should be avoided until the gut flora is back in balance.
The indications of SIBO mirror the symptoms of other gastrointestinal disorders, including IBS. According to a study published in the World Journal of Gastroenterology, there’s good reason for the similar symptoms — there’s a definite association between IBS and SIBO. Researchers suggest that physicians give consideration of excluding SIBO before giving a definitive diagnosis of IBS. (3)
Common symptoms of SIBO and IBS include:
- Weight loss
- Joint pain
Causes and Risk Factors
There are a number of underlying conditions believed to contribute to small intestine bacterial overgrowth. These include aging, dysmotility (when muscles in the digestive system don’t work properly), chronic pancreatitis, diabetes, diverticulosis, a structural defect in the small intestine, injury, fistula, intestinal lymphoma and scleroderma. (4)
The use of certain medications, including immunosuppressant medications, proton pump inhibitors, immune system disorders, recent abdominal surgery and celiac disease are also associated with an increased risk for developing SIBO. Celiac disease can be of particular concern as it disturbs gut motility leading to improper small intestine functioning. (5)
According to a study published in the American Journal of Gastroenterology, 66 percent of patients with celiac disease who maintained a strict gluten-free diet tested positive for bacterial overgrowth.
In this study, patients were treated individually with a combination of antibiotics, prescription medications for worms and parasites, and a change in diet. All patients reported their symptoms were abated after SIBO treatment. (6)
Another underlying cause of SIBO symptoms is blind loop syndrome. This occurs when the small intestine actually forms a loop, causing food to bypass parts of the digestive tract. This causes food to move more slowly through the system, and the result is a breeding ground for bacteria. (7)
Metabolic disorders, including type 2 diabetes that’s not properly controlled, are believed to lead or contribute to certain gastrointestinal disorders. In fact, a study published in Diabetes & Metabolism indicates that SIBO was present in 43 percent of diabetics with chronic diabetes. (8)
Aging is another risk factor for developing small intestine bacterial overgrowth. As we age, the digestive tract slows down. It’s generally accepted that non-hospitalized adults over the age of 61 have a 15 percent prevalence rate of SIBO, in contrast with just under 6 percent in individuals 24 to 59 years old. A study published in the Journal of the American Geriatric Society also found that over 30 percent of disabled older adults have SIBO. (9)
Rosacea, a skin condition that causes redness and rashes on the face, (10) is also associated with SIBO symptoms. Researchers from the Department of Internal Medicine at the University of Genoa in Italy found that rosacea patients have a significantly higher prevalence rate of SIBO.
For those who suffer with rosacea, there’s good news — this study also indicates “an almost complete regression of their cutaneous lesions and maintained this excellent result for at least 9 months” after the eradication of SIBO. (11)
As you can see, small intestinal bacterial overgrowth is linked, caused or associated with a wide array of conditions. Even those not thought to be related to the gastrointestinal tract seem to correlate with SIBO symptoms.
In order to diagnose SIBO, doctors use a hydrogen breath test to measure the amount of gas produced by the bacteria in the small intestine. The test measures the amount of hydrogen and methane in your body. This works because the only way the human body produces these gases is through the output of bacteria.
A solution containing one of the following sugars is used to complete the breath test:
First the patient participates in a special diet for two days prior to the test. Then the patient drinks a solution containing one of the sugars listed above, which feeds the bacteria. The breath test measures how much hydrogen and methane has been produced by the bacteria as a result. These results allow your health care professional to determine if you are experiencing SIBO. (12, 13)
SIBO, left untreated, can cause potentially serious health complications. It’s vital to get rid of the bacterial overgrowth as soon as possible.
Bacteria overgrowth in the small intestine can lead to malnutrition, one of the biggest concerns with SIBO. Essential nutrients, protein, carbohydrates and fats aren’t properly absorbed, causing deficiencies, including iron deficiency, vitamin B12 deficiency, calcium deficiency and deficiencies in the fat-soluble vitamins — vitamin A deficiency, vitamin D deficiency, vitamin E deficiency and vitamin K deficiency.
These deficiencies can lead to symptoms, including weakness, fatigue, confusion and damage to the central nervous symptom. (14)
Vitamin B12 deficiency is more common than most people believe. There are a number of factors that can lead to deficiency, besides SIBO. Vegetarians and vegans are at particular risk, as are individuals who have inadequate stomach acid or take medications that suppress stomach acid — such as proton pump inhibitors, H2 blockers and other antacids.(15)
As noted above, these commonly prescribed medications are linked to SIBO.
According to Harvard Medical School, the symptoms of vitamin B12 deficiency can appear gradually — or very rapidly. Symptoms may include numbness or tingling in extremities, anemia, jaundice, decline in cognitive function, memory loss, fatigue, weakness, and even paranoia or hallucinations. (16)
In a report in the British Journal of Haematology, researchers indicate that megaloblastic anemia, a blood disorder that causes the loss of red blood cells, is directly related to bacterial overgrowth in the small intestine. This is due to the malabsorption of vitamin B12. (17)
If you have SIBO or a vitamin B12 deficiency, it’s imperative to catch megaloblastic anemia quickly; prolonged vitamin B12 deficiency can lead to permanent nerve damage. (18)
If you experience any of these symptoms of vitamin B12 deficiency, in addition to any of the common SIBO symptoms mentioned above, take charge of your health, and get started ridding your body of small intestinal bacteria.
Small intestinal bacterial overgrowth is most often treated with antibiotics such as rifaximin (brand name Xifaxan). This helps reduce the problem bacteria but also kills off the healthy bacteria necessary for proper digestive functioning. For some patients with SIBO caused by blind loop syndrome, long-term antibiotic courses may be required. (19)
Even with antibiotics, SIBO is difficult to treat. In fact, a study published in the American Journal of Gastroenterology, researchers concluded SIBO patients treated with antibiotics have a high recurrence rate and that gastrointestinal symptoms increased during the recurrences. (20)
The good news is that researchers have found that herbal remedies are as effective as three courses of antibiotic therapy in patients who don’t respond well to rifaximin. (21) This study mentions a variety of herbal remedies but doesn’t include dosing or further details. Oregano oil, berberine extract, wormwood oil, lemon balm oil and Indian barberry root extract are all mentioned in the study.
So how do you treat SIBO and SIBO symptoms? First, it’s important to identify if there’s an underlying cause. The next step is to start reversing the nutritional deficiencies. A healthy diet, nutritional supplements and lifestyle changes are necessary to get the body back in balance.
My first recommendation to overcome SIBO is to consume smaller amounts of food during meals. Spread your meals out at 5–6 smaller portions per day rather than 3 larger meals. Eating smaller meals allows you to digest foods more quickly, which is crucial to overcoming SIBO. Overeating is one of the worst things for SIBO because it causes food to sit longer in the stomach and can also damage gastric juice production. Low stomach acid production is one of the main contributing factors of SIBO because stomach acid kills off bacteria in your upper GI regions.
Next, one of the key things you can do today to help get rid of small intestinal bacterial overgrowth is to start probiotic supplements and eat probiotic-rich foods immediately. A pilot study from researchers at the Center for Medical Education and Clinical Research in Buenos Aires, Argentina, found probiotics have a higher efficacy rate than metronidazole for individuals with SIBO. (22)
In this study, Lactobacillus casei, Lactobacillus plantarum, Streptococcus faecalis and Bifidobacterium brevis were administered for five days to half of the study group, while the other half of the study group received antibiotics for five days. All participants ate the same diet, which limited consumption of dairy products, legumes, leafy green vegetables and alcohol.
The results? An astounding 82 percent of the group receiving probiotics reported clinical improvement, while only 52 percent of the group receiving antibiotics reported clinical improvement.
In addition to probiotics and combatting nutrient deficiencies, it’s important to change your diet.
The SIBO Diet
To get started ridding your small intestine of bacteria overgrowth, start with a FODMAP elimination diet for two weeks. What are FODMAPS? They’re foods that aren’t fully absorbed in the body and end up fermenting in the digestive tract. The fermentation actually feeds the bacteria, making it more difficult to fight SIBO and SIBO symptoms.
Foods to avoid during phase 1:
- Fructose — some fruit and fruit juices, honey, processed cereals, baked goods, high-fructose corn syrup, maple syrup, processed sugars
- Lactose — conventional dairy and processed products with dairy and added lactose
- Fructans — wheat, garlic, onion, asparagus, leeks, artichokes, broccoli, cabbage
- Galactans — legumes, cabbage, Brussels sprouts, soy
- Polyols — sorbitol, isomalt, lactitol, maltitol, xylitol and erythritol, commonly found in sugar-free gum, mints and some medications
It’s important to stick with a total elimination of the foods on the “avoid” list for this period.
Reading the list, it may seem like there’s little left to eat — however, there are plenty of great-tasting and healthy foods on the SIBO diet.
Foods to enjoy during phase 1:
- Wild-caught tuna and salmon
- Grass-fed beef and lamb
- Free-range poultry and eggs
- Raw hard cheeses
- Almond or coconut milk
- Leafy greens
- Cantaloupe and honeydew melons
- Sprouted nut butters
The goal of the SIBO diet is to repair the intestinal lining, ease inflammation, get rid of the bacterial overgrowth and eat a diet rich in the essential nutrients that your body hasn’t been absorbing. During the elimination phase, keep a supply of foods from the enjoy list on hand; if you slip and consume any FODMAPS, it’s suggested to start the two-week period again.
High-quality clean proteins, including wild-caught tuna and salmon, grass-fed beef and lamb, and free-rage poultry and eggs are easy to digest — and will give your body essential nutrients and energy. While somewhat limited during the FODMAPS elimination, you can still enjoy some fruits, including tomatoes, bananas, grapes, blueberries, strawberries, cantaloupe, honeydew melons and pineapple.
As your body heals from SIBO, eating fresh pineapple, which is rich in bromelain, each day can help lower inflammation while helping digestion. Bromelain has unbelievable health benefits, particularly for those with digestive disorders, allergies, asthma and joint pain.
In addition to pineapple, bananas help improve digestive health and boost energy levels. They’re a good source of both potassium and manganese, which the body needs while healing from SIBO. Carrots, cucumbers, leafy greens, squash, quinoa and sprouted nut butters are also on the enjoy list. Don’t get in a rut eating only certain foods during this first phase; be as diverse as possible.
Phase 2 — GAPS Diet:
After two weeks avoiding FODMAPS, it’s time to transfer to the GAPS diet plan and protocol. The GAPS diet helps repair leaky gut syndrome, rebalance bacteria throughout the digestive tract and prevent toxins entering the bloodstream. This nutritional plan also helps reduce food sensitivities, improve neurological function, boost the immune system, reduce anxiety and depression and heal IBS.
There are a number of foods that you need to continue to avoid on this plan. All grains, processed sugars, high-starch foods, processed foods, and non-organic meats and dairy should still be avoided. Your system is still healing from SIBO, and repairing your digestive tract and getting your body back in balance are the priorities.
It’s important to read the entire GAPS diet plan and protocol, as there are some important aspects not to be overlooked.
GAPS Diet – Important Guidelines
- Drink one cup of bone broth with each meal.
- Use coconut oil or ghee for cooking.
- Eat fruit in between meals, not with meals.
- Introduce probiotic-rich foods slowly (cultured vegetables, kombucha, natto, etc.)
- Don’t eat store-bought yogurt; consume only raw dairy fermented 24 hours or longer.
- Include one tablespoon fermented vegetable juice with each meal. (Sauerkraut juice is readily available.)
Don’t let the protocols and guidelines of the GAPS diet intimidate you. You’ll get into the swing of it in no time, and your digestive tract will continue to heal from SIBO.
Incorporate organic coconut oil whenever possible during this stage. According to the Mayo Clinic, medium-chain triglycerides are easier to digest for people with blind loop syndrome. (23) The medium-chain fatty acids in coconut oil, are just one of the reasons I believe it to be one of the healthiest fats on earth.
Supplements for SIBO
These are the supplements that most commonly come up for SIBO symptoms and treatment and overcoming the nutritional deficiencies caused by SIBO. Follow RDA levels for each, as supplement research for overcoming SIBO is in its infancy.
- Vitamin B12
- Vitamin D
- Vitamin K
- Digestive Enzymes
Essential Oils for SIBO
In addition to dietary changes and supplements, the use of essential oils has been shown to be helpful for people with SIBO symptoms. In a case report published in the Alternative Medicine Review, peppermint oil is shown to provide relief from certain gastrointestinal symptoms, including IBS and others. (24)
This report highlighted the use of enteric-coated peppermint oil in the treatment of IBS, chronic fatigue syndrome and fibromyalgia. A single patient with SIBO reported marked improvement with peppermint oil, and researchers indicated that further investigation is needed.
Other essential oils that may be beneficial when treating SIBO symptoms include oregano oil, tarragon oil, frankincense oil, clove oil and others. Use only high-quality, food-grade essential oils. A drop or two in a glass of water prior to a meal can help reduce boating and gas, as well as other symptoms of digestive upset.
Lifestyle Changes for SIBO
A few lifestyle changes may also be helpful in healing your digestive system and getting rid of SIBO symptoms. In both phase 1 and phase 2 of the SIBO diet, eat smaller meals, ideally three to five hours apart. It’s vital that you chew each bite thoroughly; remember digestion starts in the mouth! Drink plenty of fresh water throughout the day to stay properly hydrated.
When treating SIBO symptoms, it’s important to give your body time to repair while fighting the bacterial overgrowth in your small intestine. By eliminating FODMAPS from your diet for two weeks, and then transitioning to the GAPS diet and protocol, you can start the healing process and be well on your way to killing the bacteria causing your SIBO symptoms.
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