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Dietary Recommendations for SIBO
SIBO Treatment
Basically, treatment of SIBO should include identifying the underlying cause, reducing bacteria in the gut via medicinal treatment (antibiotics, medicinal herbs or an elemental diet), attempting to maintain remission via lifestyle changes (diet, stress management, etc.) and correcting nutrition deficiencies when applicable.
SIBO is usually treated through taking antibiotics, the most prescribed being Rifaximin, which is a broad spectrum antibiotic It is characterized by a gut-localized action and minimal systemic absorption, and does not appear to cause any major disturbances in the healthy gut bacteria over the long term. However, it is estimated that roughly half of SIBO patients experience a relapse within a year, which is why it is essential to identify and treat the underlying cause. For example, prokinetics can be prescribed to help increase intestinal motility.
Treatment of SIBO with medicinal herbal therapy is an alternative to antibiotic treatment or may be an option to consider if antibiotic treatment fails. According to one study, treatment with medicinal plants could be as effective as Rifaximin for the treatment of SIBO. Further studies are needed to validate these results.
The elemental diet is also another type of treatment that can induce remission. It is a liquid diet which involves ingesting a formula that provides nutrients to be absorbed within the first few feet of small bowel, cutting gut microbiome from food source. A study which included 93 patients with SIBO showed a 66% improvement in symptoms after two to three weeks of following an elemental diet.
When it comes to nutrition, there is no specific diet based on scientific evidence for SIBO. The goal of dietary modifications is to minimize symptoms while including as little dietary restrictions as possible. Dietary recommendations should be personalized according to the patient’s symptoms and medical history. The dominant theme when modifying nutrition for SIBO is to reduce the intake of fermentable foods. It is believed that by reducing the fermentation of food, the risk of bacteria proliferation will be reduced. This involves a low-fiber approach as well as avoiding sugar alcohols and fermentable sweeteners such as sucralose.
It has been suggested that meal spacing may be beneficial to optimize gut motility. Migrating motor complexes (MCCs) are waves that stimulate digestive motility. They occur every 90 to 120 minutes, take place between meals, and are interrupted by food intake. They last less than ten minutes, but are strong enough to push food, secretions, and excess intestinal microorganisms from the small intestine to the large intestine. These waves are weaker and less frequent in a portion of patients with IBS and SIBO. Thus, it could be beneficial to space meals about four hours apart and avoid snacking or drinking caloric beverages between meals so these waves are not suppressed further. However, it is important to ensure to meet nutritional needs first. People who are only able to tolerate a small amount of food at a time should consume frequent small meals and snacks in order to meet their caloric and nutrient needs and prevent malnutrition. It should be noted that several drugs can accentuate MCCs and improve gut motility.
A low-FODMAP diet* has been shown to be effective in reducing IBS-related symptoms in about 75% of cases, but it has not been studied much for SIBO. However, since a good proportion of patients with SIBO also have IBS, it is a promising approach. One study found a slight decrease in hydrogen production with a low-FODMAP diet when compared to a high-FODMAP diet. Further studies are needed to evaluate the effects of a low-FODMAP diet in patients with SIBO. It has been suggested to wait until the treatment of antibiotics had been completed before starting the FODMAP elimination phase. This is based on the concept of microbiology thatbacteria are easier to eradicate when they are active. In the long term, it is important to implement strategies to prevent SIBO recurrence and to reintroduce a variety of fiber-rich foods into the diet according to the patient’s tolerance in order to optimize gut health.
The Low Fermentation Diet was developed by Mark Pimentel, a gastroenterologist at Cedars Sinai Medical Center in California, and a leader in the research and treatment of SIBO. It is an approach that limits fermentable carbohydrates and is intended to be simpler and less restrictive than the low-FODMAP diet. On the other hand, it has not been studied and does not include a specific reintroduction protocol as with the FODMAP approach. Other diets have been proposed for SIBO, but they are not recommended because they are very restrictive, not sustainable in the long term, and are not supported by scientific evidence. These include: Specific Carbohydrate Diet (SCD), SIBO Specific Food Guide Diet (SSFG), SIBO Bi-Phasic Diet (B-PD), Gut & Psychology Syndrome Diet (GAPs) and Low Sulphur Diet.
Finally, with regard to the intake of probiotic supplements, there is lack of consistent data to support recommending specific probiotics in the treatment of SIBO.
It should be noted that there is also another condition called SIFO (Small Intestinal Fungal Overgrowth) which is characterized by the presence of an excessive number of fungi in the small intestine and is associated with gastrointestinal symptoms. The most common symptoms are reflux, nausea, vomiting, diarrhea, bloating and gas. This condition is treated with an antifungal for a period of two to three weeks. This treatment may be effective in improving symptoms, but more studies are needed to determine if it is effective to eradicate SIFO.
*FODMAPs are fermentable carbohydrates that are partly responsible for causing symptoms in people with irritable bowel syndrome (IBS). For more info, read this article.
References
- Pimentel et al. (2020) ACG Clinical Guideline: Small Intestinal Bacterial Overgrowth. The American Journal of Gastroenterology;115(2):165-178.
- Rezaie et al. (2017) Hydrogen and Methane-Based Breath Testing in Gastrointestinal Disorders: The North American Consensus. Am J Gastroenterol;112(5):775-784.
- Lauritano et al. (2008) Small intestinal bacterial overgrowth recurrence after antibiotic therapy. Am J Gastroenterol;103(8):2031-5.
- Chedid et al. (2014) Herbal Therapy Is Equivalent to Rifaximin for the Treatment of Small Intestinal Bacterial Overgrowth. Global Advances in Health and Medicine;3(3).
- Pimentel et al. (2004) A 14-day elemental diet is highly effective in normalizing the lactulose breath test. Dig Dis Sci;49(1):73-7.
- Roland et al. (2015). Small Intestinal Transit Time Is Delayed in Small Intestinal Bacterial Overgrowth. J Clin Gastroenterol;49(7):571-6.
- McIntosh et al (2017) FODMAPs alter symptoms and the metabolome of patients with IBS: a randomised controlled trial. Gut;66(7):1241-1251.
- Erdogan and Rao (2015) Small intestinal fungal overgrowth. Curr Gastroenterol Rep;17(4):16.
Author
Kathryn holds a Bachelor Degree in Nutrition as well as a Bachelor and a Master Degree in Kinesiology, all from Laval University. She is a Registered Dietitian and active member of the Ordre professionnel des Diététistes Nutritionnistes du Québec (ODNQ) and of the American Academy of Nutrition and Dietetics. She holds the Monash University's certification for the FODMAP diet and IBS, and has considerable clinical experience in that area. She is also an accomplished athlete, having ran track and cross-country at a national level. Kathryn specializes in sports nutrition, weight loss, diabetes, as well as heart and gastrointestinal health.
I have SIBO and Dr told me not to eat Garlic , but He gave me Sibotic Supplement it has content Allium Garlic Extract.
Should I not eat garlic or it’s ok to eat Garlic
Hi Jenny,
Garlic contains fermentable carbohydrates (it is high in FODMAP), so you might want to avoid it in the short term, but once your symptoms improve it is important to reintroduce it.
Is it possible to cure IMO with non antibiotics ie herbs oregano etc