Small intestinal bacterial overgrowth (SIBO) is defined as the presence of an abnormally high number of coliform bacteria in the small bowel. First, make sure you’ve read part 1 of this blog: Understanding Sibo, which goes into understanding the condition, the symptoms, and how to properly diagnose it.
So, you have SIBO or suspect you do, and you are most likely REALLY confused. This blog is going to cover treatment options, how to manage it, diet recommendations, and what to avoid.
You can assume you have SIBO, but without the actual test results from a lactulose breath test, you don’t know whether you are hydrogen or methane dominant. As I covered in Understanding SIbo, the bacteria in your small intestine release either hydrogen or methane gases when they consume undigested food particles. It’s important to know which version you have as that can affect treatment.
MONEY SAVING TIP: The good news is, you can usually request a lactulose breath test from your regular Gastroenterologist now, and so it will be covered on most insurance. But, YOU WILL HAVE TO ASK. Otherwise, they’ll say you have IBS and send you on your way.
First, you need to understand that SIBO is a lifelong problem. It CAN get better. You CAN manage it. But there is no eradicating it or “wiping it out” with antibiotics, fixing it with herbal supplements or crazy diet plans that people might try to sell you. Here’s the SIBO treatment options you might be presented with:
Antibiotics. Xifaxan to be exact. This is a non-absorbable small intestine targeting antibiotic. You might also get a combo of Xifaxan and Neomycin. I was prescribed this, inappropriately. I researched it, didn't take it. Then when I went back a year later, they told me that I never should have been given the prescription because I had methane dominant SIBO. Antibiotics only target hydrogen dominant.
Not only do antibiotics only target hydrogen dominant SIBO, they have shown little to no success for LONG TERM treatment. People might feel better for a few months? Maybe not at all. Then, symptoms start to creep in and they get put on another round. I have seen some people put on these antibiotics for a WHOLE MONTH at at time, several times throughout the year.
Insanely strict diets. I tried this too. Purchased some ebook from someone who “completely healed SIBO” after following this diet for 6 months. They mostly focus on low fiber, no sugar, no starch. It’s like eating, basically nothing. The idea is to starve off the bad guys, which feed on undigested food particles and sugars.
There are SO MANY different opinions on HOW to eat to manage SIBO, that no specific diet will work for everyone. Even in the people I talk to online, I find that we all have different “trigger foods.”
Herbal protocols. I went on an herbal “killing” protocol for a few months when I was under the treatment of Dr. Kalish. It was ALOT of supplements and takes a lot of discipline. The idea is to kill off all the bad bacteria in combination with a restrictive diet. I had some immediate relief from this — mostly because I was barely eating anything but veggies. As with antibiotics, the issues tend to come back, it’s just a matter of when.
Eating With SIBO
The problem with any health condition is that what is “healthy” might not be healthy for YOU, given your circumstances. You have to throw out a lot of rules when managing SIBO. You will feel like you’re taking steps backwards in your health journey, but it’s necessary to managing your symptoms. Keep in mind, you don’t need to avoid these things FOREVER, but to get things under control for awhile, yes you do.
Sugar and Sibo
The main thing to understand is that when bacteria get sugar, they are most active and produce gas and symptoms.
But it’s not just eating excess sugar that’s the problem (which can cause SIBO to begin with), it’s the type of sugar. Glucose and sucrose (table sugar), are far easier to digest than fructose (fruit sugar). And lactose (milk sugar) is even less digestible, due to humans lacking the enzyme lactase (because we aren’t cows).
Sugar alcohols are completely indigestible and are discussed below under “what to avoid.”
Fiber, is actually an indigestible long chain of sugar, also discussed below. And things we generally think of as healthy—fiber supplements, raw veggies, and whole grains, are unfortunately not recommended. For example, as SIBO expert Dr. Pimentel recommends, you would opt for white bread over multi grain. I KNOW. What? The simpler the sugar, the better.
The good news? Pasta is ok, y’all
What Foods + drinks to avoid with Sibo
SUGAR ALCOHOLS: (xylitol, sucralose, ethrylitol, isomalt, lactitol, maltitol, mannitol, sorbitol) are completely indigestible — that is why they have no affect on blood sugar and are great for diabetics or those trying to lose weight. Xylitol is actually something I recommend to people trying to lower sugar intake, but not if you have SIBO. Since things like fiber and undigested food particles are what the bad bacteria feed off, you can see why this is a problem. Artificial sweeteners are also a NO.
EXCESS FIBER: again back to the fact that fiber is by nature NOT DIGESTIBLE. It is by definition, indigestible long chains of sugar. So they provide lots of food for the bad guys. Also, if you have issues with things moving (SIBO-C) then fiber sitting in your gut and fermenting is bad news. Dr. Pimentel, leading SIBO expert, even recommends not eating many leafy greens either because they contain cellulose (plant fiber). Raw veggies should be limited, for sure!
FERMENTED FOODS: (keifer, sauerkraut, kombucha, kimchi, wine/beer, miso) Dr. Pimentel also recommends a low fermentation diet. I have found fermented foods to be a nightmare. When you look at what kombucha is made of (fermented yeast, bacteria, sugar) it’s no wonder it makes me worse! Yes, these are “good” bacteria, so this has to be determined on a case by case basis, but most find they can’t tolerate them.
PROBIOTICS: lots of conflicting info about this because although probiotics are “good bacteria” it sounds counter productive to add more bacteria when you have bacterial overgrowth. But, ALL BACTERIA FERMENT. All bacteria produce gas. So it’s no wonder that SIBO patients often get worse (or remain the same) on probiotics.
However, some research is starting to show that certain strains can be beneficial in SIBO treatment when combined with antibiotic treatment. This study is one that Chris Kressner discusses here, which shows some promising insights.
***In my experience and research, I have found that Megaspore Biotic is the best probiotic for SIBO sufferers. It is very specific in how it helps kill off bad bacteria and maintain BALANCE with the good, not just throw a TON of more bacteria in the mix. That is the ultimate goal.
DAIRY, BUT REALLY JUST LACTOSE: if you didn’t know already, lactose is indigestible to humans — because we aren’t cows and we don’t produce the enzyme lactase. So, you can see how this is an issue when you don’t want undigested things hanging around. Go lactose free, if you do dairy at all.
BEANS + LEGUMES: obviously beans are known to cause digestive issues. When you get a bit better, you will find by trial and error which ones you can tolerate. For instance, I can eat black beans, but chickpeas are a NO.
GUMS: almost always contain sugar alcohols (even the kind I use has xylitol) so these are a NO. Also, gum isn’t the best for those with digestive issues anyway.
COFFEE + ALCOHOL: both are okay in small amounts, but it’s what you put in them that’s going to cause the issue.
Things That Are Helpful To Reduce Sibo Symptoms
DIGESTIVE ENZYMES: So if a major issue with SIBO is undigested food particles, it would make sense that you need to break down your food better. As HCL and other enzymes are often compromised with SIBO (and we also make less as we age) these can help tremendously. It also help to gain more nutrition from foods, as malnutrition is a side effect of SIBO with the bacteria competing for the nutrients.
I wrote a whole post here about what digestive enzymes to take and when.
MEGASPORE BIOTIC: As discussed above, it has proven to be the best in my experience and most practitioners I’ve talked to in regards to treating SIBO. It really helps to kill off bad bacteria, and maintain the balance between good and bad.
EAT MOSTLY COOKED VEGGIES: Raw foods, high in fiber, are not your friend. If you do eat them, I recommend taking Veggie Gest by Enzymedica.
DO NOT EAT BEFORE BED: Every 4 hours, your intestines do a “cleansing wave” which prevents bacteria from building up. When you are digesting, you aren’t cleaning. Over night you have the most waves occur, and you NEED THEM. Motil Pro is a supplement many doctors use to help gut motility (keep things moving) and aid cleansing waves.
SPROUTED GRAINS, BEANS, and SEEDS: Sprouting was how we originally ate these items, and we were better for it. It helps remove phytic acid, which binds to nutrients, and also makes them more easily digested.
DO NOT DRINK WITH MEALS: Liquids dilute your enzymes and stomach acid, so only drink enough to take your pills and wait an hour afterward. Also, stick to room temperature water, cold things hault digestion.
LIMIT ANTIBIOTIC USE: Overuse of antibiotics are a cause of SIBO, so you certainly don’t want to take them unless necessary. Keep in mind, antibiotics don’t actually shorten the duration of a cold (it even says so on the label) and they don’t work for anything viral. Proceed with caution as they kill off bad AND good bacteria in the gut.
SWAP PROTEIN POWDER FOR COLLAGEN: Stick to grass fed collagen instead of protein powders that are filled with whey, fillers, sugar alcohols and fibers. Plus, collagen is more bioavailable and broken down into amino acids already.
Dr. Siebecker’s site (check her study tab for all the latest research)
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