SIBO Symposium Notes: Overview of Nutritional Therapies

I got a lot of views on the last post, so I’m glad I could be helpful to the SIBO community. Thanks for all of your support. Some of the SIBO Symposium talks were incredibly technical in nature (lots of medical jargon) and being that I am not in the healthcare field (or science for that matter) I don’t know if I could do the topics any justice other than trying to copy what they say word for word, which would be very challenging…. so I think I will stick to the topics that I got the most out of, knowing that most people would also get the most out of them, too. You can probably read about the other topics after some of the experts summarize their takeaways 🙂 or alternatively, NUNM Continuing Education is still selling the recordings, so you can access it that way (I believe it’s $455 for the entire symposium, and $55 per talk). Anyway, the following are my notes from Kate Scarlata’s presentation. I tried to capture as much as I could as accurately as possible. Notes below….

Overview of Nutritional Therapies for SIBO with Kate Scarlata, RDN, LDN

Disclosure: diets that are commonly used in SIBO treatments

  • My personal pros and cons to these different approaches
  • Deeper dive into the low FODMAP diet: current research, 3 phases of nutritional plan

My Story

  • Been a dietitian for more than 25 years
  • At 30, when pregnant, experienced a strangulated bowel
    • Had an ovarian cyst removed at 18
    • Adhesions caused the scar tissue to wrap around and strangle the intestine
    • 3 months pregnant with colicky pain, admitted to ER
    • Had 6 feet of small intestine removed, including the ileocecal valve
    • 10 years later, developed abdominal discomfort and bloating
      • It was 2003, nobody yet talking about SIBO
      • Fired her GI, and asked a new doctor to prescribe what she needed

Bacterial Overgrowth

  • Heterogeneous condition
  • Dependent on what microbes are overgrown in your small bowel to determine what symptoms will occur
    • Some microbes metabolize bile salts, so if bacteria metabolize the bile salts, you will malabsorb fat or have bile acid induced diarrhea
      • Usually presents as IBS-D
    • Carbohydrate metabolizing bacteria generally create the gas and bloating
      • Diarrhea not as common
      • Presents as significant amounts of bloating
    • Gram negative coliforms such as Klebsiella cause inflammation in the gut
      • Will see flattening of the villi (similar to what we see in Celiacs)
      • Typically lower in the small bowel
      • Presents as problems with starches and sugars
    • We all have our own microbial fingerprints
    • Trillions of bacteria in our gut, about 1000 different species
      • We don’t know of a perfect gut microbiome combination
      • Our response to diet is very individual so we must treat with an individual approach
    • Dietary changes can affect the fecal microbial fingerprint in just 1 day

Kate Scarlata’s Viewpoint on each of the diets

  • Important sticking point: none of these diets have been studied specifically for SIBO
  • We do have a lot of evidence in the low FODMAP diet for patients with IBS, and SIBO and IBS are intertwined
  • SIBO Specific Diet
    • Originated from Dr. Siebecker in Portland
    • Will absolutely make you feel better
    • Very restrictive, reduced carbohydrates
    • No science behind this diet
    • In practice: Patients that do this approach are usually malnourished, besides themselves emotionally, and have mindset of legal/illegal which makes them afraid to expand their diet
    • Decrease in quality of life, difficult to eat socially
    • Long term effect on colonic microbiome has not been studied
    • Can result in low fiber, high protein, which is not good long term for colonic microbiome
  • Specific Carbohydrate Diet
    • Also very restrictive with no starches, no simple carbohydrates that require enzymes
    • Evidence in kids with inflammatory bowel disease, particularly with those with Chhorn’s
    • First started as a dietary method to treat Celiac’s disease many years ago
    • Popularized by Elaine Gottschall who had a child with Ulcerative Colitis
    • Composed primarily of monosaccharides
      • Category of carbohydrates that are absorbed into the bloodstream
      • Premise is that everyone doesn’t break down these complex carbohydrates due to lack of the enzymes, which feeds harmful bacteria
      • Reality is that there are many fibers that are digested that are prebiotics, so feed probiotic or healthy microbes
      • Majority of people with SIBO are probably not lacking the enzymes to break down complex carbohydrates
    • People usually feel hungry on the diet due to lack of potatoes, rice
    • Science shows us that although fructose is allowed on the diet because it’s a monosaccharide, fructose malabsorption exists in 1 in 3 people (even though this is the primary form of sugar on the diet)
    • Absorption of sucrose and starches likely not a significant problem in most SIBO patients
    • Women are majority of IBS/SIBO patients, and they have less serotonin than men
      • Increase serotonin by complex carbs
      • SCD results in decreased serotonin
    • Methane positive and hydrogen positive = higher risk for hypoglycemia, so risk of not getting enough carbohydrates with this approach
    • Avoids processed foods, focuses on whole foods which is good
    • Improves the quality of the diet
    • Despise the use of terms Legal/Illegal – leads to an unhealthy relationship with food
    • Includes highly fermentable foods like garlic and onion that can create a lot of gas
  • GAPS (Gut and Psychology Syndrome Diet)
    • No science, my least favorite
    • Hinges on fear
      • Potentially going to cure food allergies, autism, joint problems, ADHD
      • Targeting children – so parents dealing with sick kids use this diet as a “cure all” for them
      • Recommends skin sensitivity test for food
    • Good because avoids processed foods
    • Fruit cannot be eaten with protein in this diet, which protein helps enhance fructose absorption
    • Meat stock used all day with and between meals
      • Worry of lead contamination overdosing with so much broth
    • Very high in animal fat and protein, not enough carbohydrates
      • High fat can feed archaea (methanogens)
      • Protein has unfavorable metabolites
        • Need balance because we all malabsorb protein
        • Potential for unfavorable bacteria metabolites to feed off of malabsorbed protein
      • Helps reduce some of the bloating but goes too far
    • Low FODMAP
      • Very strong evidence, science based for IBS
        • 60% of people with IBS-D fulfill the criteria for SIBO
      • Moderately restrictive, but intended for short term use to heal the gut, and then liberalize as tolerated
      • Carbohydrate intolerance extremely common in people with SIBO
      • Lactose, excess fructose, and fructans hardest groups for people clinically
      • 50 – 86 patients have a clinically meaningful response to low FODMAP diet
      • Reduces osmotic load that causes diarrhea
      • Reduces gas production in the distal small bowel (reduces food source for bacteria)
      • Associated with less histamine release (maybe because we’re feeding less bacteria with the ability to break down histamine, or could be because reduces distention and mast cells aren’t being activated)
      • Moderately restrictive but allows foods from every food group, which is a good thing
      • Visceral hypersensitivity has not been fully studied, but less pain seems to be an effect of the low FODMAP diet
      • Cons: Can be misused by staying on it indefinitely
        • Should be used as a healing phase, then a reintroduction phase
        • Looks at SIBO as IBS on steroids – may need to be on the healing phase for 6 to 8 weeks, whereas only 2 weeks on IBS
        • Need to work with a dietitian! Many people try to do it alone.
      • Con: reduces GOS (prebiotics) which can cause long term effects
        • Try to reintroduce when tolerated
      • Cons: allows processed foods, less nutrition, less fiber, emulsifiers
    • The Cedars-Sinai or low fermentation diet (by Dr. Pimentel)
      • Not studied, least restrictive
      • Can work for a mild case of SIBO
      • Emphasizes discrete meals and allowing time for the MMC to work
      • It avoids some fermentable foods, but not all
      • Go out, be as normal as you can. Good mindset approach to diet
      • Nutritional inaccuracies
        • Pasta and white bread lack nutrition, have fructans which are highly fermentable for some people
        • Butter not allowed due to lactose, though it has ~ .1g of lactose per TB which most people should tolerate
        • Gluten free diets are low carbohydrate – not necessarily, many products are based on rice which is very high in carbohydrates
      • Allows foods that grow under the ground such as onion, garlic, sweet potato, but these are highly fermentable for most people
    • Fast Tract Diet
      • Not been studied in SIBO
      • Says hinged on science but only based on one case study (with only 9 people)
      • Formula used to judge how fermentable a food is
      • Use sometimes in practice in the sense that if something has a low glycemic index, it takes a long time for the food to be absorbed
      • Some fermentable foods that don’t fit into the equation such as garlic and onion since they are low in carbohydrates
      • Reduces fermentation, so less bloating
      • Allows sucralose, which is controversial, and more recently we have done breath tests after giving sucralose where it can be fermentable based on the individual’s bacteria

 

Low FODMAP is a great starting point for the majority of SIBO patients

  • Around since 2005, originated from Monash University in Melbourne, Australia
  • FODMAP rich foods are reduced initially, then reintroduced methodically to tailor the diet to the individual
    • We all have our own fingerprint of microbes, so we all react differently to FODMAPs
  • FODMAPs are osmotic and pull water into the gut, especially heavy feeling in constipated patients
  • FODMAP effects are cumulative
    • We all have our own personal threshold for FODMAPs
  • Heightened sense of pain in SIBO patients
  • Bacterial fermentation can affect the motility of the gut
  • Why are FODMAPs malabsorbed?
    • Very common to malabsorb lactose, for 70% of population this is true
      • Common to have reduction in the enzyme after weaned from breast milk
    • Fructose has a slow transport mechanism and is poorly absorbed
      • Needs glucose for certain pathways
    • Fructans and GOS we all lack enzymes for absorption (but not everyone feels sick from them)
      • Due to various metabolites being made
      • Bacteria and movement of gut different in all of us
    • Polyols malabsorbed especially when inflammation is present
      • Common in Celiacs
      • Absorbed in pores in small intestine
      • Erythritol (a polyol) in presence of fructose results in greater fructose malabsorption, so avoid Truvia!
    • High FODMAP sources
      • Lactose: wet cheeses, milk, custard, ice cream, yogurt
      • Fructose: apples, boysenberry, figs, mangos
      • Fructans: dried fruit, nectarine, persimmon, watermelon, garlic, onion, wheat, chicory root extract
      • GOS: legumes, pistachios, cashews
      • Polyols: apples, apricots, blackberries, cauliflower, mushrooms, sugar alcohols (mannitol, sorbitol)

3 Phase Nutritional Approach

  • Remove high FODMAP foods for 2 to 6 weeks
  • Try to reintroduce FODMAPs via the Challenge Phase
  • Integrate the tolerated FODMAPs back onto the plate
    • Goal: to have the most nutritional balanced diet while controlling the patient’s symptoms

Global FODMAP Research Trials in IBS

  • Lot of interest in low FODMAP diet globally
  • Small numbers of subjects (only up to 100)
  • All studies had dietary advice given by trained dietitians
    • Patients found diet easy to adhere to
    • Efficacy in symptom management (50 to 70% of symptoms)
  • Randomized control trial in Australia
    • Comparison between moderate FODMAPs like an average Australian diet to a low FODMAP diet
    • Provided all of the food to make sure diets were compliant
    • Patients analyzed symptoms with visual analog scale
    • Patients with IBS on the moderate FODMAP diet
      • Higher symptoms compared to low FODMAP diet
    • Healthy control patients were OK regardless of moderate or low FODMAP diet
    • 70% of patients that benefitted from the low FODMAP diet were across the board (both types of IBS, constipation and diarrhea)
  • Randomized control trial in the US
    • 84 patients
      • 45 on low FODMAP
      • 39 on modified NICE diet (diet used in the UK specific for IBS therapy)
    • Participants were asked if they had adequate symptom relief after a week
      • Not statistically significant results, but the low FODMAP group did a little better
    • People were then asked about quality of life standpoint
      • Patients had a small increase at least with NICE diet but a larger increase with low FODMAP
    • Abdominal pain and bloating were significantly less with low FODMAP diet
  • Another study in healthy controls (16 healthy subjects)
    • Wanted to see with an MRI what happened when people ingested FODMAPS, if you could see the distention or gas in the colon
    • MRI taken before they ate food
    • MRI taken after drinking water with glucose, water with fructose, and water with inulin, or mix of water with glucose and fructose
      • Followed up with a scan every hour for a total of 300 minutes
      • After every MRI, they measured the breath Hydrogen level
        • Results: 50% saw an increase in Hydrogen of at least 20ppm after the fructose
          • Quick rise in fermentation but dissipates quickly with fructose
          • No rise when fructose mixed with glucose, absorbed much better (sucrose is glucose and fructose, so it should be well absorbed)
        • 81% showed a rise in Hydrogen after inulin
          • This continues to get higher over time as bacteria ferment it
        • Water content: quick rise with fructose, glucose helps with this
        • Fructans: trouble by fermentation and gas production, not by water content
      • Another study in Canada looking at low FODMAP diet and measuring metabolites (urinary)
        • Low FODMAP diet resulted in 8 fold reduction in Histamine (not sure what that means)
        • Metabolite picture is being evaluated more in recent studies
        • 2 other metabolites increased associated with anti-inflammatory effects (but don’t know the full implications of that)
      • Study presented in 2016 at DDW (Digestive Disease Week)
        • 12 individuals with IBS-D
          • Measured the LPS (a bacterial endotoxin)
            • Found it was twice as high in individuals with IBS-D
            • Put them on a low FODMAP diet and the LPS normalized similar to healthy controls
          • Looked for bacterial richness
            • Bacteria in the gut had much more diversity in the bacteria
          • In animals, took LPS rich feces and put it into rats
            • Administered colonic distention to rats
              • Individuals with IBS-D feces were more sensitive to the colonic distention
              • What’s causing the visceral hypersensitivity?

Application of the Low FODMAP Diet in Kate’s Practice

  • Screens all clients for Celiac before modifying diet (makes sure they are eating gluten so the test is accurate)
    • If patient has already removed gluten, she will do the celiac gene testing (usually not covered by insurance – if positive for gene, it doesn’t tell us anything. But if negative, they can rule out Celiac)
  • Looks for alarm features like blood in stool, experiencing night sweats
    • Not normal for IBS/SIBO, so she will send them back to their doctor
  • Assess for appropriateness for full elimination diet
    • Individuals with eating disorders have dysbiotic colonic environments
      • Often malnourished and have issues with motility
      • Anorexics that have resumed healthy eating have a permanently altered gut microbiome
      • Won’t put patient with a history of an eating disorder on a full elimination low FODMAP diet and always asks patients if it’s a part of their history
      • A lot of people with SIBO have fears associated with eating, but it’s a little different than a true eating disorder
      • If the patient has a history of an eating disorder, allow therapist to evaluate and decide for them if dietary modifications are suitable rather than make that call themselves
      • Looks at clinical hypnotherapy for those patients with eating struggles to modify more the mind/body than the diet
    • Is this individual ready to change their diet?
      • The answer is pretty much always yes for symptom relief
    • FODMAP swaps
      • Find out first what they like to eat to make their diet similar to their old diet without causing problems
        • If they like garlic, incorporate garlic infused oils (fructans are only water soluble, not fat soluble)
        • Onion can also be sautéed in oil, just remove the pieces before making the dish, but make sure you sautee them alone (if you add tomatoes, water is added so the fructans have something to dissolve into – so oil and onion only at first, remove pieces, then add other ingredients)
        • Legumes – keep quantities small
          • Space throughout the day for Vegetarians
          • Canned beans are lower in FODMAPs, but discard the water before eating.
            • Soaked beans do not lower FODMAPs in the same amounts as canned, so stick with canned.
          • Wheat flour is off the table, so bake with gluten free blends
            • 1 for 1 Bob’s Red Mill, Trader Joe’s, King Arthur, etc.
          • No soymilk, but Firm tofu OK
            • Silken tofu is not suitable
            • Edamame is suitable
          • Swap out milk for lactose free, hemp, almond, coconut, rice milks.
          • Sourdough bread is suitable when it’s a slow leavened bread
            • Yeast is often added to accelerate the process, so not low FODMAP
          • Patient improvement
            • With dietitian overview and meal plan, patients saw relief in just 1 week
            • When managing the dietary guidelines alone, can take up to 4 weeks to experience relief
          • No standardized protocol for FODMAP reintroduction
            • Tolerance can change over time, so try again in the future (because gut flora change over time)
            • Consume a quantity of food that is normal for the patient
              • Ex: don’t drink a whole gallon of milk
            • Select foods that only have the FODMAP that is being challenged
              • Apples have sorbitol and fructose, so not a good challenge food
            • If patient passes a challenge, go back to low FODMAP for each continuing challenge
            • Might test 3 groups, take a break for a month, and then do the remaining challenges
            • Failed challenge defined by noticeable negative consequence
              • Not just a single bubble in the gut, it would be more painful gas
              • Constipation returned
              • Ran to the bathroom
            • Mannitol challenge example
              • ½ cup of raw mushrooms (you can cook it but measure raw)
              • Then increase to 1 cup of mushrooms
              • Then increase to 1.5 cups of mushrooms
              • Track symptoms, what else they ate, cooked or raw, and when did they experience symptoms
            • Diet is only one piece of the SIBO “pie”
              • Still need to identify the underlying cause with GI doctor
              • Using motility drugs can help
            • Orthorexia common in SIBO
              • Healthy eating gone too far – patients instructed to go on too restrictive of a diet
              • Leads to malnutrition, fears of foods, impairment of daily functioning
              • Remind patients they did NOT cause their own SIBO
              • Work on developing peace with food, not fear.
            • Study primarily in Animals
              • Bacteria eat what we don’t digest
                • Too much protein results in negative metabolites, sulfide gas, ammonia
                • Carbs are preferred fuel source for bacteria
                  • Bacteria produce butyrate which encourages mucin which maintains the gut integrity
                  • When you don’t feed the bacteria, they eat you
                    • Study: fiber rich diet in rats, then put them on a fiber-free diet and the bacteria broke down the mucin layer and started to eat it

Fermented Foods

  • Kombucha, Yogurt, Sauerkraut – all have FODMAPs
    • Some people think that by taking complex carbohydrates and fermenting them (break them down) it will help with digestion
    • If easier to digest, will small bowel bacteria be able to get to foods they normally couldn’t because they were too complex before? Yes.
    • Not all microbes added to ferment are probiotic (associated with good health)

Stress and Gut Microbiome

  • Changes in gut microbiome lead to changes in emotional behavior
  • Being sick is stressful – is your diet causing you stress?
  • Serotonin is not regulated by the microbiome directly but it is indirectly

Role of Probiotics

  • Probiotics recommended during antibiotics because of better decontamination rate, but more research is needed
    • Reuteri (DSM 17938) probiotic strand shown to dramatically reduce methane and improve bowel movements
      • Treatments not as effective with antibiotics, so worth it to try this particular strain
      • Try for 4 weeks, twice a day with 108 CFU (100 million CFUs) capsule

Conclusions

  • Space meals for MMC – 3 to 4 hours is sufficient
  • Balance the plate
  • Less processed foods, less refined grains, less additives such as emulsifiers
  • Remember long term colonic environment – want to feel well but also keep gut microbiome healthy for the long term
  • Work to understand the underlying cause beyond diet
    • Work with a trusted team, the more integrated, the better
    • Primary doctor, GI doctor, dietitian, pelvic floor therapist
  • Stress management techniques should be included in dietary considerations
  • No evidence based diet for SIBO but since a large overlap with IBS, the low FODMAP diet is the most evidence based start for most patients in the SIBO population
  • Remember that SIBO requires more than just a diet approach

Q & A

  • How do you approach patients who aren’t able to expand their intake of foods, still have multiple food intolerances after SIBO treatment and low FODMAP diet?
    • What are the food intolerances – did the food just cause a gas bubble? If on low FODMAP, have them do a food log and find out what their symptoms were and navigate the arts and science of what is truly bothering them.
  • Re: fat rich diets feed methanogens and high protein and fat can lead to excess bacterial metabolites – can you provide a source for further reading on this?
    • Yes, I can and I’ll send it to Justin afterwards. But absolutely, there’s a number of studies.
  • How do you approach patients who have difficulty spacing out meals; patients who feel light headed or dizzy even a couple hours after eating?
    • Lightheadedness and hypoglycemia trumps the eating window. Look at what they’re eating, make sure they have fiber and fat with their meals so they stay satisfied. Individuals with both hydrogen and methane, bacteria are getting the carbs so episodic hypoglycemia is observed.
  • What about resistant starches like boiled cooled potatoes in SIBO?
    • I don’t encourage a ton of them initially since they are highly fermentable, but when expanding the diet, resistant starches increase butyrate production in some people which is favorable. Bacteria have to be able to break it down and produce the butyrate. Use to rebuild the microbiome after the SIBO is cleared.
  • What are your thoughts on juicing in general, vs. as part of fasting in addition to the possible benefits of a juice fast?
    • I don’t do that. Juicing – look at the picture. If patient has severe gastroparesis, we may incorporate some juices as needed but often what happens is that people are making juices or smoothies with 7 cups of spinach, 3 bananas – if its more than you would eat on a plate, it’s too much.
  • For patients with chronic SIBO, what is your approach to diet since they may be more restricted?
    • I’m your poster child. I am not on a very restrictive diet. I’m like a tortoise, put my head out and eat a bunch of stuff, then go back to low FODMAP. Bacteria change regularly so a little bit of trusting your gut, expand the diet as you can and go back when you can’t. Chronic SIBO is usually with methane in practice, and the most important thing is keep the bowels moving.

 

For some reason, Kate’s talk was just what I needed to realize within myself that I needed to make changes to my lifestyle and diet. I think a lot of us are in this mindset of restriction, and not feeding the bacteria, but that really isn’t what the diet is intended for (at least not in my opinion). You won’t become cured by following any diet, no matter how restrictive (again, my opinion–also not taking Elemental Diet into account). The diet is meant to help the patient get control of their symptoms, determine which foods are most bothersome, and try to incorporate as much variety as possible beyond that. You don’t need to go Keto/LCHF, and on the other hand, no need to go raw vegan either (I’ve seen both meat heavy and fruit/vegetable heavy diets preached in the SIBO Support Group on Facebook). I think the best approach is balance, but I also know that we’re all super different. Maybe Keto or Veganism works super well for one person–neither of those work very well for me. I’m doing much better incorporating a few fruits and some squash. I’m even going to try to reintroduce grains next week. Be patient with yourself, and don’t be afraid to experiment a little to figure out what works for you personally. As Kate said, our microbes change over time, and so do our reactions to food. Maybe a break from fruit was what I needed to be able to digest it better again. Just my two cents!

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s