Diet to Support SIBO

Allison Siebecker ND, MSOM, LAc

NTA Conference March 3-5 2017 Vancouver, Wa

1 © Dr. Siebecker 2011-2017

SIBO Diets • SIBO Specific Food Guide (SSFG) (Siebecker)

– SIBO Bi-Phasic Diet (B-PD) (Jacobi)

• Fast Track Diet: IBS (FTD) (Robillard)

• Cedars-Sinai Low Fermentation Diet (C-SLFD) (Pimentel)

• Low FODMAP Diet (LFD) (Shepherd/Gibson) IBS/IBD

• Specific Carbohydrate Diet (SCD) (Haas/Gottschall) Celiac/IBD

– Gut and Psychology Syndrome Diet (GAPS) (Campbell-McBride) +Autism/Brain

• Paleo- Various Forms (Many) Optimal Health

Formulated for: SIBO

2

All target & reduce Carbohydrates © Dr. Siebecker 2011-2017

Resources See: SIBOInfo: Treatment: Diet

• SSFG: SSFG Handout SIBOInfo.com

– SIBO Bi-Phasic Diet: PDF available at SIBOTest.com

• LFD: Monash University APP The Complete Low-FODMAP Diet book

• SCD: Breaking the Vicious Cycle book & .info • SCDLifestyle.com (How To)

– GAPS: GAPS book, Gaps Guide book (Lashkov)

• C-SD: A New IBS Solution, Handout

• Fast Track: Fast Track Digestion IBS

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How Does Diet Help SIBO?

1. Reduce symptoms

– While treatment is in progress: Abx/HAbx can take time to reduce sx

– For chronic SIBO

– If no other Tx is desired, Diet can give adequate Sx relief for some

2. Prevention of relapse (along w/ prokinetic): essential

3. Decrease extra-intestinal sx & improve overall health

– Low carbohydrate diets are famous for improving health

• It doesn’t: Eradicate SIBO/cure the condition

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How Much Does Diet Help SIBO Symptoms?

• SSFG/B-PD: 75-90%

• SCD: 60-75% – IBD: 84% remission (Nieves, PMID). - Pediatric IBD: 100% (Suskind)

– Various Conditions: Significant relief I 75% (BTVC Survey)

• LFD: Hit or Miss – IBS: Good relief in 75% (Gibson) , 86% (Staudacher)

– IBD: 50-75% (Gibson, Gearry)

• C-SD: 60-80%

clinical guestimates from 6 SIBO Dr. Specialists: 12,000+ patients

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Trends: SCD better for IBD LFD better for IBS

SSFG/B-PD/C-SD better for SIBO

Carbohydrate Malabsorption The Heart of SIBO Diets

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Malabsorption

• When nutrients bypass absorption in the small intestine.

– Fat = leads to steatorrhea (fatty stools) as the fat exits the body

– Protein = leads to edema

– Vitamins/minerals = leads to various deficiency diseases

– Carbohydrates = leads to symptoms of SIBO/IBS

• Bloating, constipation/diarrhea, pain, flatulence, belching, nausea, GERD

• Caused by many things (anything that hinders digestion & absorption)

– Disease, drugs, damage, functional disorders

– Ex: insufficient chewing, enzyme deficiency, Celiac Disease, SIBO

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Carbohydrate (CHO) Malabsorption

• When CHO bypass absorption in the Small Intestine & are left in the lumen of either the SI or LI 1. CHO get fermented by bacteria creating GAS

Carbohydrates are the primary food for bacteria

2. CHO sitting in the intestine have an osmotic effect drawing water in

• Gas & water trigger GI symptoms

– Bloating, constipation/diarrhea, pain, flatulence, belching, nausea, GERD

• 1° SIBO symptoms are due to Carbohydrate Malabsorption

– This is why all SIBO Diets target & reduce carbohydrates

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How SIBO Causes Carbohydrate Malabsorption

• The SI is not designed for a lot of bacteria – LI is the place for bacteria, where they do good things for us

• But by being in the wrong location (SI), bacteria:

1. Eat host’s food, especially carbs (SI Fermentation)

= Carbohydrate Malabsorption

2. Damage SI physical structure and function

– Leading to maldigestion & more malabsorption

= Carbohydrate Malabsorption

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2 Causes of Carbohydrate Malabsorption

in SIBO

1. Small Intestine Fermentation

2. Small Intestine Damage

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1. Small Intestine Fermentation

SI Bacterial Overgrowth

Bacteria Eat Host’s Food

Gas GI Symptoms

Premature Bacterial Exposure to Host Food

Fermentation

Food = Growth

(O'Mahoney 2010, Cummings 1980)

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Small Intestine Damage

(Riordan 1997, Jonas 1977, Jonas 1978, Prizont 1981, Riepe 1980, Shindo 1998, Tabaqchali 1968, Saltzman 1994, DiBaise 2008, Kaufman 1997, Ament 1972, Sherman 1985, Giannella 1974, Toskes 1975, Riordan 1997, Lauritano 2010, Arrieta 2006, Goebel 2008, O'Mahoney 2010, Lee 2006, Bohm 2013, Gabrielli 2013, Cummings 1980) © Dr. Siebecker 2011-2017

→ fat malabsorption

→ systemic sx

GI Sx

Bacterial Gas Causes 1° GI Symptoms

• Bloating= physical swelling

• Pain= intestines sensitive to pressure, Visceral Hypersensitivity feature of IBS, muscles contract against gas

• Altered BM’s = Hydrogen> Diarrhea/Mixed, Methane> Constipation

• Belching, Flatulence= gas exiting

• GERD/Nausea= gas back pressure, reverse motility due to methane

• HS ͠ body pain, constipation, bladder irritation, extremity tingling/numbness, sulfur smelling gas

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Normal Absorption Standard

CHO Malabsorption SIBO

Malabsorption

Fiber

Food

Bacteria

SI

LI ₒₒ Gas

x

Absorption & Malabsorption

← Water

← Water Lactose

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Main Principles

• Carbohydrates are the problem in SIBO

• Which carbohydrate foods are a problem varies in each individual. This is based on:

• Types of Bacteria: different bacteria ferment/eat different carbs

• Where bacteria are Located: high up or lower down

• Brush Border Damage: allows more fermentation

• Growing Conditions alter carb levels within the same food

• Hydrochloric Acid: amount, efficiency (stimulates release of enzymes)

• Carbohydrate Transporters & Digestive Enzymes: type, amount, efficiency

• Other: pre-existing disease, histamine intolerance, bile issues…

17 © Dr. Siebecker 2011-2017

Main Principles

• Individual customization of diet is necessary & imperative

– To find which CHO are tolerated & which trigger symptoms

• Pick a SIBO Diet, then Customize

– Start any & then begin experimenting with CHO’s to customize it

• Any food that is tolerated (= doesn’t trigger sx) is OK to eat

– For SIBO (though other circumstances may apply)

18 © Dr. Siebecker 2011-2017

Choosing a SIBO Diet • SSFG/B-PD= 1. Severe SIBO (less foods tolerated) 2. Inadequate

relief from other diets 3. Many use these for all SIBO since they work best.

• SCD= 1. Moderate SIBO 2.IBD/Celiac/diarrheal disease

• GAPS= GI issues that coexist with mood/brain disorders

• LFD= 1. Prevention once tolerances have expanded 2. Underweight patients 3. Mild SIBO (those that tolerate

grains/starch/fiber/sucrose) 4. Vegetarians/Vegans

• C-SD= same as LFD + 5. those that can’t/won’t do other diets (it’s the easiest to follow)

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Dietary Prevention

• Space meals 4 hrs apart & 12 hr overnight fast to maximize MMC

• Low carb diet

– Cedars-Sinai Diet is a SIBO prevention diet

• Allows ½-1 c refined grain/meal, 40g sugar/day

– Any SIBO Diet – expanded to tolerance

– Any Low Carb Diet that is tolerated, ex. Paleo

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Diet During Abx/HAbx Treatment

• 2 Conflicting Approaches

– Low Carb and High Carb

• Low: reduce bact so there’s less to kill & less die off

• High: Feed bact so they’ll replicate allowing Abx to work better

– Both seem to work for the Dr’s who use them= not key for success

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Diet with Abx/HAbx: Considerations • Abx: If not already on SIBO Diet, don’t start until after Abx

– To take advantage of the High Carb idea

• HAbx: may want to start a SIBO Diet since Tx course is longer

– To help with Sx - SB-D uses this approach

– Or at least: No salad/raw veg, no overt fiber (flax)

If already on SIBO Diet, esp if very restricted, stay on whatever diet helps Sx during Tx

– Based on feedback I’ve heard. Exception: many tolerate starch (wt rice, potato)

• SIBO Diet before Tx may decrease die off (like candida diet) (B-PD)

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Typical Phases of Chronic SIBO

1. Bad (limited foods tolerated)

2. During Tx often better- up to 100% Sx relief

– More foods tolerated sometimes can eat anything

3. Year 1 – Relapses interspersed with #2

4. Year 2-3 – Get in the Groove

– Understand/learn their diet better

– Base GI Health continues to improve

• Tx’s are repeated, prokinetics & other preventions continue

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What the NTP can offer

• Know the diets (spend time with them/study)

– Recipe/food preparation tips (i.e. not just how to make yogurt but best way)

– Know the differences between diets

• Meal Plans, Snack & Travel ideas = “what do I eat”

• Guided experimentation to help customize

• Nutritional Evaluation of diet (using a program)

– Then fix dietary deficiencies with food suggestions/recipes

• Help with Weight Gain

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Recipes & Meal Plans

• SIBO Cookbooks – SIBO Summer Cookbook

– SIBO Family Favorites

– SIBO Christmas E-Cookbook by Rebecca Coomes

– Based on The SIBO Bi-Phasic Diet (SSFG aligned into phases)

• SIBO Recipe Sites – Subscription: Gut Rx Guru’s (uses Coomes’s recipe's, covers other GI issues too)

– Free:HealthyGut, SIBODietRecipes, VitalFoodTherapeutics, BridgetownNutrition

• See: SIBOInfo.com: Resources: Cookbooks 25 © Dr. Siebecker 2011-2017

Guided Food Experimentations • Learning tolerances takes time b/c there are always confounding factors

– Menses, poor sleep, started/stopped supp/rx, ate 2-4 other new foods

• Repeat experiment 3 times – by then you can tell (takes time!)

• Start with a small amount to minimize possible bad reaction

– ¼ cup or less. If tolerated=increase by dbl. If not= wait till recovered.

Portion size (amounts) matter. Frequency (how often) matter. Hard to determine!

• Tolerated= Sx don’t worsen. (already have Sx: did it worsen or new sx)

– GI Sx from SIBO show within hrs–next day (next day for some BM changes)

• Tolerances change over time

– Worse w/ relapses/flares. Better w/ continued Tx/Management over time

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SIBO Food Reactions

• Different type of food reaction than protein/immune mediated

• Protein/Immune: Ab mediated, blood test, delayed Sx, systemic Sx

• SIBO: bacterial fermentation mediated, breath test, 1 day Sx, GI Sx

– systemic Sx also possible via leaky gut & endotoxin/LPS

• SIBO patients can have both types of intolerances

– as well as histamine, salicylate… (ugh)

• Immune= all or nothing Vs Bact Fermentation= amount matters

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Weight Gain Strategies (Reduce bacteria with Tx: Abx, HAbx, ED (2000 calories))

• Eat more food, more often: set a timer (it’s a job)

• Find & Eat more tolerated CHO

– Starch (White: rice/potato/wheat (bread/pasta: if gluten is tolerated))

– Low Fodmap grains (corn, rice, millet, quinoa, oats)

– Squash, Fruit, Nuts, LFD Beans, glucose/sucrose/sweeteners

• Eat Lactose free dairy (esp high fat varieties)

– Aged Cheese, Homemade 24-hour yogurt made from half & half, Commercial lactose free half & half or whole milk, Dry curd cottage cheese, Lactase treated cream

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Weight Gain Strategies

• Shakes (ingredients as tolerated)

– 1. HM 24 hr ½ & ½ yogurt/lactose-free whole milk/coconut/nut milk 2. nut butter 3. egg yolks 4. fruit 5. fruit juice 6. clover honey/sweetener 7. oil 8. cinnamon/ vanilla

• Drink caloric beverages with meals &/or throughout the day

– Natural/homemade soda, lemonade, juice, milk/milk alternatives

• Eat Pork (Chinese medicine dietetics say ‘pork builds flesh’) Bacon!

• Enhance Digestion & Absorption

– Enzymes w/meals, HCl/bitters/apple cider vinegar w/meals, Heal brush border (colostrum, glutamine, zinc carnosine)(mucopolysacc can aggv)

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SIBO Diet Tips

• Avoid raw food/salad, whole grains & beans.

• Careful w/ nuts/seeds & winter squash. Coconut bothers many.

• Choose low fodmap fruit and veg (resource: SSFG or LFD App)

• Starch may be tolerated: white rice, white potato, white wheat (if gluten is tolerated). Often one of these is tolerated but not another.

• Lactose Free dairy is often well tolerated

• Sugar & clover honey are often well tolerated (unless there’s yeast)

• Cocoa is often tolerated

• Amount matters- small amounts of indiv foods may be tolerated when larger amounts aren’t

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Summary

• Pick a SIBO Diet - Then Start Customizing It

– Trial & Error takes time but is necessary

Trust the body’s reaction over any list/diet

• Diet is one of the best tools patients have to manage symptoms & gain control

– Relief can be remarkable: 75%+

• NTP has an extremely important role to play

• Stay updated: SIBOInfo newsletter (welcome page)

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More Resources

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Resources: Cookbooks

• SCD

– Breaking the Vicious Cycle (Gottschall)

– Grain-Free Gourmet (Bager & Lass)

– Everyday Grain-Free Gourmet

– Healing Foods (Ramacher)

– Eat Well Feel Well (Conrad)

– And: Recipes for the SCD & Adventures in the Family Kitchen (Prasad), Lucy's SCD Cookbook (Rosset), A taste of Wellness (Weiss)

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Resources: Cookbooks

• Low FODMAP

– The Low-FODMAP Diet Cookbook

– The 2-Step Low-FODMAP Eating Plan

– The Complete Low-FODMAP Diet

– Low-Fodmap 28-Day Plan (Scarlotta)

– The Low-FODMAP Cookbook (Benjamen)

– The Quiet Gut Cookbook (Sonoma Press)

(Sheppard, Gibson, Chey)

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Resources: Cookbooks, Recipe Site

• Other- Elana’s Pantry

– ElanasPantry.com

• originally SCD based, now more Paleo

– The Gluten-Free Almond Flour Cookbook

An all time favorite of mine

– Gluten-Free Cupcakes

– Paleo Cooking from Elana's Pantry

• Note: SIBO Diet familiarity necessary • Careful with: arrowroot flour, agave, yacon syrup

35 © Dr. Siebecker 2011-2017