In part one of this series, we gave an overview of small intestinal bacterial overgrowth—otherwise known as SIBO. In part two, we discussed how to diagnose it. This third and final installment explores how to treat it.
It’s no secret that SIBO can be difficult to treat. Finding true resolution requires an all-encompassing approach that includes dietary and lifestyle changes to balance the gut.
A Quick Refresher
Your digestive system has several sections with specific roles. After you swallow a mouthful of food, it makes its way to your small intestine, where the bulk of the work of drawing out nutrients takes place. What’s left passes into your large intestine, where a host of bacteria and fungi help finish the job. Then, waste products make their way out of your body.
While those bacteria are essential in the large intestine, when they proliferate in the small intestine, they cause SIBO and can undermine digestion and cause various ailments.
Likely the most important dietary intervention in treating SIBO is eliminating inflammatory foods. Foods that are full of refined carbohydrates, sugars, preservatives, and artificial ingredients fuel the bacteria that then proliferate throughout the small intestine.
Not only that, but these foods also drive systemic inflammation that can weaken the immune system, which can make one more susceptible to SIBO. Conversely, focusing on real, nutrient-dense foods such as quality protein, vegetables, fruits, and non-inflammatory fats will help to balance the microbiome.
There are many clinicians that prescribe other dietary interventions for SIBO, including the low-FODMAP diet (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols), an elemental diet, the specific carbohydrate diet (SCD), the gut and psychology syndrome diet (GAPS), low fermentation diet (LF), or low/no starch diet. What most of these diets have in common is limiting the types of carbohydrates consumed to avoid feeding the bacterial overgrowth in the small intestine. Many of these diets help heal the gut lining, but sometimes offer incomplete reversal of bacteria in the small intestine.
The most restrictive of these dietary interventions is the elemental diet, which includes several weeks of not consuming food and drinking only a solution of easily assimilated nutrients including vitamins, minerals, amino acids, fats, and certain sugars that won’t make it to the small intestine. While this has shown some promise along with other antimicrobial and motility-activating nutraceuticals and/or medications, patient compliance is a consideration. In other words, it doesn’t always work because people can’t stick to it.
Probably the most utilized diet for SIBO is the low-FODMAP diet, which limits short-chain carbohydrates that are not completely absorbed in the gastrointestinal tract. These short-chain carbohydrates can linger in the small intestine and feed the overgrowth of bacteria, which leads to various gastrointestinal symptoms.
Oftentimes, removing FODMAPS from the diet offers short-term relief because it decreases symptoms. However, this diet doesn’t eradicate the overgrowth of bacteria in the small intestine. Also, those who abide by a low-FODMAP diet for a long period of time run the risk of harming the beneficial bacteria in the large intestine that are crucial for overall health. The large intestine needs fermentable carbohydrates to feed the beneficial bacteria in the large intestine.
In fact, beneficial bacteria in the large intestine produce butyrate when adequate fermentable carbohydrates are consumed. Butyrate is a short-chain fatty acid with many health benefits, including having an anti-inflammatory and protective mechanism on the health of the gut, namely the large intestine.
There’s a significant distinction between not experiencing symptoms, which some of the diets offer, and actually reversing bacterial overgrowth in the small intestine.
Restore Gut Integrity
It’s important to support the health of your intestinal wall to recover from SIBO. Incorporating collagen and bone broth into your diet will help to soothe inflammation within the gut and restore its integrity. In addition, nutrients such as L-glutamine, zinc carnosine, lactose-free colostrum, and various immunoglobulins can help to rebuild tight cell junctions within the gut lining. Additionally, low stomach acid (hydrochloric acid or HCl) can be a contributing factor to SIBO. Supplementing HCl can be helpful in several ways: to promote gastric motility, support the release of gastric, pancreatic, and gallbladder secretions, and hinder or kill harmful bacterial species.
Please note, probiotic supplementation is controversial for treating SIBO, but if an individual can handle taking them, they can help support the gut.
Support the Immune System
Individuals with SIBO often have compromised immune systems. A healthy immune system is important to prevent illnesses, including a recurrence of SIBO.
Fortunately, compounds such as curcumin (found in turmeric), resveratrol (found in the skin of grapes, blueberries, raspberries, and more), and liposomal glutathione have a profound impact on supporting the immune system.
SIBO patients are often nutrient-depleted and have low vitamin D levels. Low vitamin D levels are associated with low immune function, so supplementing appropriately with vitamin D may be indicated.
You can also boost immune function by removing potential exposures to environmental toxins, molds, and other pathogens such as viruses and fungal infections.
Adequate sleep, exercise, and stress management are also critical to an optimally functioning immune system.
Herbal antimicrobials are powerful tools in helping to rebalance the bacterial colonies in the gut and squelch bacterial overgrowth in the small intestine.
Some common herbal antimicrobials used for SIBO are berberine, oregano, allicin (from garlic), and a couple of herbal compounds called Biocidin and Atrantil.
Since a potential cause of SIBO is the decreased activity of the migrating motor complex or a slowing of the gastrointestinal smooth muscle activity, prokinetic agents are often recommended.
Prokinetic herbs that increase the muscular contractions in the small intestine include ginger, globe artichoke, a combination supplement called Iberogast, and various Chinese herbal formulas.
Tone the Vagus Nerve
Known as the wanderer, the vagus nerve is the longest cranial nerve connecting the brain to the gut and the rest of the body. The vagus nerve is responsible for regulating the autonomic nervous system and the involuntary functions of the body such as breathing, blinking, the beating of the heart, organ stimulation, and digestion.
When there is vagal nerve dysfunction, it impairs the migrating motor complex and overall digestion. It’s hard to say which came first, the SIBO or the slow migrating motor complex, but there is a direct correlation with vagal nerve tone.
There are various strategies to tone the vagus nerve including singing, humming, gargling, taking cold showers, box breathing, massage, prayer and meditation, mindfulness, and managing stress. Perhaps the most important strategy is managing stress, as stress has a profound impact on gut physiology and function.
Some severe cases of SIBO may require the use of pharmaceuticals, including antibiotics, to reduce bacteria in the small intestine. Rifaximin and neomycin are fairly safe and well-tolerated antibiotics that have been shown to be about 85 percent effective in treating SIBO, depending on what kind of SIBO it is. As mentioned above, prokinetic medications can also help. Common prescriptions, including low-dose naltrexone (LDN) and erythromycin, are often successful in activating the migrating motor complex.
An Important Reminder
As with any health intervention, individualized treatment is far superior to a one-size-fits-all approach. I suggest working with a skilled functional or integrative medicine doctor to come up with a personalized plan based on your unique physiology to resolve gastrointestinal complaints and SIBO.
Dr. Ashley Turner is a traditionally trained naturopath and board-certified doctor of holistic health for Restorative Wellness Center. As an expert in functional medicine, Dr. Ashley is the author of the gut-healing guide “Restorative Kitchen and Restorative Traditions,” a cookbook comprised of non-inflammatory holiday recipes.