While SIBO is quite the buzzword these days, it is not always truly present clinically.
You may have leaky gut, unidentified food allergies or sensitivities, as well as a more general imbalance of gut flora called “dysbiosis” (or all of the above!).
While the treatment approaches can be similar, there are some rather restrictive strategies that may not be necessary if you do not have true SIBO.
Knowing the difference may save you time, energy, and money when developing a protocol for yourself.
The gold standard for SIBO testing is lactulose or hydrogen breath testing. You consume a lactulose (a type of sugar)-containing solution and your breath is sampled at specific time intervals.
If abnormal bacteria are present, they will ferment the sugar early in the gastrointestinal tract, and abnormal levels of methane and/or hydrogen gas will be measured in your breath. Knowing whether you have methane-producing, hydrogen-producing, or mixed-type overgrowth (or no overgrowth), can change the treatment protocol.
Organic Acid and Stool Testing
Other functional testing may include organic acid markers found in the urine that measure metabolites from bacteria and yeast that can also be an indirect measure of overgrowth and dysbiosis.
In my experience, stool testing is too variable at this time to trust. A stool sample could be sent to five different labs and you’d be given five different test results on bacteria and yeast composition.
Stool testing can be helpful for identifying fatty stool, inflammatory markers or otherwise – but is not recommended specifically for “SIBO” testing. A health professional may “suspect” SIBO from stool testing, but that’s as far as their confidence can go.
In my experience, the organic acid tests are used for a more general functional picture of intestinal and metabolic health, which may then lead to further investigation into a more specific diagnosis like SIBO.
If you just perform breath testing, the result is that you are either positive or negative for SIBO. While this may be your primary goal for a consultation, if you find that you are negative for SIBO, it can still leave many questions unanswered.
If you look at broader functional markers like those in organic acid testing, you get a lot of information to work with independent of a SIBO diagnosis.
You may not have SIBO, but it doesn’t mean that there are not imbalances to address!
So I generally would lead testing with functional urine organic acid testing, and order breath testing after the fact (or ideally do both together). Of course, each case needs to be considered independently and factors like cost are inherently involved.
So why would you seek out SIBO testing in the first place? The first step is to identify the range of SIBO symptoms.
Common SIBO Symptoms:
General symptoms of SIBO include:
Bloating, gas, burping, abdominal discomfort, constipation and/or diarrhea, heartburn, nausea, headache, tiredness, skin conditions, fatty stools, and symptoms associated with poor absorption of certain nutrients like vitamin D, iron, vitamin K, or Vitamin B12 (ex. energy, bone health, mood).
SIBO can also be involved in low thyroid activity (1), food intolerance (ex. lactose, gluten, etc) (2), gallstones (3), Crohn’s disease flareup (4), scleroderma (5), celiac disease (6), pancreatitis (7), diverticulitis (8), diabetes (9), cirrhosis and liver encephalopathy (10), leaky gut and fibromyalgia (11), non-alcoholic fatty liver (12), kidney and bladder inflammation (interstitial cystitis) (13), restless leg syndrome (14), rosacea (15), esophageal inflammation (16), and possibly microscopic colitis (17).
Any condition where dysbiosis may be involved is a trigger for possible SIBO involvement.
Anxiety, Depression, and Mood Disorders:
In my experience, anxiety, depression, and other mood disorders also can be rooted in SIBO (& dysbiosis). The majority of your brain neurotransmitters are actually produced in the gut – and so many intestinal issues can be associated with mood disorders.
Histamine Intolerance and SIBO
Some bacteria in the gut are histamine-producing. When these bacteria are overgrown, the body cannot handle the excess histamine and symptoms develop. Excess histamine can cause allergic-like symptoms – but also be related to flare-ups with anxiety, inflammation, or difficulty sleeping.
Certain individuals do not metabolize their histamine efficiently due to genetic differences in a few genes (such as DAO, HDC, HNMT or ABP-1) – and are at more risk for short-term and long-term issues with histamine.
Just because you carry one slow copy of a gene does not suddenly make you a candidate – typically those with problems carry two “slow” copies of one or more genes. Moreover, those with slow copies may only experience histamine-related problems when they also have SIBO present.
If you have bacon and coffee for breakfast, leftover meat for lunch, and tomato sauce pasta for dinner with a glass of wine – you could also trigger histamine symptoms.
Stress can cause histamine-like symptoms too.
Those with primary histamine intolerance may actually suffer with something different known as Mast Cell Activation Disorder (MCAD). These individuals need to carry an Epi-pen with them and must be careful about histamine-containing/releasing foods on a daily basis.
MCAD is different than functional issues with histamine intolerance. These are relatively less common variations. Nevertheless, if you’re reading this, it may apply to you and help you decide what treatment or testing approaches are best for you .
Usually, I’m only looking at histamine intolerance as a subset of SIBO or dysbiosis, and will dig deeper into histamine as a primary issue only if the client is not responding to a normal SIBO or dysbiosis protocol.
A Low-FODMAP diet stands for Low-Fermentable, Oligosaccharides, Disaccharides, Monosaccharides, And Polyols.
These are starches in the diet, even from healthy foods, that feed good bacteria, but when bad bacteria are present, they can feed them too. And that’s the tricky part…
Occasionally in the case of SIBO or general dysbiosis, a period of low-FODMAP eating can help starve unwanted bacteria without going to prescription antibiotics. It can also serve as a transitional diet out of more aggressive plans, or be part of a 50% calorie diet that helps reduce total FODMAPs in the diet to support gastrointestinal rest and recovery.
I’ve put together a comprehensive resource on Low-FODMAP eating. Additionally, Microbiome Labs released FODMATE, an enzyme that naturally breaks down 95% of FODMAPs in the diet and can support a low-FODMAP protocol. A FODMATE enzyme can help when you cheat on your diet too when it comes to birthdays and holidays, but you didn’t hear it from me. Ideally, you have a plan of action in these circumstances too, but I’m practical to all circumstances.
When eating a carbohydrate containing meal, I’ll take Berberine Reset, NAC, and FODMATE. If I feel I might be exposed to wheat, Wheat Rescue is a go-to as well if cross-contamination (or hosts that won’t be denied on trying their dish) is a concern.
Now, FODMAPs that are healthy can be essential to support healthy bacteria long-term but in the short-term when unwanted bacteria are present, all FODMAPs, even from healthy sources can still be problematic.
Nevertheless, a low-FODMAP diet can be an important option when healing or transitioning from more aggressive protocols.
When push comes to shove, American diets are eating way too many FODMAPs that can irritate the gut and delay healing.
Elemental Diet Protocol:
The approach that comes to mind most often for an aggressive SIBO protocol that may or may not involve antibiotics is the elemental diet. The elemental diet consists of a powdered shake that reproduces all calorie, protein, and micronutrient needs in their elemental or most digestible form without need for digestive action.
I’ve created a comprehensive resource on the elemental diet. And, a hidden secret is you can use the meal-replacement shakes periodically as part of a “gut reset” over 48 hours, or 1-5 days. This is enough time to give the digestive system a break, enzymes to recover, bacteria to chill out, and jumpstart gut motility.
When SIBO is a clinical problem, however, it can take 14 days or so to reroute the ship – so keep expectations in line and consult with your health professional.
Because they don’t require fermentation and breakdown, elemental diets can give the GI system a much needed break and simultanously starve unwanted bacteria. A protocol of 1-14 days followed by a partial elemental diet, or low-FODMAP diet where new foods are reintroduced one at a time can be the pinnacle of a natural approach to SIBO.
Because some elemental formulas can be high in dextrose, a natural sugar, they do risk feeding yeast growth while starving unwanted bacteria. That’s why I use a dextrose-free formula that uses medium chain triglycerides to make up calorie content (that are also naturally balancing to gut bacteria and yeast while acting as a non-sugar energy source to the body and brain).
if eating foods alongside an elemental diet for a SIBO protocol, make it low-FODMAP, and/or use a FODMAP-digestive enzyme like FODMATE as a support.
I like to emphasize that a low-FODMAP diet and elemental diet are intended as short-term solutions to give the gut a break and starve bad bacteria. Over too long of a time, one might starve the wanted bacteria too and this is not advised. This pivot point happens at around 14-days. Eventually, you need FODMAPs to support good bacteria too – reintroduce them to tolerance.
An elemental diet can be useful to clean the slate without following an overly restrictive diet, but long-term, be mindful to eat diverse foods that feed a diverse amount of microbes in the gut. This is always the goal to re-establish or maintain good bacteria in the gut.
When in doubt, whether SIBO is a concern or not, I highly recommend a functional stool test to measure microbiome diversity known as BiomeFx.
Learn why this approach is so useful and cutting edge based and an improvement on old testing technology: Personalized Microbiome Analysis.
Putting a SIBO Protocol Together:
So if you have been suffering with chronic bloating, gas, and intestinal discomfort that doesn’t seem to have a rhyme or reason to it – you may benefit from having yourself evaluated for SIBO and related disorders.
Cases of anxiety and depression that do not respond to medication (as much as 30-40% of individuals) may also benefit from evaluation to at least rule out SIBO involvement. The same could be argued for non-responsive skin issues like rosacea, psoriasis, and eczema.
Keep in mind that if you’ve been taking immune-suppressive medication, antibiotic (pharmaceutical and herbal), or probiotic/prebiotics, it may affect test results and make sure you inform your doctor prior to testing and treatment.
In the worst case scenario, having yourself tested for SIBO, organic acids, or general microbiome health may give you some functional information on your gut and metabolism that you can act on today to balance the gut, optimize wellness, & prevent later problems from developing.
I hope that this discussion has opened up a wealth of ideas for you and the next stages for your care and treatment.