AHS13 Allison Siebecker — Small Intestine Bacterial Overgrowth


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Many people who try an Ancestral Diet don’t get adequate relief for their digestive complaints. A key reason why may be the presence of SIBO. This presentation will discuss symptoms, causes, pathophysiology, diagnosis and treatment of SIBO. A simple breath test can diagnose SIBO and treatments include diet, antibiotics, herbal antibiotics, elemental diet, and probiotics. Central in all treatment of SIBO is a low- carbohydrate, grain-free diet (Specific Carbohydrate Diet, Gut and Psychology Diet, modified Low Fodmaps Diet). Discussion will include why an ancestral diet can benefit digestion and how the SIBO diets differ from standard Paleo/Primal diets.

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  • Hold questions. You have more slides which I’ve included for your reference in future Reason talk about this at AHS: Many people who try an Ancestral Diet don’t get adequate relief for their digestive complaints- SIBO could be the reason why. It’s a common condtn. I want to show you how cmn but 1 st let me show you the sx’s:
  • (Constipation is a sx of both IBS (& SIBO). Many people think only diarrhea is part of IBS.) How many in this room have seen a pt or know someone with these sx’s? Virtually all of you- here are the stats on how cmn it is. (Practitioners: If you see a pt with any of these, think of SIBO)
  • SIBO is not a new disease it’s how we’re thinking of it that’s new. What catapulted SIBO into awareness. J Musculoskeletal Pain, 2001;9:107-113, Am J Gastro 2000;95:3503-06 Other studies show lower ranges of Ibs=SIbo 64% highest
  • That’s why this topic is relevant & why we should care about SIBO- millions of people suffering & they need help. (Practitioners: demand is greater than the supply of well trained doctors. Up to 50% of visits to GI office are for IBS) Here’s the list of associated dz’s (next slide)
  • I have an educational website on SIBO- Update this list regularly as new studies come out- every condition listed has study links on my site. Astonishing list! Bold= GI, Underlined= to note. SIBO found to be linked to a lot of dz’s- we would suspect this since we say GI problems cause dz The most important point of this list: think of SIBO when you think of these cond’s FM- reported pts test the highest levels of SIBO of any condition. Restless Legs- 80% improvement w/tx. Acne Rosacea- 51% improvement w/tx (check new art)
  • Orient ourselves as to which part of the body we’re talking about. St & SI separated by pyloric sphincter. SI is long 15-22 ft & it’s named in 3 parts: D, J, I. SI & LI are separated by ICV, important to note that the SI & LI are separate organs with diff functions. SI- dig & abs Vs LI- waste, absorbs water/SCFA.
  • Coloniz= when bunch bact make a home 4 themselves in SI. N 4 bact coloniz LI- it’s designed for it, but if make a bunch of bact make a home in SI they interfere w/dig & abs of one’s food. This is why the SI has protective measures in place: HCl… -When protective measure fail that BO develops -MMC= most important digestive func you’ve probably never heard of! Form of peristalsis that moves bact down into LI: during fasting= overnight and btw meals. -Lack of MMC= thought to be the predominant cause of SIBO (next slide)(video’s website) -LI bacteria (migrated up), Oropharyngeal bacteria (mouth/throat), Normal SI bacteria. Not camylobacter, cholera, salmonella, shigella Issue= they’re in the wrong place & in the wrong amt’s
  • Gastroent= acute dz. Hypothy(5 theories), MDys(mm weakness), SLE=Systemic lupus erythematosus(hypothy, n dmg), IG= idiopathic gastroparesis -CRF= corticotrophin releasing factor. (CRF>ACTH> cortisol, DHEA, aldosterone) Some studies=ACTH +’s MMC but w/dysmotility: Fukado (http://gut.bmj.com/content/42/6/845.full.pdf), St MMC (-) SI (-) but less so: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714186/ -Stress= sympathetic ns- fight or flight vs para- rest & digest. They don’t happen at the same time, it’s either/or. Spending a lot of time in Sym will mean the MMC is not getting a good chance to work.
  • Stricture= narrowing/tightening (scarring), Adhesions= fibrous bands, Malrotation= duod obstruction, Atresia= narrowing
  • Gastroen= St flu/food pois. During a bout of gastroenteritis, pathogenic bacteria secrete a toxin that disrupt muscle & nerve connections, inactivating MMC to allow for their colonization Weakness= pre-existing GI weakness # GE= dmg can add up w/ea bout until a certain level of dmg decreases the MMC enough so that SIBO forms (density of ICC= threshold is .12 density)
  • N dmg is no small moon! Some= no GI probs b4 acute gastroenteritis (traveling). Many= bit of a GI weakness/probs here & there (C section or inherited dysbiotic flora- mom= initial malcolonization) + acute gastroenteritis (traveling) Others= DZ: I’ve seen scleroderma & diverticulitis= SIBO -Maybe we’re in the middle of Evolution and it’s not pretty: maybe humans are trying to evolve ruminant digestion; that is- another GI compartment filled with bacteria to digest all the carbs we’ve been increasingly eating the last 10,000 years. We are designed to digest carbs: carb digesting enzymes & carb transporters to get them into bd. Maybe we’ve just been eating too much, esp recently.
  • Separate the problems SIBO causes in the body into 2 & also the sx’s that come from the problems into 2= GI sx experienced in the GIT, Systemic sx are everything else.
  • Because they’re there. Technical term for bact eating= fermt Most bact overgrown in SIBO= make gas. Not all bact make gas but most. Cause of GI sx= also N/, Gerd
  • Methane infused into SI of animals = 70% reduction in transit time Extremely new and enlightening info- Bacteria can cause constipation. Shouldn’t be so surprising since we know bact can cause diarr- C diff Abx induced Diarr. B4 this- no one had know the cause of chr constip- except not enough fiber/water/sit on the toilet longer. In fact, in case of SIBO, fiber can make it worse:
  • This list= lots of Paleo friendly items- this is a key area that those w/ dig probs/SIBO on Paleo may be missing Prebx are not bad, if you don’t have SIBO, they’re helpful. But SIBO is a dz that Prebx will make worse. Insoluble fiber is somewhat ferm= it’s more of a bulking agent but is very irritating to dmg intestines ex) loofa sponge over a wound. =Cellulose, lignin. Β-glycosidic= bacteria digest, α-glycosidic bonds= Humans -usually (some exceptions may be GOS (raffinose, stachyose))
  • This is the most important point for understanding the difference btw the SIBO diets & Paleo/Primal diets. SIBO creates a pathological situation that requires an altered diet- removing starch (if you’re on a version w/ wt rice/tubers), lactose (if you’re on a version w/dairy), sucrose containing foods like dark choc (if you’re on a version w/ choc), & possibly higher fructose foods like stone fruit Lactose- studies show that even Lc Intol pt’s can handle up to 1c milk with a meal w/o sx. But this is not the case in SIBO, even a tiny amt= sx, bc bact are there & eat it (slime monster ex)
  • 2 nd way of classifying Sx: Systemic sx= Leaky SI & fat sol vit malabs. LSI= partially dig foods cx BB & trigger the immune sys to rx foreign invader- result in a multitude of sx in virtually any system in the body. =food reactions: rash, mucus, h/a, jt pain, fatigue….
  • 2 ways to dx: based on Sx/Hx alone (no test) & w/ testing. We’ve alredy been over the sx & a bit of the hx.
  • SKIP 1) Abx for other reason= dental, sinus infx. 2) Prebx in food (chia, flax) or in Pbx 3) Think of fiber as alleviating const- but not in these pt’s b/c fiber (sol) feeds bact. We can’t digest it but they can. 4) Carbs < GI sx: sugars & fruit= yeast. 5) dt surgy, Kd stones. Cmn. 6) bact use iron-steal it. R/o ulcer, fibroid. 7) Often coexist. GF diets can contain a lot of food for the bacteria, such as arrowroot, potato starch & GF grains. Other reasons: cx-rx foods, chr self-per inflamm 8) xs’ive gas in SI
  • -don’t confuse lac tu lose w/lactose; lactulose=SIBO vs lactose=Lactose Intol -Resources: my website Resources: Testing
  • -I run both DNA/culture stool testing on most of my pt’s and see no correlation. Normal stool test can occur w/SIBO (excepting fat malabsorption). -Direct test=endoscopic cult (like gluc- can’t reach most of SI, 80% SI bact can’t be cult/anaerobic, oral contam) -I’ve seen 2 false neg
  • Focus on diet. In your notes you have my Key Tx Points (next slide)
  • -Time to tx= Old healing principle= 1-3 mo healing or tx/ yr cond. -Diet doesn’t seem to be able to correct the underlying cause of decreased MMC- mb there’s permanent n dmg -Sx relief is obtained by staying on the diet strictly for most. The hope is that once the SIBO’s gone & prevented in part by a prokin, diet can be expanded
  • SKIP These points are the lessons learned over 4 years. Failure to do these things accounts for a large degree of the referrals I get. I see a lot of tx failure pt-as given me the chance to figure out why. That’s what these points are. #1 #2 is gold: with this you can predict duration of tx #3 often they get worse & their test results get worse too “pissed off bact syndrome” #4 Neo or Met needed. Sensitive to diff drugs. Habx= only ID’ed allicin from garlic. Very common problem in pt’s coming from other dr- Ihave SIBO but Rifaximin didn’t work- take a look at test=M- give Dbl Abx & it starts to work #5 This is the great benefit to ND’s having herbs in our toolkit. We have more options.
  • SKIP #6- Is it gone? Did the intervention work. If not, switch what you’re doing. Try diff Abx, try a diff killing method. Bact are sensitive to diff Abx. #7- my clinical experience that both are needed. Maybe a small % can do just one but that’s a risk the pt & I would have to decide together This is a deal breaker for some. But they're judging from a place of not feeling better. #8 This means that they will be eating problem foods for them until they figure it out. whatever diet you give or they put themselves on will need to be adapted. Warn them & expect this. It takes months or longer to ID problem foods. There are strategies for shortening this but I still see it taking this long. Ex: Avocado, orange/nightshades. Additionally often there is a food or food group that once added in=better- honey, dairy, probiotic foods.
  • -Read about these diets in summary or in detail on my website -SCD- developed for Celiac, IBD & SIBO. Gaps is the SCD modified for Autism & w/ the addition of WAP principles. -Fodmaps- developed for IBD & IBS but doesn’t go far enough for SIBO b/c it allows GF grains, starchy tubers, sugar & various sweeteners. It helps ID which Frt & Veg are more fermentable by bact & it also emphasized dose as a key issue for indiv tolerability -Basically= Paleo & SIBO are very similar
  • At 1 st = until digestion improves Focus is not Ht, metabolism, BS or anything else- it’s to ease, calm & assist digestion in the setting of SIBO. Technically Gaps is focused on Autism (brain/mood) but Autism has a hefty digestive component which is why Dr C-M altered SCD for it very similar
  • Veg oil/ saccharine: not eaten by most on SCD All of these are based upon the individual tolerability
  • -SIBO= underweight & severely restricted diet. Discussed in Paleo world= put weight on, we want to take advantage of that . -B/c gaps is formulated for Autism & casein is often a prob= cultured veg vs dairy. Key differences btw Scd/Gaps - Lots of ways we can react to dairy & plenty of folks can’t do it, but the key issue for digestion= lactose & lots who think they can’t have dairy Can tol LcF -From paleolithic/evolutionary perspective I’ll leave up to you all to decide about eating dairy. I will simply report to you that way more people than I thought could, tolerate LcF dairy & most importantly, it greatly helps the health of those who can.
  • SKIP
  • Taking these foods out can make all the difference. Pt on Paleo= salad & chia Tubers: allowed= rutabagas, beets Wt rice/pot= wgt gain: try wt rice 1 st = studies show it’s fermented less/makes less H gas vs potato (Ref). Idea/hope= so quickly brokn down that it absorbs high up before it gets to where the bact are. But: Indiv based- some tolerate it, many don’t.
  • Fruit category is combined to fit on chart. Chart=Paleo’s with GI sx: any Paleo yes’es? Try stopping. Even the 4 yes’es (dairy, fruit juice, honey, coffee) are not OK for all SIBO’ers. Every category on this chart may need to be out if you’re having GI probs/SIBO. Tubers: beets, rutabaga, celery root= allowed SIBO. Fruit raw: exception is bananas
  • I recommend diet to everyone
  • SKIP
  • AHS13 Allison Siebecker — Small Intestine Bacterial Overgrowth

    1. 1. Small Intestine Bacterial Overgrowth Dr Allison Siebecker AHS, August 2013 www.siboinfo.com copyright Dr Allison Siebecker 2013
    2. 2. copyright Dr Allison Siebecker 2013 SIBO Symptoms: GI & Systemic • Bloating/ abdominal Gas – Belching, flatulence • Abdominal Pain, Cramps • Constipation, Diarrhea, both • Heartburn/ GERD • Nausea • Leaky Gut/SI Sx- any Systemic sx: food sensitivities, h/a, joint P, respiratory, skin, brain • Malabsorption Sx- steatorrhea, anemia IBS
    3. 3. SIBO= Underlying Cause of IBS • Drs Pimentel/Lin/ Chow: 2000 • Tx’ed thousands of IBS pt’s successfully with SIBO protocol • 84% IBS test+ SIBO • 75% of those whose breath tests normalized after tx, had improvement in sx’s (Am J Gastroenterology 2003) copyright Dr Allison Siebecker
    4. 4. Prevalence: SIBO is extremely common • IBS alone effects up to 20% of US= 62,782,808 – Up to 84% of people w/ IBS have SIBO= 52,737,558 – Not all studies show rates that high= 60% avg = 37,669,684 • Then we have to factor in all the other dz that occur with SIBO (35+ so far), either as 1. a cause, 2. a comorbidity, or 3. a result. – It’s possible that 35%-50% of US has SIBO =109,869,914- 156,957,020 people copyright Dr Allison Siebecker
    5. 5. SIBO Associated Conditions & Risk Factors Study links on www.siboinfo.com: About SIBO; Assoc Dz Acne Acne Rosacea Acromegaly Alcohol Consumption (moderate intake) Anemia Autism Celiac Disease/ Tropical Sprue Chronic Fatigue Syndrome CLL (Chronic Lymphocytic Leukemia) Cystic Fibrosis Diabetes Diverticulitis Dyspepsia Elderly Age Erosive Esophagitis Gallstones Gastroparesis Fibromyalgia GERD Hepatic Encephalopathy (Minimal) H pylori Infection Hypochlorhydria Hypothyroid/ Hashimoto's Thyroiditis IBD (Crohn's, Ulcerative Colitis) IBS Interstitial Cystitis Leaky Gut Liver Cirrhosis Lyme Medications: Proton Pump Inhibitors, Opiates Muscular Dystrophy (myotonic Type 1) NASH /NAFLD (non-alcoholic: steatohepatitis/fatty liver disease) Obesity Pancreatitis Parkinson's Prostatitis (chronic) Restless Leg Syndrome Rheumatoid Arthritis Scleroderma Surgery: Post-Gastrectomy copyright Dr Allison Siebecker
    6. 6. Dr Allison Siebecker Small Intestine Review
    7. 7. What is SIBO? • Bacterial Colonization of the SI – SI should have low Bacterial counts (101-2/top ) – LI is the place for Bacterial colonization (1010-11 ) • SIBO= Damage SI structure & function – SI compartment not designed for colonization – SI bact coloniz intereferes w/ digest & absorb • Protective measures keep bact low in SI – St acid, Bile, Enz, Galt, Migrating Motor Complex • SIBO= normal GIT bacteria, not pathogenic copyright Dr Allison Siebecker
    8. 8. Etiology (Cause) Anything that allows bacteria to back up in the Small Intestine 1. Slowed motility in the SI ( MMC) •Dz: Gastroenteritis, Diabetes, Hypothyroid, Musc Dystrophy, Sclerosis, SLE, Br/Spinal Injury, IG • Drugs: Opiates Test subjects given morphine (which inhibits MMC) develop SIBO • Surgery: nerve damage, scarring, adhesions • Stress: Increased CRF inhibits MMC & HCl copyright Dr Allison Siebecker
    9. 9. 2. Obstruction of the SI •Dz: Cancer: tumors, IBD-strictures, Cystic Fibrosis- xs mucus •Surgery: strictures, adhesions •Congenital: malrotation, atresia 3. Non draining pockets/sections of SI •Dz: SI Diverticulitis •Surgery: Blind loops copyright Dr Allison Siebecker 2013 Etiology (Cause) Anything that allows bacteria to back up in SI
    10. 10. Gastroenteritis (GE) Post-infectious IBS/SIBO Pimentel • 7-31% (50%) gastroenteritis > PI-IBS/SIBO • bact secrete a toxin>disrupt musc & nerve connections, inactivating MMC> colonization • Cdt b looks like something on our SI nerves, IS attacks SI nerves while attacking cdt b= damaging our nerves> MMC> SIBO • MOA: Cx rx/molecular mimicry= AI mediated • #, severity, tx, weakness, can go unnoticedcopyright Dr Allison Siebecker 2013
    11. 11. Etiology (Cause) • SIBO is a disease that recurs often b/c underlying cause either can’t be corrected or unknown how – Scarring=scleroderma: progressive, incurable – MMC dt nerve dmg from acute GE (perm?) • How Most Get SIBO= Combo of factors, ea adding up until breaking point. – hx GE + hypothyroid + period of stress (2wks) – hx GE + hx occ mild IBS + opioids • Thought= evolving ruminant digestion? copyright Dr Allison Siebecker 2013
    12. 12. Pathophysiology copyright Dr Allison Siebecker 2013
    13. 13. copyright Dr Allison Siebecker SIBO Pathophysiology #1 Bacteria compete for & steal our Food SI Bacterial OvergrowthSI Bacterial Overgrowth Bacteria Eat Our FoodBacteria Eat Our Food GasGas GI Sx bloating, painGI Sx bloating, pain constipation/diarrheaconstipation/diarrhea Premature Bacterial Exposure to Host’s Food Fermentation Food = Growth
    14. 14. Dr Allison Siebecker Bacterial Gas Hydrogen, Methane, Hydrogen Sulfide • Hydrogen, Methane not made by humans – Certain bacteria convert H M or HS • Gas Causes Abdominal Sx of IBS – Bloating/distention= physical swelling – Pain= GIT sensitive to pressure, musc contract against gas, Visc Hypersens in IBS – Eructation, flatulence= gas exiting – GERD/Nausea= gas back pressure – Altered BM’s = H>diarrhea/ M>constipation
    15. 15. Fiber/ Prebiotcs (Prebx) • Indigestible to us= no enz break bonds • Digestible to bact= have enz – Fiber exclusively feeds bact= Prebx (food for bact) • Soluble Fiber: Inulin, psyllium, flax, chia, hemp, gums (guar, xanthan, locust bean, acacia/arabic, mastic), beta glucan (oat bran/mushroom), alginate, glucomanan (konjac mannan), carrageenan, agar agar, arabinogalactan, pectin • Oligosaccharides: FOS, GOS, MOS copyright Dr Allison Siebecker
    16. 16. Key Point • In the case of SIBO, non-prebiotic carbs, carbs that we should be able to digest & absorb= become Prebx (feeding them, not us) – feed bact in the SI- just b/c bact are there • Starch from Grains & Tubers • Lactose (only digestible to some- genes) – Worse lactose intolerance in SIBO • Sucrose & sometimes Fructose & Glucose copyright Dr Allison Siebecker 2013
    17. 17. Dr Allison Siebecker SIBO Pathophysiology #2 Damage= GI & Systemic Sx SI Bacterial OvergrowthSI Bacterial Overgrowth DisaccharidasesDisaccharidases (-) Carb Transporters(-) Carb Transporters Blunted VilliBlunted Villi GI Sx’sGI Sx’s Elongated Crypt DepthElongated Crypt Depth Intestinal PermeabilityIntestinal Permeability Systemic Sx’sSystemic Sx’s Hydrogen, Methane GasHydrogen, Methane Gas GI Sx’s:GI Sx’s: BloatingBloating Constipation/ DiarrheaConstipation/ Diarrhea PainPain Inflammatory cytokinesInflammatory cytokines Digest Brush BorderDigest Brush Border Bile DeconjugationBile Deconjugation steatorrheasteatorrhea fat sol vit deficiencyfat sol vit deficiency A, D, E, KA, D, E, K Bacterial Actions Fermentation of Unabsorbed Carbohydrate Damage the Brush Border Bacterial Growth
    18. 18. Diagnosis/Testing copyright Dr Allison Siebecker 2013
    19. 19. copyright Dr Allison Siebecker 2013 When to consider SIBO? • If the symptoms (sx) of IBS are present – Bloating, constipation/diarrhea, abdom pain • If one of the associated diseases along with digestive symptoms is present • If a key indicator is present – See your notes
    20. 20. Key Indicators • Antibiotics (Abx) improve GI sx • Prebiotics (Prebx) worsen GI sx (in Pbx) • Fiber worsens constipation (& other GI sx’s) • Carbs worsen GI sx (grains/veg/beans) • GI sx start after opiate use (dt surgery) • Chronic low ferritin with no other cause • Gluten-free diet fails to improve Celiac pt • Pancreas obscured by gas bubble on CT copyright Dr Allison Siebecker 2013
    21. 21. Dr Allison Siebecker • Challenge test: lactulose=prebx meant to feed bact>gas. Sx/dz may increase/aggr • Measures gas that only bacteria produce, (H,M) which indirectly shows their presence – collections every 15-20 min x 2 or 3 hrs= it’s the timing that reflects the SI= avg 2 hrs – 1/5 H/M in SI diffuses across Brush Border> blood> lungs= expired • Performed at home with mail-in kits or in a facility with a machine (lab/hospital/office) Testing- Lactulose Breath Test (LBT)
    22. 22. Dr Allison Siebecker SIBO Breath Testing- LBT • Stool tests reflect the LI, not the SI – Stool dx LIBO, not SIBO (dx:fat malabsorption) • Other Breath tests: Urea-H pylori, CHO intol (lactose, fructose, sucrose, mannitol) • Glucose can be used dx duodenal SIBO • SIBO Testing is controversial- much debate – Gluc vs Lact, (+) criteria, timing, sen/spec stats – Indirect, imperfect, future options limited – I find it reliable. Simple/detailed/non-invas/inexpensive
    23. 23. Treatment copyright Dr Allison Siebecker 2013
    24. 24. SIBO Treatment Protocol Variation of the Cedars-Sinai Protocol (Pimentel 2006) Drs Siebecker & Sandberg-Lewis (2010) SIBO Suspected Hx GI/Extra GI, Meds, Dz Antibiotic Elemental Diet x 2-3 wks Diet SCD, GAPS x 1.5+ years 1. Rifaximin: Diarrhea/Mixed 550mg tid x 10-14 days 2. Rifaximin + Neomycin: Constipation 550mg tid + 500mg bid x 10-14 days or Rif + Metronidazole 250mg tid x 10-14 d Optional: Probiotic, Antifungal SIBO Lactulose Breath Test Or: GBT, Organic Acid Test SIBO Breath Re-Test Feel Better- 90% Partial Improvement/ Not Better Re-Assess within 2 weeks Prevention 1. Diet (SCD/Gaps, C-SD, Fodmap) 2. Prokinetic x 3 mo+ :Prucalopride 1-4mg hs :Erythromycin 50mg hs :LDN 2.5-5mg hs Optional: Probiotic, HCl/bitters, BB healing supplements Re-Treat SIBO (+)SIBO (-) Consider other Dx Treat SIBO 4 options Hx Herbal Antibiotics 1. Berberine Herbs 2. Garlic/Allicin (methane) 3. Oregano 4. Cinnamon 1-3 caps 2-3 x day x 4 weeks Optional: Probiotic, Antifungal Relapse
    25. 25. Treatment • Algorithm + Key Tx Points – Tx takes time to master & SIBO takes time to tx • Bacteria are sensitive to diff killing agents – No sensitivity testing for SI bact – May not get result you hoped for= try st else • Adults often need more than Diet for Tx – Diet= insufficient sx relief -Diet=underweight – Diet= severly limited to get any sx relief – My opinion:Diet is not enough to dislodge SIBO copyright Dr Allison Siebecker 2013
    26. 26. copyright Dr Allison Siebecker Key SIBO Tx Points for Success • Test (3 hour Lactulose Breath Test) – dx, severity, gas type, methodical approach • Successive Tx Rounds (Abx/HAbx) needed – If gas is above 35-45 ppm – Because avg gas dec from Abx/HAbx=25-35 ppm • Methane &/or constipation cases are harder to treat • Double Abx Tx or Allicin needed for methane/constipation cases • Vary tx method as needed (Abx, HAbx, ED)
    27. 27. Key SIBO Tx Points for Success • Re-Test to assess results • Both Prokinetic & Diet for prevention • Diet must be customized to the individual through their own trial & error – There’s no one “diet” that is perfect for anyone – There’s no test to find one’s perfect diet copyright Dr Allison Siebecker
    28. 28. Diet copyright Dr Allison Siebecker 2013
    29. 29. copyright Dr Allison Siebecker Dietary Treatments for SIBO 1. Specific Carbohydrate Diet (SCD) 2. Gut And Psychology Syndrome Diet (GAPS) 3. Modified Low Fodmap diet (Modfod) – no grains, tubers, sgr & combined w/ SCD/Gaps  For prevention only, after SIBO gone – Diet may expand as tolerated= grains/tubers/sgr – Cedars-Sinai Diet, Low Fodmap Diet, Less Strict Paleo/Primal Diets • Don’t remove polysacch’s/go far enough for tx
    30. 30. copyright Dr Allison Siebecker 2013
    31. 31. Key Points of SIBO Diets • Decrease CHO: poly/oligo/di-saccharides – Avoids Grains, Starch, Starchy Veggies, some Beans, Sugar & most sweeteners, Lactose, Fiber/Prebx foods • Allow monosac= glucose/fructose as honey • Intro Diet to decrease bact, aid tiss healing • Progressive- easier to digest foods at 1st – no raw fruit or veg, nuts or beans at 1st – fruit & veg= peel, de-seed, cook & puree at 1st • Like Paleo focused on digestion copyright Dr Allison Siebecker 2013
    32. 32. SIBO Diets: Allow Stricter Paleo: Not allowedNot allowed • Dairy- as lactose free, esp HM ygt • Legumes- later in diet & only certain types • Winter squash, beets, rutabagas • Fruit juice- Scd: not from conc, Gaps: HM • Honey- esp clover (sm= stevia) • Alcohol/wine: later, sm amts, certain types • Coffee: later, weak • SCD (not Gaps):Vegetable oil, Saccharine copyright Dr Allison Siebecker 2013
    33. 33. Lactose Free Dairy Points • SCD= nutrition/calories/Pbx (HM ygt) • Many w/ SIBO tolerate it & do better with it – Increased energy, stabilize weight loss, helps digestion (ygt), increases food pleasure – Surprising! Dairy= bad? Not for many w/SIBO • Key prob for Dairy Paleo= Store bought yogurt is not lactose free – Most fermented for 4 hours = 30% reduction in lactose, LcF versions= pectin copyright Dr Allison Siebecker 2013
    34. 34. SCD Lactose Free Dairy Foods • Homemade 24 hr yogurt/sour cream • Aged cheese, Dry Curd Cottage Cheese • Ghee/butter • Lactase enzyme treated cream in small amts • Commercial lactose-free dairy (LcF milk discouraged on SCD, pectin often in LcF ygt) copyright Dr Allison Siebecker 2013
    35. 35. SIBO Diets: Don’t Allow Paleo: AllowedAllowed (per version) • Raw vegetables (salads)- at start • Vegetable seed/skins- at start • Raw fruit- at start (except v ripe banana) • Fiber food/supps: chia/hemp/psyllium • Tubers (pot/sw pot/yam) • White Rice • Cocoa/chocolate/cacao (even w/out sgr) • Sugars other than honey/sacch/stevia copyright Dr Allison Siebecker 2013
    36. 36. • Dairy* Yes:Lc Free No or Yes • Grains No No or Yes • Legumes No:1st /Yes:later No (or Yes) • Veg: tubers No No or Yes • Veg: raw, skins No:1st /Yes:later Yes • Fruit: raw/juice* Mb:later/Yes Yes/No • Fiber foods No Yes • Sweeteners* Yes:Hny/stv/sacc No or Yes • Alcohol Mb:later No or Yes • Chocolate No No or Yes • Coffee* Yes:weak No or Yes *individually based copyright Dr Allison Siebecker 2013 SIBO diets vs Paleo diets Food SIBO Paleo
    37. 37. Summary • SIBO is common • Sx are the same as IBS • Bacteria ferment carbs into gas> GI sx • Dx= Lactulose Breath Test • Tx= 4 options, 3=quick killing & Diet • Prevention= Diet + Prokinetics • Diet= Scd/Gaps/Modfod very similar Paleo • Paleo w/SIBO= reduce listed carbs copyright Dr Allison Siebecker 2013
    38. 38. Diet Summary for Paleo folks with SIBO • Consider: Lactose free dairy, esp HM ygt • Avoid: starchy tubers, beans, raw vegetables & fruit, fiber/Prebx foods, sweeteners other than honey, grains • May need to avoid certain veggies (see Fodmaps), high amt’s of veggies (dose matters), fruit, nuts/seeds copyright Dr Allison Siebecker 2013
    39. 39. Announcement: Upcoming SIBO Symposium! • Drs Pimentel, Weinstock, Siebecker and Sandberg-Lewis= speakers • In Portland, Or • Live webinar for distance viewers • Recorded webinar may be purchased after • Jan 17,18 2014 • Visit www.ncnm.edu/sibo-conference copyright Dr Allison Siebecker 2013
    40. 40. Resources See www.siboinfo.com under: •‘Resources’ for: – Labs -Books – Websites -Cookbooks – MMC videos -you tubes/classes •‘Treatment’: ‘Diet’, for more diet info •For (+) test criteria, see ‘About’: ‘Testing’ or my Townsend article (‘Contact’: ‘Bio’) copyright Dr Allison Siebecker 2013