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What is SIBO?
Small Intestine Bacterial Overgrowth (SIBO) is an accumulation of bacteria in the small intestine. It is believed that the overgrown bacteria may be from bacteria that normally live in the gastrointestinal tract, but have abnormally overgrown in an inappropriate location. While our large bowel is teeming with bacteria, the small bowel should contain much fewer bacteria, relatively.
This small bowel bacterial overgrowth can interfere with our normal digestion and absorption of food and can cause damage to the lining or intestinal membrane (leaky gut syndrome).
Symptoms of SIBO
The main symptoms of SIBO are those of Irritable Bowel Syndrome (IBS). SIBO has been shown to exist in up to 84% of IBS patients and is therefore theorized to be a significant underlying cause. The gastrointestinal symptoms of SIBO may typically involve bloating, gas, burping, abdominal discomfort, constipation and/or diarrhea, heartburn, and nausea.
SIBO can be associated with many other disorders, beyond IBS—either as an underlying cause or as a byproduct of the pre-existing condition. Please see a full list of conditions that may be associated with SIBO, found here and here.
The Elemental Diet as a treatment for SIBO & IBS has gotten a lot of attention in recent years thanks to Dr. Allison Siebecker and Dr. Steven Sandberg-Lewis. The Elemental Diet has been studied and proven to be an incredibly effective treatment for these conditions.
Treatment using an Elemental Diet ranges from 2 to 3 weeks and is 80 – 85% effective in eradicating bacterial overgrowth. This is considered a VERY effective treatment—and far surpasses antibiotic success rates!
The idea here is that certain bacteria may be killed by herbs, certain bacteria may be killed by antibiotics, but in theory ALL bacteria would respond to starvation—dying off from 2-weeks without ingesting any solid food!
A course of antibiotics or herbal antimicrobials typically decreases bacterial overgrowth by about 30 ppm in a 2-3 week period. Allison Siebecker has seen an Elemental Diet decrease bacteria by 150 ppm in a 2-week course! We have seen similar results in our office, as I will illustrate below.
Choosing an Elemental Diet can:
- reduce treatment time significantly
- help a person avoid multiple rounds of antibiotics or herbal antimicrobials
- be used if the particular mix of overgrown bacteria has shown resistance to the antibiotics or herbal antimicrobials. We call this recalcitrant SIBO, and have seen an Elemental Diet incredibly effective in these cases – as you will see below!
Testing For SIBO
SIBO breath testing measures the hydrogen (H2) & methane (CH4) gas* produced by bacteria in the intestines. Hydrogen and methane are gases produced by bacteria, not by humans. These gas levels are graphed over time, for 2 or 3 hours.
Patients follow a 1-day prep diet before the test, eliminating certain foods that would feed the small intestinal bacteria. After the first baseline breath sample is taken, patients drink a sugar solution of lactulose (food for bacteria) and proceeds with breath testing, every 15 or 20 minutes for the next 2 or 3 hours. If bacteria are present to consume the lactulose, hydrogen and/or methane gasses will be their byproduct.
*since the original writing of this post, a third gas – hydrogen sulfide (H2S) – can now be tested
Interpreting SIBO Results
If gas levels above a certain threshold (20 ppm for hydrogen or 10 ppm for methane) are detected, you can presume that bacteria are present in small bowel. To test positive for SIBO, these spikes in gas levels will be seen in the first 90-minutes of testing, when the lactulose is presumed to be in the small bowel. After 90-minutes, the lactulose should have reached the colon.
Please note: until recently 120 minutes was considered the cutoff, as you will see in some of the older test results below. There are also other subtleties to accurately interpreting SIBO test results, but I am keeping it very basic for the purpose of this post.
Using an Elemental Diet to Treat SIBO
While we have had very good success in our office using both herbal protocols and antibiotics to treat SIBO, I want to highlight the use of the Elemental Diet here using two case studies. The truth is, we could show dozens of cases in which the Elemental Diet has been effective for eradicating SIBO. We have personally seen close to a 100% success rate when an Elemental Diet has been utilized.
Case Study #1: 30 Year- Old Male
This client is a perfect example of recalcitrant SIBO and very high hydrogen gas levels. In his first test, his hydrogen gas levels were above 20 ppm at 60 minutes and continued to rise to 133 ppm by 120 minutes (the cutoff time being used in 2017).
This second test was done after a low sugar/carbohydrate diet and two rounds of herbs (about 4-6 weeks each) as well as a 2-week course of the antibiotic of choice for SIBO, Rifaximin. As you can see, at 60, 75, and 90 minutes his gas levels still remain significantly greater (31 – 147 ppm) than the 20 ppm we would call “negative” and his symptoms persisted.
This last test was completed after I led this client through a 2-week Elemental Diet. As you can see, his SIBO was eradicated entirely! Now in the first 90 minutes, his gas levels peak at only 6 ppm (again, “negative” is below 20 ppm).
More than seven months later, this client reported feeling excellent when we last spoke – regular bowel movements and significantly better overall.
Case Study #2: 45 Year- Old Female
This client presented with a long GI history (amongst other conditions) and her testing showed very elevated hydrogen gas levels at 45, 60, 75 and 90 minutes (31 – 100 ppm). Due to the many conditions she was dealing with, she decided to embark on a 2-week Elemental Diet as her first treatment. She was very motivated and eager to feel better as quickly as possible. In addition, her high gas levels would likely have required a strict diet and multiple courses of antibiotics or antimicrobial herbs to clear SIBO.
As you can see from her retest below, (done on day 15, after a 2-week Elemental Diet was completed) her gas levels are down significantly and her SIBO was eradicated! Her 45, 60, and 75 are all below the 20 ppm for SIBO to be “negative”.
Again, 90 minutes is the transition point between the small and large bowel and, although her 23 ppm at 90 minutes is slightly above the 20 ppm that we consider “negative”, the lactulose solution (taken to perform the breath test) combined with 2-weeks without solid food in her system, would both encourage a slightly faster transit time, making it likely that we are getting a reading from her large bowel by 90 minutes time.
More meaningful is that 5-month from this testing, this client reports no bloating, no GI pain, and regular bowel movements. Additionally, her skin has cleared and her musculoskeletal pain (arthritis & pain from a spinal injury) has been eliminated.
I hope this post and these case studies illustrate how SIBO can be helped by an Elemental Diet within a short time frame and with dramatic results!
You can read more on the Elemental Diet Program Page – and be sure to check out our client success stories at the bottom of that page. Please reach out to Debbie if you have any condition that an Elemental Diet might benefit and are interested in one-on-one support.
Lastly, in my first blog post when I wrote about the Elemental Diet, I linked to several studies showing the other conditions that an Elemental Diet might help treat. Here are three additional studies that show the link between SIBO & IBS.
- IBS associated with imbalance of gut flora, with SIBO often present https://www.ncbi.nlm.nih.gov/pubmed/15316000; https://www.ncbi.nlm.nih.gov/pubmed/22262197
- Removal of SIBO is associated with 75% reduction of symptoms in IBS patients https://www.ncbi.nlm.nih.gov/pubmed/12591062
I’ve been looking for results from the combination of antibiotics, herbs and the elemental diet. The two cases you provided is well presented with breath test before and after. Very informative.
Thank you. Glad to hear it was helpful!
Debbie, do you know how the elemental diet impacts Candida? Thanks.
Angela,
I think how an ED effects Candida somewhat depends on which ED formula you are using and what the ingredients are. I personally put all my clients on a natural antifungal before, during, and for 2 weeks post ED to ensure that we cover our bases 🙂
I am in atlanta. Would you do telehealth appointments? I’ve been feeling awful for nearly 3 years. I have some common and some weird symptoms such as bloating, incessant burping, bad constipation and dizziness. I feel the need to constantly eat to keep up my strength. My labs over the past 3 years have shown no predisbetes (A1C) . I recently took a breath test on Friday for SIBO. I’m hoping for a diagnosis of some sort so that I can get help. It’s almost become debilitating. I have a lot of food se sensitivities but the allergy test came back negative. I’ve had stubborn h pylori in the past but the RX is too strong for me. I feel like the bacteria is taking over my body and eating the food before me hence the hypoglycemia… please offer any advice that you can. I really need help.
Hi Shan, I will email you directly 🙂
I’ve been struggling with SIBO for 3-4 plus years with strong symptoms of anxiety , irritability, bloating , constipation and insomnia.
I’ve been experimenting with ED dextrose free recently and I just started a prescription of xifaxin and neomycin. ( 3rd prescription of xifaxin in 2 years)
Would it be ok to use lowfod map foods/SIBO friendly foods for one meal a day and one ED drink (2 scoops) a day while using the 14 days of antibiotics and then do a 14 day ED only to hopefully eradicate the SIBO then follow that with a whole30 for 30 days then continue with a paleo life style with IF and select times for 1-3 days water fasting monthly.
This seems like a good plan to me. I’m very much open to your feedback. Thank you 🙏
I see your email and I will email you directly Debbie. I’d be happy to work with you and guide you though this.
Hi, I am having sibo. I would like to get your suggestion about the treatment. Can you do the virtual appointment?
Hi, do you know if any of your clients who have been a few years post elemental diet have ever re-encountered a resurfacing of symptoms?
Thanks.
Yes, it can be common for symptoms to relapse. While an ED is very effective at eradicating SIBO, steps must also be taken post ED to identify the root cause and decrease the likelihood of recurrence.
Hello- my husband is starting his second week of Xifaxin today. He is not seeing results, and his doctor recommended the ED. Can he start the diet while on antibiotics? The second week if the diet he would be off Xifaxin. Thanks.
I have never personally used an ED with Xifaxin, but I have used herbs with an ED in certain situations. I would suggest that he re-test for SIBO after the 2-weeks of antibiotics, and then if he is still positive, consult with someone to help him get to the root. If he was methane positive, Xifaxin is not complete treatment. I would be happy to work with him. Feel free to reach out to me directly at debbie@mindfulnutrition.com
Hi Debbie,
I’m wondering if you have ever used an ED on a pregnant woman? I have seen studies of the diet being used safely to treat Crohn’s disease in pregnancy but nothing recent for Sibo.
Thanks,
Hannah
Hannah,
Thanks for the note. I have not personally treated a pregnant woman for SIBO using an ED. I would only consider that if you have extremely high gas levels and you are under the supervision of your MD/OBGYN and you work with someone who can calculate your caloric needs correctly.
Dear Debbie, I am terrified of the weight loss I have suffered recently, but I have had this experience before, first time augmentin stopped it in ’97, the next in 2009, metronidazole was a miracle drug for me, when a friend told me I had low acid and that was what caused it when flu got down to my stomach and persisted, and the last time, in 2 019, an under the gumline abscess which when found had a 7 mm pocket of pus which went down to my stomach causing erosions of the antrum and an esophageal ulcer and made me very sick, but my ob-gyn saved me with 250 mg. of metronidazole twice a day. (Rifaxamin had done nothing for me and my problem seems to be methane based.) But after the metronidazole curbed the weight loss, I had to address the gastr itis with close to 2 months of omeprazole. This time, I had gone through a very stressful move that was forced on us, (apartment being sold), and out of fear of covid I had been taking 1,000 mg of Vitamin C, with other vits, D3, B 1 2 , Nac, 50 MG. OF ZINC AND 500 MG. QUERCETIN, but my mistake was taking the C on an empty stomach fi rst thing in the morning, not r ealizing this was likely irritating my stomach lining and making it porous for the penetration of the pathogen. Each time it has been non h. pylori. A recent endoscopy shows a “mild” erythema of the stomach lining; (ulcer is gone, apparently fixed by the omeprazole and a miracle), but again I am losing weight, and sure I have SIBO. The constipation was so bad I overdid it with ex-lax (2 , and then another the following day, which gave me palpitations. Since I have used sennakot, much gentler. I was seemingly fine as late as April when friends noticed my unintentional weight loss and I then got sick with burping, nausea, dizziness, flatulence, constipation and GERD.Taking omeprazole although added th roa t coat, and slippery elm tonight instead, and was put on med for heart rate control; I am afraid of possible side effect s f rom th eantibiotics, especially as I am now older. My ob-gyn again tried the metronidazole, at 250 mg. twice a day and did not have bad side effects, but was still on the vitamin C at the time so maybe nothing would have worked then, but since C was discontinued. I am considering the ED, but I fear weight loss will be worse; maybe there is a partial ED you could guide me through? I am also pre-diabetic at 1 13- 1 19 for glucose which is the way I was in 2 01 9, also so was looking at the dextrose-free option. I am sticking to salmon, sa rdines, leafy gr eens, papaya, ripe bananas, some avocado, carrots, ginger helps with costochondritis that was onset with this ailment. Drank potato juice tonight for the GERD. I sleep on my left with head elevated. I will not get through this without help. Allopathic docto rs he rethink h. pylor i is the only pathogen in stomach, but I do not have that and did not in the past.
In case you wondered, I tried the metronidazole right away while still on the C when I discovered the SIBO again, and that was at the end of May, and I took it for a week. But did not halt the disease this time, although may have been because of the active gastritis due to the C which I discontinued. I take Co Q10 and fish oils, still taking B1 2 and D3. Considered MegaSpore Biotic but do not want to make more mistakes if probiotics are not in order now. Very worried about possible extreme side effects of the antibiotics; they did not cause the palpitations; I think it was the effort and the stimulant effects of the EX Lax, which I overdid just last week.
Hi Phyllis,
Thank you for sharing some of your story. It sounds like you’ve been though a lot! If you would like to learn more about becoming a client and working with me on your health goals, please email me at debbie@mindfulnutrition.com
Thank you!
Hi Debbie, I just heard your podcasts on sibo with Brian Jerby and found both very informative. I “self diagnosed” me having methane sibo based on all the symptoms after a stressful stretch in life and started Atrantel 2 weeks ago which I tolerate and is helping. I have cut out anything that irritates my stomach but by the end of the day is still bloated. I just received my order of Aborb plus which I plan on starting in about a week too many things going on this coming week.
I heard on podcast you are thinking of doing a study using Atrantel together with elemental diet, and is wondering what you charge for per consult, and if you accept new clients?
Hi Birgitte,
Thanks for inquiring. I will email you directly…