SIBO: What Is It and How Do You Deal With It?

Everyone experiences gas and bloating from time to time. Even diarrhea or constipation. But what if those become the norm? Perhaps they are accompanied by weight gain or weight loss, anemia, abdominal pain, or food intolerances. Those symptoms could indicate Small Intestinal Bacterial Overgrowth (SIBO).

What is SIBO?

SIBO (Small Intestine Bacterial Overgrowth) is a condition where bacteria that should normally inhabit the colon (large intestine) are present in increased numbers in the small intestine.

What does SIBO look and feel like?

• Gas
• Bloating
• Diarrhea and/or constipation
• Malabsorption
• Anemia
• Weight gain or loss
• Abdominal pain
• Food intolerances
• Systemic inflammation

If these symptoms sound like Irritable Bowel Syndrome (IBS), that’s because 60%-80% of all IBS cases are actually caused by SIBO!

Why does SIBO happen?

Normally, our gut has natural mechanisms (such as hydrochloric acid, motility, and the ileocecal valve) to keep bacteria relatively quarantined in the large intestine so that the small intestine remains comparatively sterile. 
In SIBO, however, microorganisms from the colon excessively populate the small bowel. Some possible causes may include:

• Intestinal infection (parasites or food poisoning)
• Low fiber and high sugar diet
• History of abdominal surgery
• Diabetes (or other conditions that can affect the neurological system)
• Celiac disease
• Intestinal adhesions (or other anatomical differences)
• Chronic antibiotic use or acid-blocking medications

SIBO Diagnosis

 Diagnosis of SIBO can be a challenge. Standardization and mainstream acceptance are lacking in the medical community.

Types of SIBO

Currently, three types of SIBO have been identified. While bloating, gas, and abdominal pain are the hallmark SIBO symptoms, each SIBO type has distinct symptoms.

• Hydrogen Dominant: diarrhea or mixed constipation/diarrhea.
• Methane Dominant: now referred to as Intestinal Methanogen Overgrowth (IMO) – constipation.
• Hydrogen Sulfide: diarrhea, nausea, bladder pain, and gas that smells like sulfur (rotten eggs).

While each SIBO type has typical presentations, symptoms may also present atypically. Testing options are available, but limited. 

Diagnostic Tools

• Breath Tests. The least invasive and most widely available test for SIBO, breath tests are now available for all three SIBO varieties. Research suggests they are not validated diagnostic tools, and prominent clinicians have varying opinions about their usefulness. 

• Jejunal Aspirates. Although considered the “gold standard” in the research community, these tests are invasive. (They include biopsies of mucosal juices in the mid-region of the small intestine). These tests are expensive and largely unavailable.

Bearing all this in mind, taking a breath test may offer greater insight versus diagnosis based on symptoms alone.

Treatments

To date, addressing SIBO has been largely empirical, as it has not undergone the scrutiny of sponsored clinical trials. As such, there are currently three supported types of therapeutic approaches: antibiotics, botanicals, and dietary.

Antibiotics

The mainstay of conventional SIBO treatment is antibiotics. Practitioners are using rifaximin (non-systemic) to treat hydrogen dominant, while metronidazole (systemic) and neomycin are often used for methane dominant. 

Perhaps the most important question to consider regarding using antibiotics to treat SIBO is, do the benefits outweigh the risks? Evidence has revealed that the impacts of some antibiotics can remain for long periods. 

Botanicals

While the research into herbs to address SIBO is still evolving, it offers a promising alternative to costly antibiotics and may be less disruptive to the microbiome. Herbs tested for their effects regarding SIBO include oil of oregano, berberine, wormwood, lemon balm, red thyme, Indian barberry, garlic, black cumin, cloves, cinnamon, thyme, all-spice, bay leaves, mustard, peppermint, and rosemary. 

Dietary

Individuals with SIBO run the risk of developing a B12 deficiency (leading to neuropathy in some cases), as well as anemia due to B-12, B6, folate, or iron deficiency. Fortunately, as Hippocrates said, we can let food be our medicine. 

Foods containing glutamine, curcumin, zinc, and omega-3 fatty acids are particularly useful at alleviating intestinal inflammation, often present in SIBO. Think meat, shellfish, and peanut butter (zinc); bone broth (glutamine), turmeric (curcumin), and salmon (omega 3). Other foods replete with common SIBO nutrient deficiencies include:

• Vitamin A: Eggs, lactose-free milk, carrots, arugula, spinach
• Vitamin D: Lactose-free milk, fatty fish such as salmon, sardines, as well as the sun
• Vitamin E: Sunflower seeds, peanuts, olive oil (garlic-infused olive oil too!)
• Vitamin K: Arugula, spinach, swiss chard
• Vitamin B6: Salmon, chicken, spinach
• Folate: Broccoli, spinach, romaine lettuce, fortified white rice
• Vitamin B-12: Meat, fish, poultry, lactose-free milk
• Iron: Meat, fish, poultry, quinoa, potatoes, spinach

If you or a loved one think you might be dealing with SIBO, this overview will hopefully help you create a game plan to address it. Understanding the symptoms, types of SIBO, diagnostic tools, and therapeutic approaches is a great place to start!

Here’s a SIBO-safe recipe to try! These flavor-packed energy balls are a great snack when you’re on the go and are simple to make.

Oat, cranberry, and chocolate chip energy balls¹⁰

Serving size = 1-2 balls 

1 cup rolled oats
1 tbsp chia seeds
1 tbsp flax seeds OR ground flax seeds
1.5 tsp ground cinnamon
1 tsp ground OR fresh-grated ginger
½ cup dried cranberries
1.5 Tbsp maple syrup
½ cup puffed quinoa
½ cup natural creamy peanut butter (OR other nut/seed butter that is free of added sugar, salt, and oil)
2 Tbsp refined coconut oil, separated into 1 tbsp increments 
2 Tbsp mini dark chocolate chips

1. Place oats, spices, flax, and chia into a food processor and process until the mixture is flour-like in consistency.
2. Add cranberries, maple syrup, and puffed quinoa to the food processor, then add ½ cup peanut butter and continue to process until a dough begins to form and stick together. Assess the dough by pinching it to see if it sticks together. If not, add 1 tbsp refined coconut oil. NOTE: Dough may be slightly crumbly after peanut butter is added. This is okay.
3. Add chocolate chips and pulse several times until well distributed through the dough.
4. Using a large spoon, scoop out a spoonful of dough and roll it between your hands into neat balls. Place balls in an airtight container and store them in the fridge.

Notes: 

1. For a nut-free alternative, blend 64g of sunflower seeds into a paste and use in place of peanut butter.
2. Dough may appear crumbly before forming into balls. This is okay – they will still form balls.
3. If you have IBS or SIBO, consider the serving size the maximum amount to eat in one sitting. Consuming more than this serving size may result in GI distress due to exceeding the “safe” concentration of FODMAPs in the cranberries (1 tbsp cranberries is the limit).
4. To reduce sugar content, swap regular dried cranberries with reduced-sugar dried cranberries.

Preparation Time: 20 minutes
Yields: 14-16, 1-inch balls
Equipment: food processor, large spoon, spatula
Recipe adapted from Monash University FODMAP Diet by Ashley Bent