Swedish Egg

Swedish Egg

Tuesday, April 21, 2015

Article Review: SIBO Treatment Strategies by Aglaée Jacob

Aglaée Jacob, MS, RD is a French Canadian holistic dietitian specializing in the Paleo approach to digestive health. I've been following her work since 2013 when I first found out about SIBO, and have always appreciated her professionalism and attention to detail.

Today I'd like to share some highlights from an informative article by Aglaée on the Treatment and Management of SIBO, published in Today's Dietitian in December, 2012. I've underlined the parts that stand out to me for emphasis:

"SIBO and IBS symptoms are the same: abdominal distension, flatulence, cramping, diarrhea, and constipation. These digestive symptoms result from both the high osmotic activity and fermentation potential of incompletely digested and unabsorbed carbohydrates present in the small intestines."

In other words, bloating and distention are caused by accumulations of gas (the byproduct of bacterial fermentation) and water (drawn into the gut via osmotic activity) that build up in the small intestine. The presence of gas and water make your belly expand like a balloon. The reason this fermentation and osmotic activity happens is related to the presence of undigested carbohydrates in your gut.

"Both the gas produced by intestinal fermentation and the water drawn through osmosis can contribute to bloating in SIBO patients. The type of gas produced by the bacteria also seems to impact the motility of the intestines. Hydrogen-producing patients are more likely to suffer from diarrhea, while methane producers are more prone to constipation."

I'm super fascinated by the impact of bacterial gas type on motility. A C-type myself, I have long been a proud producer of odorless methane farts. Methane-producing bacteria get overgrown when slow transit time causes an overgrowth of hydrogen producing bacteria. But isn't it ironic (if not ingenious, from the microbe's point of view) that methane itself is a CAUSE of constipation. Why might this be?

"Research conducted by Mark Pimentel, MD, director of the gastrointestinal motility program at Cedars-Sinai Medical Center and author of A New IBS Solution, indicates that increased intestinal transit time associated with methane isn’t due to decreased motility but rather to hyperactive reverse peristalsis.[1]"

What the hell: hyperactive reverse peristalsis? Doesn't that sound a lot like "poop going in the wrong direction—with a quickness"? I need to learn more about this. According to the dictionary, "reverse peristalsis" also means "vomiting." Con-fu-sing! Note to self: further investigation warranted.

Anyway, the article continues with some basic dietary recommendations for IBS, specifically the strict avoidance of fermentable carbohydrates. This means a) following a low-FODMAP diet and b) further avoidance of all polysaccharides (grains and starchy veggies), even those which are considered lower in FODMAPs, until symptoms resolve:

"Digestive symptoms tend to significantly improve after SIBO treatment, but it’s important for patients, especially in the beginning, to avoid foods that can contribute to intestinal fermentation. Damage to the lining of the small intestines can impair secretion of brush border enzymes, such as lactase, sucrase, and maltase, according to SIBO expert Allison Siebecker, ND.[2] Undigested lactose, sucrose, and maltose (starch fragments) aren’t absorbed and can become substrates for intestinal fermentation. Restricting lactose, sugars, and starches can attenuate bloating and normalize bowel movements until the brush border is sufficiently healed to normally produce digestive enzymes again.[2]

"Foods containing FODMAPs (fermentable oligo-, di-, mono-saccharides and polyols) also can ferment in the small intestines and therefore should be limited if they induce symptoms in SIBO patients.[2] FODMAPs include fructose (eg, high-fructose corn syrup, agave syrup, honey, apples, pears); lactose (eg, milk and yogurt); fructans (eg, wheat, barley, rye, onions, garlic); galactans (eg, legumes); and polyols (eg, sugar alcohols, mushrooms, cauliflower, avocados, stone fruits)."

Beyond eating the right foods (for as long as necessary until healing has occurred) another recommendation for treating SIBO is to NOT eat between meals, also known as meal spacing. Meal spacing allows for proper functioning of the MMC (Migrating Motor Complex), a mechanical wave-like process that cleans out the small intestine between meals:

"One of the most common underlying causes of SIBO is the impairment of the migrating motor complex (MMC). The MMC corresponds to cleansing waves activated approximately every 90 minutes in the small intestines when fasting to prevent the accumulation of debris and excessive amounts of bacteria. Pimentel found that the MMC is decreased by 70% in SIBO patients.[1] Apart from snacking, stress also negatively impacts the MMC. Encourage patients to space their meals every three to five hours and better manage their stress to promote regular MMC activation and prevent SIBO from returning."

Eating too often throughout the day (the popular Graze Method) and high stress levels both impair the MMC. Meal spacing boils down to waiting at least 3 and preferably 4-5 hours after a meal before you consume any kind of caloric food or drink. This means only water (or another non-caloric beverage, such as unsweetened herbal tea) would be allowed. Such mini-fasts permit the cleansing wave of the MMC to push excess bacteria out of the small intestine.

Meal spacing is a strategy I try to apply consistently. Bonus: Meal spacing rests the digestive organs, increases energy and helps stimulate healthy appetite, adding to the pleasure and enjoyment of eating. As for stress management, consider deep breathing, meditation, yoga and exercise. A strong, metabolically active body and a calm, quiet mind are well worth cultivating, don't you agree?

Click here to read the Today's Dietitian (Vol. 14, No. 12, p.16) article, excerpted above, in its entirety.

Click here to visit the website of Aglaée Jacob, The Paleo Dietitian. (You really should. She's got sound advice, tasty recipes and great diet handouts available for free download, too!)

1. Pimentel M. A New IBS Solution. Sherman Oaks, California: Health Point Press; 2005.
2. Siebecker A. Small intestine bacterial overgrowth: clinical strategies (webinar). September 17, 2011. http://ce.ncnm.edu/course/search.php?search=SIBO. Accessed September 25, 2012.

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