This post is the third installment of a three-part series on Small Intestine Bacterial Overgrowth focusing on SIBO diet, food lists, and lifestyle changes. For more on SIBO symptoms and testing, see Part 1. For more on herbal antibiotics, supplements and probiotics for SIBO, see Part 2.
One of the questions I’ve gotten the most around my recent battle with critters in my small intestine is what’s the best SIBO diet.
There seems to be a lot of bewilderment around what to eat to combat SIBO on its own, versus what to eat during the “kill phase” of treatment, and then a whole lot more confusion when it comes to transitioning to the next phase of healing.
Though I’ve been seeing an integrative doctor in New York who did a fantastic job getting me the testing and diagnosis I needed, like many healthcare professionals, he’s only had so much rope to dole out when it came to gently towing me through the process of making over my life for SIBO.
The materials he offered at the moment of diagnosis were a small helping hand, but I’ve largely been on my own since, wading through the murky waters of internet information, and designing my own protocol the best I can.
In the last part of this series on treatment, I discussed my herbal antibiotic and supplement protocol. But the aspect of treatment that had the biggest impact on my symptoms were the changes I made to my diet, which included removing high FODMAP foods and making a host of modifications to not just what I was eating, but how I was eating it.
I’m going to discuss some of the opinions around these diet choices below. But before I do, I want to reiterate something I said in part 1: though your diet can certainly help you heal your gut from SIBO, it’s rarely the root cause, and therefore usually not the lone cure.
There is a difference between controlling symptoms and actually clearing the bacteria. And it takes a more complex approach than diet alone to do the latter.
The reason I say this is to mitigate some of the fears I’ve witnessed around relapse.
The goal of any SIBO treatment–diet, supplements, or otherwise–is to get you eating a diverse, nutrient-rich array of vegetables, no matter how many fermentable sugars they contain. Staying on a restrictive diet long-term is not necessary for prevention, and may in fact be damaging to the overall health of your bacterial ecosystem in the large intestine.
As for me, I’m currently in the process of slowly reintroducing foods I removed, feeling out my tolerance, and continuing to give my digestive system some additional legs up so I can leave the SIBO chapter of my wellness project behind me.
If you’re looking for a helping hand experimenting with a SIBO friendly diet, I recently added a 4-week low FODMAP meal plan to my online course, 4 Weeks to Wellness. It would be an honor to coach you along this leg of your healing journey and provide all the support I can in the kitchen and beyond!
With health and hedonism,
WHAT DIETS WORK FOR TREATING AND HEALING SIBO?
It’s always important to be reminded that you have options. So, to start, I want to give you an overview of some of the most talked about diets for SIBO, and when during the treatment process, they are applied.
The main objective during the “kill phase” is to remove as many of your bacteria’s food sources as possible. And in brief, your critters like to feast on sugar.
The low FODMAP diet, which eliminates easily fermentable short-chain sugars that are found in many plants, and the SCD diet, which goes a step further and eliminates all sugars and grains, help alleviate symptoms by starving the bacteria of their favorite foods.
The secondary aim of these diets is to heal the intestinal lining by removing irritating ingredients and supplementing with foods that help rebuild. Since leaky gut is commonly associated with SIBO, thanks to unwanted bacteria eating away at your intestinal lining and creating more permeability, the healing phase is just as important.
Low FODMAP Diet (LFD): The most widely discussed option in conjunction with IBS and SIBO, this diet removes various types of sugars, including legumes, dairy, wheat, high fructose fruits and sweeteners (including honey and agave), artificial sweeteners, and many vegetables. It’s thought that some of these ingredients are poorly absorbed and irritating to the higher levels of the intestinal tract, so removing them gives you both relief from the unwanted gas that’s produced when bacteria eat your food for you, and also allows the digestive tract to heal. You can find more in-depth information on the low FODMAP diet and how to cook for it here. You can also download my FREE low FODMAP e-book here!
Specific Carbohydrate Diet (SCD): Unlike LFD above, this approach is progressive, meaning that it begins strict and evolves to be more lenient as your gut heals. Grains, starchy vegetables, lactose, some beans and any sweeteners other than honey, saccharine and occasional stevia are prohibited. The diet also emphasizes cooked foods and minimal fiber in the beginning phases until your intestinal wall begins to repair itself.
SIBO Specific Food Guide (SSFG): This is Dr. Alison Siebecker’s hybrid approach. It combines the best of both diets above, reducing a broader range of fermentable carbohydrates than any other SIBO diet (including most sugars, grains, starchy vegetables, legumes, and dairy). It’s worth noting that Dr. Siebecker usually deals in more complex, serious cases of SIBO that have been hard to eradicate, so this more restrictive diet may be the approach of last resort after trying one of the two above.
Gut And Psychology Syndrome Diet (GAPS): a similar approach to the SCD, but with even more phases, the GAPS diet is thought of as a good option as a phase two to the low FODMAP diet during your healing phase. As you start reintroducing high FODMAP foods in slow, targeted intervals, you can also begin experimenting with some of the tennets of the GAPS diet which seeks to rebuild your digestive tract through daily bone broth and retrain your gut’s immune system through fermented foods like sauerkraut juice. Using lots of healthy fats like coconut oil and ghee in cooking also helps heal the gut and lubricate your system.
HOW STRICT DOES MY SIBO DIET HAVE TO BE?
These diets can feel like an incredibly complex jigsaw puzzle with countless inconsistencies and contradictions. Which is why I think the most important thing you can do is start somewhere, picking and choosing as many ingredients as you’re willing to give up without completely isolating your life.
The varying dietary approaches should be an empowering sign that perfection is not necessary for curing SIBO.
These types of elimination diets are not an exact science. And in fact, there is an argument to be made about teasing your system with high FODMAP foods or simple sugars during treatment to ensure that your bacteria don’t go dormant.
Many doctors, like Chris Kresser, don’t believe in completely reducing your critters’ food sources while on herbal or regular antibiotics. While these strict diets may prevent bacteria from multiplying, they can also cause them to go into hibernation, which means the medication won’t be as effective at killing the whole population.
The happy medium you want to find with your diet is between managing the more uncomfortable symptoms of SIBO and making sure your bacteria don’t go into hiding.
Here’s the sweet spot I found:
During the first two weeks, I took on a fairly restrictive approach with my diet, eliminating all added sugar, only eating whole grains (like brown rice and quinoa), and reducing my FODMAP’s as much as possible.
I figured that this was the stage when my bacteria were most prominent and out of control. I also wanted to reduce my symptoms immediately and begin to heal any permeability in my gut that may have resulted from the unchecked feeding frenzy that had been taking place.
In additional to the diet, I also decided to take on a month-long vice detox, meaning no alcohol or coffee, in conjunction with my kill phase.
Eating out was understandably incredibly difficult during the beginning stage. I only ate 2 meals at restaurants in the first 3 weeks! But at the halfway mark, I began loosening my grip slightly on the FODMAP elimination, allowing myself the occasional (like once a week) condiment or sauce at a restaurant that I knew probably had garlic or onion in it. This allowed me to a) have a more flexible stress-free life, and b) keep my bacteria on their toes, even if it meant a small set back in my symptoms.
The reason I didn’t go hardcore SCD is because I know my body and have found that my energy bottoms out when I am too strictly paleo/low-carb. My other medical advisor, Heidi Lovie, says this is fairly common with Hashimoto’s and one reason why it’s important to do some trial and error while taking on a SIBO diet. Whole grains with more insoluble fiber are less likely to give your critters a fast infusion of sugar to eat. And minimal portions gave me the carbs I was craving. It also made cooking at home 24/7, less of a slog when I could resort to a few quick fixes like quinoa pasta.
Hashi Posse, take note.
THE BIGGEST LIFESTYLE CHANGES THAT SUPPORT SIBO TREATMENT
With digestive issues like SIBO, it’s not just what you eat, but how you eat it. In fact, the way you consume your food could be a big contributing factor to what caused your SIBO in the first place.
You can review the root causes here, but most revolve around a malfunction of the Migrating Motor Complex, too little stomach acid, or structural impediments like scar tissue from abdominal surgeries or endometriosis. The lifestyle changes below can be game changers for some of these contributing issues—perhaps even more so than diet.
Try intermittent fasting. Some people will advocate for small meals throughout the day so that your intestines never have too much on their plate, so to speak. In my interview with Dr. Will Cole, and through my own personal experience, I’m more apt to advise you to, instead, limit yourself to two meals a day and wait at least 14 hours between dinner and breakfast the following morning to let your digestion catch up. Especially if you’re SIBO-C, i.e. prone to constipation, this could be a game changer and something you might want to continue post-treatment.
Eat two main meals a day and avoid snacking. Part 2 of the first recommendation is to stop snacking. Your MMC needs at least 90 minutes in a fasting state to kick into gear. If you’re the type of person who always needs to be sticking small amounts of food in your mouth, this could be a big contributing factor to SIBO. In general, I’m not a big believer in snacking. It seems like a habit that’s been ingrained in us from packaged food brands that advertise on television, not an actual necessity for eating well. If you’re feeding yourself nutritious, well-balanced meals—meaning foods that are full of fiber, healthy fats and protein, and free of hidden sugars—on a regular schedule, you shouldn’t be facing the types of food cravings that drive snacking. If you find that you become starving two hours after lunch, it’s time to reconsider what you’re eating for those meals. Perhaps you’re not having a big or filling enough lunch. Perhaps you have bigger fish to fry when it comes to balancing your blood sugar. Use your SIBO protocol as a time to reboot how you look at meal time and find foods that keep you fuller for longer.
Drink lemon water before meals. Adding 2 tablespoons or fresh lemon juice or apple cider vinegar to 8 ounces of water before you eat will help stimulate your stomach acid. If this is a problem for you (and you can ask your doctor to test you for low stomach acid) there are also pills you can take to supplement Hydrochloric Acid.
Kick the Antacids and Proton Pump Inhibitors. Per the above, these drugs are not helping, they’re hurting. Your stomach acid is designed to kill bacteria and make it impossible for outside invaders to reach the small intestine. When levels are low, this doesn’t happen. Cue, SIBO.
Eat slowly and chew your food until it’s mush. When you have SIBO, your digestive system is already in distress. You’re not absorbing your food properly, and there’s bacteria competing for precious nutrient resources. The best way you can ensure easy assimilation and give your critters less substance is to chew your food as well as possible. This takes practice. Frankly, it takes forever. And it’s annoying. But it’s worth it. Your intestines don’t have teeth! You can try Robyn Youklis’ fantastic Chewing Challenge to get some chews under your belt.
Start with cooked, soft foods and soups. Depending on how bad your symptoms are, and/or how bad you are at chewing, you may find it helpful to stick with soft or pureed foods during the first few weeks of your treatment. Cooked foods are generally easier on the digestive system, and simple soups allow for you to do less work if chewing is not your strong suit.
Drink lots of water in between meals. Regardless of whether you’re SIBO-C or SIBO-D, staying well hydrated is hugely important for making sure your digestive system runs on schedule, and if you’re prone to the latter, replenishing some of the vital liquids you might be losing down the toilet.
Supplement with collagen. One of the big tenets of the GAPS diet is to drink bone broth every single day. Though it’s usually a leg of the diet that’s not incorporated until post-treatment, I think it’s a great addition during every phase of the process. Bone broth is packed with amino acids and collagen that help heal the lining of the intestines. Making your own stock is also an important first step towards cooking for a low FODMAP diet, since most commercial broths have garlic and onion in them. I basically had bone broth in my slow cooker for 4-weeks straight, adding more water and veggie scraps every day. If you don’t feel like making it though, you can buy collagen peptides and add them to your soups, morning tea, or smoothies.
Try to wear looser clothes. Okay, okay. Not everyone wants to wear a muu muu to work. But perhaps during your kill phase, it’s worth giving your gut a break from the Spanx and other modern corsets. As we’ve learned, structural problems—meaning anything that constricts our organs and give them less room to do their jobs—is a precursor to SIBO. See what happens to your digestion when you give your insides a little room to breathe.
Get an intestinal massage. I mentioned visceral manipulation in part 2 of this series, but it’s worth repeating here. Practitioners of VM are adept at helping to break up scar tissue and other strictures that impede mobility of your intestines. This kind of bodywork is non-invasive and can do wonders for your digestion, even if you don’t have SIBO!
HOW DO YOU PREVENT A SIBO RELAPSE?
I’ve heard from many of you who are afraid to loosen your grip on your diet for fear of relapse. In reality though, as I mentioned above, your diet is not what’s causing your SIBO, and therefore the second you stray from your protocol does not mean a switch is flipped and the bacteria comes back.
Once you’ve finished your treatment plan, waited 2 weeks to re-test, and gotten the result that your SIBO has been cleared, it’s time to start shifting your diet.
There are plenty of resources out there about how to reintroduce low FODMAP foods in stages, and I provide my own worksheets and guidance in my online course, 4 Weeks to Wellness. Just remember that reincorporating inulin-rich vegetables and nutritious fruits is important for maintaining good overall gut health, which is equally important for prevention.
The second aspect of the healing/prevention phase is adding probiotics and fermented foods to ensure that your gut’s immune system is back on track. You may find that you’re sensitive to these foods for a little while, so make sure to go slow. I drank 1 tablespoon of kombucha every day for a week, then upped it to 1/4 cup, then 1/2. Now three weeks in, I’m drinking half a bottle.
In the GAPS protocol, it’s recommended that you add 1 tablespoon of fermented vegetable juice to your meals, which is another great tactic. Your doctor may also recommend taking one or several robust probiotics as part of your supplement regimen.
The most important aspect of preventing a relapse though is sticking with some of the lifestyle changes I mentioned above. When my system is feeling backed up and I’m not evacuating properly, I reach back into my motility tool kit: I skip breakfast, I drink more water, I try not to snack. I sip bone broth. If in dire straights, I’ll add smooth move tea or natural calm.
Luckily, your digestive system will tell you how you’re doing on a daily basis. If symptoms flare up, or you’re becoming less regular, you can always resort to eating low FODMAP for a day, opting for pureed soups, or chewing your food until it’s pulp.
You also may want to consider continuing with some of your supplements, as I have. Particularly digestive enzymes, the occasional drop of oregano oil, and a prokinetic.
The latter is something I started immediately upon completing treatment, and something I may need to rely on indefinitely to ensure my MMC is running as it should. Here is a list of options to explore. I am currently on Low Dose Naltrexone and I can really feel the difference in how things are moving through my system.
Finally, the biggest thing you can do to treat, heal and prevent relapse of SIBO is to get your stress under control. Stress is a noted contributing factor to developing SIBO, and certainly one that will make symptoms flair up even once the critters are gone. Our gut has a mind of its own. Literally. And it’s irrevocably connected to how we think, feel, and process uncomfortable emotions and fears.
You can’t cure this. It’s a fact of life. What you can do is tackle the problem from both ends: eat for your gut and make room in your days to soothe the mind. Go to yoga, journal, soak in the tub, meditate, take daily walks–whatever you need to do to unwind. If this has been a historic problem that you have yet to tackle, we cover many of the strategies I just mentioned and more in my online course.
Still have questions about taking on a low FODMAP diet for SIBO and how to go about it?
Need 4-weeks worth of easy low FODMAP recipes with a step-by-step meal plan laid out for you?
I recently added a low FODMAP track to my online course, 4 Weeks to Wellness. You’ll now receive a 20 recipe cookbook, shopping lists, elimination diet guidance and reintroduction worksheets, in addition to the many other resources in the normal program.