Month: September 2019

There is much “push back” when it comes to the standard advice to “eat less and exercise more” as a means of losing weight, and for good reason. For one, metabolism will slow as a result of caloric restriction — making it that much more difficult to lose weight when deliberately cutting calories. Another reason is that it is exceedingly difficult for an obese person to exercise. For many, just getting around is a chore. It is for this reason that I focus on helping people be less hungry by eating a different mix of protein, fat and carbohydrate — because a natural byproduct of being less hungry, is eating less. Being active is possible once a person is losing weight and not feeling hungry all the time.  Yes, they are still “eating less and moving more” — but as a result, not as the focus.

Addendum (Sept 10 2019) — Weight loss is not only about what we eat.  It’s also about when we don’t eat; whether it’s having times between meals where we don’t eat, or not eating from the end of supper until the first meal of the following day (whenever that is). Thanks Dr. Andy Phung for the reminder!

A new study published yesterday (September 9, 2019) in the journal Nature Medicine[1] has found that “eating less and exercising more” may actually be good advice as we age — because it turns out that we have decreased fat turnover as we age. If we eat the same amount as we always have and don’t increase the amount we exercise,  we will end up gaining approximately 20% over a 10-15 year period [3].

Until recently little was known about fat turnover [2] — which is the storage and removal of fat from adipocytes (fat cells). A 2011 study showed that  during the average ten-year lifespan of human fat cells, the fat in them (triglycerides) turns over six times, in both men and women [2], and that when people are obese, the fat removal rate decreases and the amount of fat as triglyceride stored each year increases [2]. What we didn’t know until now is  what happened to fat turnover as we age.  This follow-up study headed by the same lead researcher as the 2011 study explored this issue, as well as differences in fat turnover after people have bariatric surgery which helps explain why some people regain their weight after weight loss, where as others don’t.

Eating Less Matters as We Age

Fat turnover is a difference between the rate of fat uptake into fat cells and the fat removal rate. High fat storage but low fat removal is what results in the accumulation of fat and in obesity. The “bad news” of this new study is that fat accumulation due to decreased fat turnover is what happens as we age, leading to accumulation of fat. That is, even if we don’t eat more or exercise less than previously, we will store more fat — which can result in as much as a 20% increase in body weight over 13 years [3].

“Those who didn’t compensate for that (i.e. decrease fat turnover) by eating less calories gained weight by an average of 20 percent”[3].

Researchers from the University of Uppsala in Sweden and the University of Lyon in France studied the fat cells of 54 men and women over an average 13 year period [3] and regardless of whether the subjects gained weight or lost weight, they had a decreased fat turnover. 

Since fat turnover is decreased as we age, to prevent weight gain we need to take in less calories than we used to, even if we are just as active.

Why We Regain Weight After Weight Loss

The study also looked at fat turnover in 41 women who underwent bariatric surgery. Results showed that only those who had a low lipid turnover rate before the surgery were able to increase their lipid turnover after surgery and maintain their weight loss 4-7 years after surgery [1]. Researchers think that if people had a high lipid turnover rate before surgery, there is less ‘room’ for them to increase their lipid turnover rate after surgery, which is why they regain the weight. This could explain why so many people who lose incredible amounts of weight following any one of a number of “diets” regain it (and then some) afterwards.

Exercise and Lipid Turnover

Previous studies have reported that fat turnover increases as we exercise [2], so based on this new study, the idea of ‘eating less and exercising more’ actually matters as we age. We can either decrease our intake as we age and/or be a little more active and avoid gaining weight — which is easy enough to do for those who are slim, if they know.

But what about those who are already overweight or obese and now find out they are more prone to storing fat now that they’re older, even though they eat the exact same way and haven’t changed their activity level?

I believe the solution is the same regardless of a person’s age — focusing on the person eating in such a way as to be less hungry, so that in the end they end up eating less. As they lose weight because they’re not hungry all the time, being more active is easier to implement.  The difference between it being “doable” depends on what we focus on. As covered in a previous article, we understand why a person who eats foods that are a combination of fat and carbs together eat more, but my approach is to gradually adjust the amount of carbohydrate in the diet, so that people can eat more protein and healthy fat, and end up feeling less hungry. When they aren’t being driven by the reward system of their brain (see linked article) to want more and more foods with carbs and fat together, it is much easier for them to eat when they are actually hungry. As they do, their weight drops as a result.

In light of this new study, what is important is that as people age there is a natural tendency to put on weight, even if they eat the same and don’t change their activity level. This means older people need to modify the amount of calories they take in and/or expend more energy, the question is how.

If you would like more information about my services, please have a look under the Services tab or in the Shop and if you have any questions, please feel free to send me a note using the Contact Me form above, and I will reply as soon as I can.

To your good health!

Joy

You can follow me on:

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Copyright ©2019 The Low Carb Healthy Fat Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the ”content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

References

1. Arner P, Bernard S, Appelsved K-Y et al. (2019). “Adipose lipid turnover and long-term changes in body weight.” Nature Medicine 25(9): 1385-1389.
2. Arner, P. et al. Dynamics of human adipose lipid turnover in health and metabolic disease. Nature 478, 110—113 (2011).
3. Karolinska Institutet, New study shows why people gain weight as they get older, Published: 2019-09-09 18:35, https://news.ki.se/new-study-shows-why-people-gain-weight-as-they-get-older

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In the first article in this series about Small Intestinal Bacterial Overgrowth (SIBO), I covered what SIBO is, how common it is, as well as its symptoms. In the second article, I outlined different tests used to diagnose SIBO, some of the challenges with those, the difference between hydrogen-dominant and methane-dominant SIBO, and why Irritable Bowel Syndrome (IBS) that does not improve despite adopting appropriate dietary changes may be SIBO.  In this article (which is part 3 in the series), I outline the main dietary approaches used in treating SIBO along with antibiotic and evidence-based herbal antimicrobial therapy, and elaborate as to whether dietary changes should come before- or after antimicrobial treatment.

In discussing the treatment of Small Intestinal Bacterial Overgrowth, it’s important to keep in mind that SIBO is the presence of types of bacteria in the small intestine that are not supposed to be there.  While dietary changes can help improve the symptoms, in and by themselves, they will not result in the elimination of the bacteria that are contributing to the symptoms. The bacteria that are foreign to the small intestine need to be eradicated, and the underlying cause of the SIBO needs to be addressed. As outlined in the first article, Small Intestinal Bacterial Overgrowth may be caused by several conditions, including low stomach acid (achlorhydria), pancreatic insufficiency, anatomical abnormalities such as small intestinal obstruction, diverticula, or fistula (which are abnormal connections between an organ and the intestine), as well as slowing of intestinal movements (motility disorders) that are common in those with diabetes mellitus, as well as due to alcohol consumption and several other factors. Addressing those underlying causes is needed, along with correcting intestinal flora imbalance.

There are two important factors to keep in mind when it comes to Small Bacterial Overgrowth treatment; (1) despite antibiotic treatment, an older (2008) study found that recurrence of SIBO as diagnosed by glucose breath tests occurs in almost half of all people within a year of treatment [1], however individuals in this study that relapsed were older aged (which is associated with decreased stomach acid), and had a history chronic use of proton-pump inhibitor medication (which also results in lower stomach acid), (2) addressing the underlying cause of SIBO is necessary, otherwise recurrence is likely.

Three Phases of Dietary Treatment for SIBO

Some clinicians take a single dietary approach with SIBO and prescribe one of several low fermentable carbohydrate diets; either a low-FODMAP diet or the Specific Carbohydrate Diet (SCD), or a combination or variation of these. These diets limit the food sources for bacteria that live in the gut (both the small and large intestine), thereby reducing symptoms. At first glance, this may seem like an effective approach, except it has two drawbacks;

• Following a diet low in fermentable carbohydrate for periods longer than a month has also been shown to reduce beneficial bacteria in the gut, such as bifidobacteria [2].
• Some researchers, such as Dr. Mark Pimentel’s group at the Gastrointestinal Motility Program at Cedars-Sinai Medical Center, suggest that some fermentable carbohydrates remain in the diet while treating with antimicrobials based on the concept that bacteria are easier to eradicate when they’re active. Antimicrobials act on the replicating cell wall of bacteria, so when bacteria are being starved, they aren’t replicating.

A 2010 study found that treatment of SIBO with the first-line antibiotic Rifaximin alone was only 62% effective; however, when Rifaximin was combined with a specific fermentable carbohydrate called partially hydrolyzed guar gum (PHGG), the eradication rate was 85% [3]. In addition, the addition of PHGG during the antibiotic treatment phase also prevented the eradication of both of the beneficial bacteria, lactobacilli and bifidobacteria, from the large intestine.

I take a 3-phase approach to dietary support treatment of SIBO.

Phase I

A first phase of dietary treatment includes the use of a low fermentable carbohydrate diet for 4-6 weeks which enables people to begin to feel better. This is of huge importance to quality of life, after so long of feeling quite unwell! By also including the addition of partially hydrolyzed guar gum (PHGG) in the diet, it allows for the small amount of bacterial growth needed so that once the person is treated with antimicrobials, it is likely to be more successful.

Use of PHGG is also well-known to reduce the symptoms of IBS in both the constipation and diarrhea subtypes [4,5] and since most people with SIBO experience one of these symptoms, or both alternating, addition of PHGG is also beneficial for helping people feel much better, while preparing for the antimicrobial treatment phase.

Phase II

The second phase of dietary treatment coincides with the 4-week period of antimicrobial treatment prescribed by the gastroenterologist or Functional Medicine MD. During this phase, the low fermentable carbohydrate diet is maintained along with the PHGG intake, but begins to include some additional fermentable carbohydrate food, as tolerated. This helps feed the bacteria just enough so that the antimicrobials are more likely to be effective, but without making the person feel unwell.

As mentioned above, studies have shown that the antimicrobials, along with PHGG may result in up to 85% eradication[3]. A study from 2009 found that eradication rates with Rifaximin alone are only about 50% [6]. It is thought that this may be due to a failure to distinguish between hydrogen-positive and methane-positive types of SIBO.  In methane-positive SIBO, eradication has been found to be as high as 85% when Rifamycin is combined with another antibiotic, Neomycin [7]. In methane-positive SIBO, Dr. Pimentel and his group recommend 550 mg Rifaximin three times per day in combination with neomycin 500 mg twice a day for 14 days, or Rifaximin 550 milligrams three times per day with Metronidazole 250 milligrams three times per day for 14 days [8]. 

Antimicrobials prescribed by some MDs and naturopaths may include herbal antimicrobials. Herbal antimicrobials (FC Cidal® with Dysbiocide® or Candibactin-AR® with Candibactin-BR®) were shown in a 2014 study to be even more effective in the eradication of SIBO bacteria than Rifaximin [8]. Of those treated with one of the herbal therapy combinations, 46% of subjects had a negative result upon re-testing, whereas only 34% of those using Rifaximin had a negative result upon re-testing. Furthermore, approximately 57% of those who failed to achieve eradication on Rifaximin, as measured by repeat breath testing, achieved eradication on one of the two herbal antimicrobial regimens [8]. Also of significance, in 2014, when the study was conducted, standard treatment with a 4-week supply of Rifaximin (two 200 mg Rifaximin tablets 3x daily) cost $1247.39, whereas the cost for the herbal therapy (2 capsules twice daily of either treatment) was no more than $120 for a one-month supply [9]. The high treatment response rate of the herbal formulations, reduced cost of treatment, and long-term Generally Recognized As Safe (GRAS) safety record of specific herbs used in the formulations [8], and the fact that these supplements can be purchased by the general public without a prescription, provide individuals and their practitioners with several treatment options.

Phase III

The last phase of dietary treatment is the gradual liberalization of the low-fermentable carbohydrate diet. After antimicrobial treatment, once the gut microbiome has been restored, a person should be able to tolerate a healthy, whole food diet. That said, it may be advantageous for a person who has had SIBO previously to continue to avoid unnecessary additions to the diet such as sugar alcohols (xylitol, erythritol, etc.) or gums such as carrageenan, xanthan gum, and guar gum (not to be confused with hydrolyzed guar gum!), as well as to limit high fructose and lactose intake.

However, if a person begins to have symptoms again, then having a new hydrogen breath run to ensure there is no recurrence of SIBO makes sense. If the breath test is negative, then further medical investigation for other underlying causes of causes, including low stomach acid, pancreatic insufficiency, or intestinal motility disorders, may be next. Given that no other underlying cause is identified, food intolerances, including histamine intolerance, A1 beta-casein intolerance, might be worth evaluating.

Final Thoughts

SIBO, like IBS, is not easy to diagnose. More clear-cut diagnoses, such as IBD, celiac disease, food allergies etc. need to be ruled out firs,t and while IBS has now gained acceptance as a “real” diagnosis, SIBO is still one of those in which there is much debate.

I have more confidence in the jejunum aspirate method of diagnosis and wonder if the breath tests really measure what they purport to measure. That said, when people previously diagnosed and unsuccessfully treated for IBS are treated with diet plus antimicrobials, many get better. Are IBS and SIBO really two diagnoses or one?

A low fermentable carbohydrate diet has long been used in the treatment of IBS, and the use of partially hydrolyzed guar gum has a successful and safe long-term history in the treatment of IBS, so continuing to use these in the treatment of SIBO, along with evidence-based antimicrobial treatment prescribed by an MD, is a sensible and safe approach.

The Gut Microbiome – so much to learn

There is so much we are discovering about the gut microbiome (the bacteria in our intestines that we live in symbiosis with) and the relationship between alterations in the gut microbiome and chronic disease.

For example, a study published on June 19, 2019, in the journal Pain [10] found a correlation between fibromyalgia (another one of those diseases that medical professionals debate the legitimacy of) and abnormalities in the gut microbiome. In this study conducted in Montreal, approximately  20 different species of bacteria were found to be abnormally high or abnormally low in the microbiomes of subjects suffering from the disease, compared with healthy controls. It was found that “fibromyalgia and the symptoms of fibromyalgia — pain, fatigue, and cognitive difficulties – contribute more than any of the other factors to the variations we see in the microbiomes of those with the disease” [11].

There is much we don’t know in terms of IBS and SIBO, but at the end of the day, people are suffering with these conditions whose quality of life is greatly affected. If the best we have to offer people diagnosed with SIBO at this time is the use of a low fermentable carbohydrate diet along with the addition of well-studied PHGG used in conjunction with antimicrobial agents prescribed by a physician — and this helps people feel significantly better, then this is the most evidence-based approach we have at this time.

More Info?

If you would like to know more about the hourly consultations and packages I provide, including SIBO support, then please click on the Services tab or have a look in the Shop. If you would like additional information, please send me a note using the Contact Me form above, and I will reply as soon as I can.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/jerdile
Facebook: https://www.facebook.com/BetterByDesignNutrition/

Copyright ©2019 BetterByDesign Nutrition Ltd.

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the ”content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything you have read or heard in our content.

References

1. Lauritano EC, Gabrielli M, Scarpellini E, Small intestinal bacterial overgrowth recurrence after antibiotic therapy. Am J Gastroenterol. 2008 Aug;103(8):2031-5.
2. Staudacher HM, Lomer MCE, Anderson JL, Fermentable Carbohydrate Restriction Reduces Luminal Bifidobacteria and Gastrointestinal Symptoms in Patients with Irritable Bowel Syndrome, The Journal of Nutrition, Volume 142, Issue 8, August 2012, Pages 1510—18, https://doi.org/10.3945/jn.112.159285
3. Furnari M, Parodi A, Gemignani L, Clinical trial: the combination of rifaximin with partially hydrolysed guar gum is more effective than rifaximin alone in eradicating small intestinal bacterial overgrowth, Alimentary Pharacology and Therapeutics, Volume 32(8) August 2010, page 1000—1006 https://doi.org/10.1111/j.1365-2036.2010.04436.x
4. Quartarone G, Role of PHGG as a dietary fiber: a review article, Minerva Gastroenterol Dietol. 2013 Dec;59(4):329-40, https://www.ncbi.nlm.nih.gov/pubmed/24212352
5. Russo L, Andreozzi P, Zito FP, Vozzella L, Partially hydrolyzed guar gum in the treatment of irritable bowel syndrome with constipation: effects of gender, age, and body mass index, Saudi J Gastroenterol. 2015 Mar-Apr;21(2):104-10. doi: 10.4103/1319-3767.153835.
6. Peralta S, Cottone C, Doveri T, Almasio PL, Craxi A. Small intestine bacterial overgrowth and irritable bowel syndrome-related symptoms: experience with Rifaximin. World J Gastroenterol. 2009;15(21):2628—2631. doi:10.3748/wjg.15.2628
7. Low K, Hwang L, Hua, J.,A Combination of Rifaximin and Neomycin Is Most Effective in Treating Irritable Bowel Syndrome Patients With Methane on Lactulose Breath Test, Journal of Clinical Gastroenterology: September 2010 – Volume 44 – Issue 8 – p 547-550, doi: 10.1097/MCG.0b013e3181c64c90
8. Scarlata K, Small Intestinal Bacterial Overgrowth (SIBO), For a Digestive Peace of Mind blog, https://blog.katescarlata.com/2014/01/22/small-intestinal-bacterial-overgrowth/
9. Chedid V, Dhalla S, Clarke JO, et al. Herbal therapy is equivalent to rifaximin for the treatment of small intestinal bacterial overgrowth. Glob Adv Health Med. 2014;3(3):16—24. doi:10.7453/gahmj.2014.019
10. Minerbi A, Gonzalez E, Brereton NJB,   et al (2019). Altered microbiome composition in individuals with fibromyalgia. PAIN, Articles in Press. https://doi.org/10.1097/j.pain.0000000000001640
11. McGill University Health Centre Press Room, Gut bacteria associated with chronic widespread pain for first time, June 19th, 2019, https://muhc.ca/news-and-patient-stories/press-releases/gut-bacteria-associated-chronic-widespread-pain-first-time

 

In the first article of this series about Small Intestinal Bacterial Overgrowth (posted here), I covered what SIBO is and how common it is, as well as its symptoms. If you haven’t yet, I’d encourage you to read that article first as it will serve as a good introduction. In this second article, I cover the different tests used in diagnosing SIBO, as well as some of the advantages and drawbacks of each. In the next article will cover various treatment options for SIBO, including dietary protocols combined with antibiotic or herbal therapies (which interestingly have been found in research studies to be equally effective as the first-line antibiotic). 

Diagnosing SIBO

One of the first challenges in diagnosing SIBO is finding a physician that is knowledgeable about the condition and current in its treatment. In the past only gastroenterologists diagnosed and treated SIBO and only after very invasive and expensive surgical tests were performed.

Before the invention of endoscopy, diagnosing SIBO required an invasive surgical procedure where a gastroenterologist would take a small amount of liquid from the jejeunum of the small intestine, and that fluid would be cultured to see what types of bacteria grew, and in what quantities.  A positive diagnosis of SIBO would occur when  >  10⁴ colony-forming units of bacteria grew per milliliter of jejunal liquid [1]. The problem with this type of testing was that it was very invasive and expensive.

The medical invention of the endoscope in the mid-1980s enabled gastroenterologists to obtain fluid from the duodenum of the small intestine using a much less invasive procedure. In endoscopy, a long, flexible tube (endoscope) is passed into the throat of a sedated patient, then into the esophagus, past the stomach and into the duodenum, where a fluid sample is collected for culturing.  One drawback to this test was that the sample was easily contaminated as it was withdrawn and the procedure was still quite invasive and expensive [1]. A second drawback is that only 30% of gut bacteria taken from the small intestine in this procedure and the one above are able to be cultured [3].  This surgical test is still invasive and expensive and as such is not widely used, although it is still considered the “gold standard” for diagnosing SIBO [2].

A brilliantly simple solution to testing for SIBO came as the result of the discovery that certain gases such as hydrogen or methane are only produced in the small intestine as the by-product of unabsorbed or incompletely absorbed carbohydrate in the diet. Simple breath tests to detect the presence of either gas provides not only the evidence of carbohydrate malabsorption (such as lactose and fructose malabsorption [3]), but the specific gas produced indicates the types of bacteria that are fermenting them (more on that below). The two breath tests for diagnosing SIBO that have become the most widely used are the glucose breath test and the lactulose breath test.

Glucose Breath Test or Lactulose Breath Test?

Either lactulose or glucose are used as substrates in hydrogen and methane breath testing for diagnosing SIBO, with some believing that glucose provides greater test accuracy [2] because glucose is absorbed completely in the upper small intestine [3], but may not be able to detect SIBO in the ileum, the far part of the small intestine, that connects to the large intestine [3]. Lactulose may be able to detect small-bowel bacterial overgrowth in the ileum [2,3].

Depending on which clinician one goes to, they  likely will have a preference for using either glucose or lactulose breath test for diagnosing SIBO, whereas some gastroenterologists prefer to use jejeunal sampling via endoscopy.

How Does a Breath Test Work?

Hydrogen or methane exhaled in the breath following consumption of either glucose or lactulose is estimated using a gas chromatograph.

Normally, a small amount of hydrogen is produced from the limited amounts of unabsorbed carbohydrate that reaches the large intestine, however large amounts may be produced if there is malaborption of carbohydrate (such as fructose or lactose) in the small intestine, or if there are the wrong types of bacteria in the small intestine.  

The hydrogen (or methane) is produced by the bacteria in the intestine, absorbed through the wall of the small-intestine, large-intestine or both, and the the hydrogen (or methane) containing blood travels up to the lungs. During a breath test, the hydrogen (or methane) is exhaled in the breath, and measured by the gas chromograph.

It is estimated that about 15%-30% of people have gut bacteria that contain Methanobrevibacter smithii, a methane-producing bacteria that recycles hydrogen by combining it with carbon dioxide, to produce methane. This bacteria converts 4 atoms of hydrogen into 1 molecule of methane [4], so people with this intestinal bacteria won’t exhale much hydrogen during the breath test (even if they have carbohydrate malabsorption or SIBO) because the hydrogen that they produce is converted into methane [3].

How the Breath Test is Performed

The person having the breath test first needs to fast overnight and have to brush their teeth and rinse their mouth with mouthwash to make sure oral bacteria don’t affect the test. At baseline, fasting breath hydrogen is estimated 3 – 4 times and averaged as basal breath hydrogen. If the person is found to have high breath hydrogen before they eat the sugar, then it may be attributed to SIBO. Then the person eats a specific amount of the test sugar; either 10 g lactulose or 100 g glucose, and the person’s breath is analyzed for hydrogen and methane every 15 minutes for 2 to 4 hours [3].  Diagnosing SIBO on the basis of a glucose breath test requires a rise in breath hydrogen by 12 ppm above baseline [3].

Based on a study published in 2000, Dr. Mark Pimentel, a key researcher in the area of SIBO from Cedar-Sinai Medical Center believes that a rise in breath hydrogen 20 ppm above basal levels within 90 minutes in a lactulose breath test should be considered a positive diagnosis of SIBO [5]. Some researchers maintain [3] that lactulose should not be used at all for diagnosing SIBO because it assumes that the time from when the lactulose is eaten until it reaches the junction of the small and large intestine (the cecum) is always greater than 90 minutes, whereas other studies indicate that it can range from 40 to 110 minutes [6]. As well, use of lactulose may only be able to diagnose 1/3 of people with SIBO [3].

A recent consensus paper from 2017 [7] published by 10 medical doctors involved in The North American Consensus group on hydrogen and methane-based breath testing concluded that both glucose breath testing and lactulose breath testing were reliable and were considered the least invasive tests for diagnosing SIBO [7]. The consensus group considered a rise in hydrogen of ≥20 ppm by 90 minutes* during glucose or lactulose breath test  for SIBO to be positive for SIBO, and methane levels ≥10 ppm was considered methane positive.

*It should be noted that some clinicians such as Dr. Mark Pimentel consider a positive hydrogen test to be anything >20 ppm, and not necessarily a 20 ppm rise above baseline. In addition, Dr. Pimentel considers a positive methane test to be a reading of >3 PPM within 90 minutes (which is significantly lower than the levels set by the consensus group, of which he was a part [8]). Since different clinicians use different cutoff points to indicate a positive test for SIBO, this leads to what some consider to be a tendency to “overdiagnose” the condition [3].

As mentioned above, since a hydrogen breath test using glucose may miss SIBO in the far part of the small intestine (ileum), and a hydrogen breath test using lactulose may only be able to diagnose 1/3 of people with SIBO, some practitioners take the approach to treat patients “as if” positive for SIBO, in the absence of a positive breath test. If the person gets better on antimicrobial therapy along with appropriate dietary support, then it is deemed that the end goal for the person to feel better has been reached. There are two challenges that come to mind with respect to this approach; first of all, often more than one round of antibiotics or herbal antimicrobials are needed to completely eradicate the bacteria population in the small intestine that are responsible for the symptoms of SIBO.  Does one do one round of treatment and hope for the best, or two rounds as that is the most likely to be effective? While Generally Recognized As Safe, even herbal treatments are not without risks, so treating “as if” is not a preferred option. The second drawback (that I will cover just below) is that the treatment for methane-dominant bacteria is different than the treatment for hydrogen-dominant bacteria. One could treat with herbal antimicrobials based on symptoms (i.e. the presence of constipation), but having a positive methane breath test (perhaps at the level of positive indicated by the consensus report, above) would enable an evidence-based treatment decision. While not without drawbacks, it is my opinion that breath testing should at least be tried unless doing so could cause a person severe gastro-intestinal discomfort.

UPDATE (Sept 5 2019): It should be noted that a recent (2018) study found that a glucose-based hydrogen and methane breath test does not detect bacterial overgrowth in the jejunum, but that a positive breath test may indicate altered jejunal function and microbial dysbiosis. This calls into question the validity of using breath tests in diagnosing SIBO. (Sundin OH, Medoza-Ladd A, Morales E et al, Does a glucose”based hydrogen and methane breath test detect bacterial overgrowth in the jejunum, Neurogastroenterology & Motility 30 (11), https://doi.org/10.1111/nmo.13350).

Positive Breath Test for Methane

As mentioned above, whether a breath test is positive for hydrogen or methane indicates something about the types of bacteria involved in SIBO. In several studies, positive methane results on breath tests have been associated with symptoms of constipation [9-12] and are 5 times more likely to have constipation than those with hydrogen dominant overgrowth [12] and the severity of constipation was found to be directly related to the level of methane [9]. Identifying whether SIBO is methane-predominant is important because the methane-producing bacteria Methanobrevibacter smithii is resistant to many antibiotics [7].

Distinguishing SIBO from IBS

As mentioned in the first article in this series on SIBO (available here) many of the symptoms of Irritable Bowel Syndrome (IBS) and SIBO are similar, including abdominal pain, bloating, gas, bouts of diarrhea or constipation or alternating diarrhea and constipation.

To make matters more confusing, Pimentel et al found that almost 80% (78%) of subjects in their study that had an abnormal lactulose breath test which suggested they had SIBO also met the Rome I criteria for IBS [5]. This begs the question how many of those who have been diagnosed with IBS based on the current Rome IV criteria [13] might actually meet the criteria for SIBO?

It is my opinion that someone who has been unsuccessful at resolving their symptoms of IBS using appropriate dietary treatment with the help of a knowledgeable Dietitian would benefit by undergoing glucose or lactulose breath testing to determine if their symptoms may be caused by SIBO.

---

In the next article, I will cover the main dietary approaches that are used in SIBO treatment, along with antibiotic or studied herbal antimicrobials.  I will also cover why some clinicians do NOT change the person’s diet until after antimicrobial treatment has been completed.

More Info?

You can find out more about the hourly consultations and packages I offer by visiting the Services tab or the Shop, and if you would like additional information please send me a note using the Contact Me form above, and I will reply as soon as I can.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/BetterByDesignNutrition/
Instagram: https://www.instagram.com/lchf_rd
Fipboard: http://flip.it/ynX-aq

Copyright ©2019 BetterByDesign Nutrition Ltd.

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the ”content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

References

1. Quigley EMM. The Spectrum of Small Intestinal Bacterial Overgrowth (SIBO), Current Gastroenterology Reports, (2019) 21:3, https://doi.org/10.1007/s11894-019-0671-z
2. Dukowicz AC, Lacy BE, Levine GM. Small intestinal bacterial overgrowth: a comprehensive review. Gastroenterol Hepatol (N Y). 2007;3(2):112—122.
3. Ghoshal UC How to interpret hydrogen breath tests. J Neurogastroenterol Motil. 2011; 17: 312—317
4. Levitt MD, Furne JK, Kuskowski M, Ruddy J. Stability of human methanogenic flora over 35 years and a review of insights obtained from breath methane measurements. Clin Gastroenterol Hepatol. 2006;4:123—129.
5. Pimentel M, Chow EJ, Lin HC, Eradication of small intestinal bacterial overgrowth reduces symptoms of irritable bowel syndrome.
   Am J Gastroenterol. 2000 Dec; 95(12):3503-6
6. Ghoshal UC, Ghoshal U, Ayyagari A, et al. Tropical sprue is associated with contamination of small bowel with aerobic bacteria and reversible prolongation of orocecal transit time. J Gastroenterol Hepatol. 2003;18:540—547
7. Rezaie A, Buresi M, Lembo A et al, Hydrogen and Methane-Based Breath Testing in Gastrointestinal Disorders: The North American Consensus, Am J Gastroenterol 2017; 112:775—784; doi: 10.1038/ajg.2017.46
8. Scarlata K, Small Intestinal Bacterial Overgrowth (SIBO) blog article, January 22, 2014, https://blog.katescarlata.com/2014/01/22/small-intestinal-bacterial-overgrowth/
9. Chatterjee S , Park S , Low K et al. Th e degree of breath methane production in IBS correlates with the severity of constipation . Am J Gastroenterol 2007 ; 102 : 837 — 41.
10.  Attaluri A , Jackson M , Valestin J et al. Methanogenic fl ora is associated with
    altered colonic transit but not stool characteristics in constipation without
    IBS . Am J Gastroenterol 2010 ; 105 : 1407 — 11.
11. Hwang L , Low K , Khoshini R et al. Evaluating breath methane as a diagnostic
    test for constipation-predominant IBS . Dig Dis Sci 2010 ; 55 : 398 — 403.
12. Kunkel D , Basseri RJ , Makhani MD et al. Methane on breath testing is
    associated with constipation: a systematic review and meta-analysis .
    Dig Dis Sci 2011 ; 56 : 1612 — 8.
13. Schmulson MJ, Drossman DA. What Is New in Rome IV. J Neurogastroenterol Motil. 2017;23(2):151—163. doi:10.5056/jnm16214

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I used to believe that SIBO was a condition that only alternative medicine practitioners such as naturopaths identified & ‘treated’, and it wasn’t a real diagnosis at all and it seems I was not alone in this belief.

This is the first article about SIBO which will outline what it is, it’s symptoms and risk factors and a subsequent article will outline how SIBO is diagnosed and some of the treatment options.

Last week I asked on Twitter “Do you believe that SIBO is a credible diagnosis?” and of the sixty one people that responded, here’s what people thought;

Fifteen percent of people thought SIBO wasn’t a legitimate medical diagnosis, while the remainder thought that either it was a credible diagnosis that not all doctors know about (62%), or that only Functional Medicine MDs diagnose and treat it (18%), or only naturopaths (5%) do.

My interest in searching the scientific literature about SIBO came when a rheumatologist suggested that it may be SIBO that was underlying the increase in joint pain that I was experiencing. While I had been diagnosed with osteoarthritis many years ago — which is a degenerative joint disease and not a normal part of aging (more in this article), the pain in my fingers had become excessive, even though there had not been any additional deterioration or deformation in those joints. If it wasn’t a rheumatologist that was suggesting SIBO as a possible cause, I would have discounted it without a thought but because the possibility was raised by a credible clinician, I decided to search the scientific literature to see what I could find.  To be honest, I was quite surprised to find that it was not only well-researched, but that there were academics at well-known universities that have been studying it!

What is SIBO?

Small Intestinal Bacterial Overgrowth (SIBO) is an increase in the type of bacteria present in the small intestine that are normally found in the large intestine (also called the colon) [1].

The small intestine consists of three parts; the duodenum connects to the stomach, the middle part is the jejunum and the last part called the ileum, attaches to the colon. It is called the small intestine because its diameter is smaller than the large intestine, although it is actually longer in length than the large intestine [2].

Normally, the small intestine contains very few bacteria and when it does, the type of bacteria found in the duodenum and jejunum are usually a specific type (i.e. lactobacilli and enterococci, gram-positive aerobes or facultative anaerobes) and are found in small amounts (< 10⁴ organisms per mL)[1] and research indicates that samples taken from the jejunum of healthy volunteers found no bacteria present at all. When the bacteria that normally populate the large intestine spills over into the small intestine, it is called Small Intestinal Bacterial Overgrowth or “SIBO”.

The body has several built-in defense mechanisms for normally preventing bacterial overgrowth of the small intestine. The major defense against small intestine bacterial overgrowth is (1) the very high acid environment of the stomach (gastric acid) which kills most bacteria, as well as (2) a normally intact ileocaecal valve which is the sphincter muscle that separates the small intestine from the large intestine. In addition, there are additional defense mechanisms such as immunoglobulins in the secretions of the small intestine, as well as  secretions from the pancreas and bile-related secretions that keep bacteria from reproducing [1].

SIBO can occur for different reasons, including low stomach acid (achlorhydria), pancreatic insufficiency, as well as anatomical abnormalities including small intestinal obstruction, diverticula (more about this in this article), fistula (which is abnormal connection between an organ and the intestine which can be created after some infections), as well as slowing of intestinal movements (motility disorders) that are common in those with diabetes mellitus, and other conditions. It has been known for many years that those that consume significant amounts of alcohol are known to be at risk for SIBO [3] but a more recent study found an association between moderate alcohol consumption and SIBO [4], which was defined as up to one drink per day for women and two drinks per day for men. It is thought that alcohol consumption may cause injury to the mucosal cells of the small intestine which contributes to a slowing of intestinal contractions (i.e. motility disorder), which is associated with SIBO. In some people, a combination of the above factors may be involved.

[Note: in my case, an underlying diagnosis of SIBO was certainly possible as I had been on a long-term, high dose of H2 antihistamines due to having Mast Cell Activation Disorder (MCAD) — medications which are known to also significantly reduce stomach acid, and I had also been diagnosed with type 2 diabetes 8 years before going into remission 2 1/2 years ago.

How Common is SIBO?

The prevalence of SIBO in young and middle-aged adults appear to be between 6 and 15% , but higher in the older adults (14.5—15.6%) [5]. Perhaps this is due to decreasing amounts of stomach acid associated with aging, as well as increase prevalence of diverticulosis and type 2 diabetes, all of which are associated with SIBO risk.

What are the Symptoms of SIBO?

Many of the symptoms of SIBO are similar to those of Irritable Bowel Syndrome (you can read more about that here), including abdominal pain, bloating, gas, bouts of diarrhea or constipation or alternating diarrhea and constipation. As mentioned above, there are other lesser known symptoms of SIBO, including joint pain.

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Update (September 4, 2019): In the second article (posted here), I outlined different tests used to diagnose SIBO, the difference between hydrogen-dominant SIBO and methane-dominant SIBO and why Irritable Bowel Syndrome (IBS) that does not improve despite adopting appropriate dietary changes may be SIBO.

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References

1. Bures J, Cyrany J, Kohoutova D, et al. Small intestinal bacterial overgrowth syndrome. World J Gastroenterol. 2010;16(24):2978—2990. doi:10.3748/wjg.v16.i24.2978
2. Medscape, Small Intestine Anatomy, Dec 8 2017, https://emedicine.medscape.com/article/1948951-overview
3. Hauge T, Persson J, Danielsson D: Mucosal Bacterial Growth in the Upper Gastrointestinal Tract in Alcoholics (Heavy Drinkers). Digestion 1997;58:591-595. doi: 10.1159/000201507
4. Gabbard SL, Lacy BE, Levine GM et al, The Impact of Alcohol Consumption and Cholecystectomy on Small Intestinal Bacterial Overgrowth, Digestive Diseases and Sciences, 2014, Volume 59, Number 3, P. 638
5. Dukowicz AC, Lacy BE, Levine GM. Small intestinal bacterial overgrowth: a comprehensive review. Gastroenterol Hepatol (N Y). 2007;3(2):112—122.

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