In Part 1, we discussed how complex treating SIBO can be and the importance of retesting. In this article, we will focus on how to prevent a relapse of SIBO and the importance of treating and preventing fungal overgrowth which can happen after treating SIBO.
The recurrence rate after treating SIBO successfully is about 50%. (1) That’s high. Unless you figure what the mechanisms are that allowed SIBO to develop in the first place, SIBO is more likely to reoccur.
Treating SIBO is a five step process
We have discussed how to kill off SIBO (Step 1) and the importance of retesting for SIBO (Step 2). Let’s move on to Steps 3 through 5.
Step 3 – Antifungals for two to three months
Some functional medicine practitioners will recommend the patient take single herb antifungals in rotation for two to three months after killing off SIBO. The reason behind this is that even with herbal antimicrobials you can deplete your healthy gut flora (good bugs). This can create an environment for fungal or yeast overgrowth in the gut. (2) Here is a partial list of antifungals you could use:
There is a difference in opinions how often you should rotate the antifungals. It varies from every week, every two weeks, and some say once per month. I’ve taken the middle ground and rotate them every two weeks. The concept behind rotating antifungals is that yeast can become resistant to them, so when you rotate them they are less apt to do so.
Again, you will need to take a biofilm disruptor during this time like Interfase Plus.
Probiotics should be taken for gut support. On top of Prescript-Assist or Primal Defense I like to add in a probiotic called Sacchoromyces boulardii. It’s a specific probiotic that acts as an antifungal.
Step 4 – Repair your gut lining
There’s no fine line in these steps after the kill off phase in step 1. You can start to repair the lining of your gut and rebuild your healthy gut flora after step 1. This is an important part of treating SIBO. Remember SIBO has a 50% recurrence rate. So if you can find out what is truly causing SIBO in the first place you can take measures to prevent it from coming back.
Repairing damage to the lining of the gut is necessary so you can start to digest and absorb nutrients properly again. You also want to seal the gut so your gut doesn’t leak out toxic proteins into your blood. Toxic proteins in the blood can lead to systemic inflammation leading to numerous symptoms and the potential for autoimmune diseases. (2, 3, 4)
The body has the innate ability to heal itself. By providing the body with good nourishment, supplements, and good brain and nerve function, the body will heal itself better and more quickly.
Short chain fatty acids (SCFAs) like butyrate stimulate the growth and repair of the cells of the inner gut lining. (5) SCFAs are produced by your good or beneficial gut bacteria. So you have to rebuild your good bacteria back up again to increase your SCFAs. More on that in a moment. There is also a supplement you can take called sodium-potassium butyrate, but the research on it has mixed results. At the time of this article, a new butyrate supplement called ProButyrate may have some promise.
You want to be on a nutrient dense diet like using the Paleo diet as a template. If you haven’t already you want to do a proper elimination diet (intro to it in ‘Anti-inflammatory Diet to Solve Your Low Back Pain?’ article) to eliminate foods that you are intolerant to. Foods you are intolerant to can create an inflammatory response which can break down the lining of the gut. A fast easy way to determine food intolerances is to get three lab tests done through Cyrex labs: Array 3, Array 4, and Array 10. These blood tests identify what foods your immune system is reacting to. You would remove the foods you are intolerant to for 60 days. You could bring the food back in again at that point to see if you can tolerate it.
Vitamins A and D play an important role in making sure the gut lining is strong. (6, 7, 8) If you don’t eat organ meats like liver once a week (good source of vitamin A and D) you may want to supplement daily with a good quality cod liver oil.
Designs for Health has a good product called GI Revive Powder that has a variety of ingredients to help repair and rebuild the gut:
Bone broth is also an important part of a diet for gut health. Bone broth is rich in glycine, gelatin, and glutamine which are crucial nutrients for repairing your gut and gut health in general. (15, 16, 17, 18, 19) I’d recommend half a cup to a cup of broth daily in the form of soups, stews, teas, or sauces.
Step 5 – Rebuild a healthy gut flora with probiotics and probiotics
The length of time it takes to rebuild a healthy gut flora is highly variable. A general rule of thumb is to focus on this step for two to three months. Even after this intense focussed step, you want to maintain your healthy gut flora with a diverse, nutrient dense diet.
A healthy gut flora plays an important role in maintaining health and preventing disease. (20, 21, 22, 23, 24, 25, 26, 27) A variety of probiotics and prebiotics are necessary to rebuild a diverse and health gut flora to help prevent SIBO.
Probiotics (and fermented foods that contain them) are the good bugs and prebiotics are the food the good bugs need to survive and grow.
Most probiotics don’t increase the number of good bugs in your gut over time. There purpose is to make sure your immune system works well and to reduce gut inflammation. (28, 29) So they provide support for the good bugs that are already in your gut.
Probiotic supplements I would recommend are:
- Prescript Assist
- Saccharomyces boulardii
- Primal Defense Ultra
Food sources of probiotics are:
- kefir (made from milk, water, or coconut or young coconut water)
- raw sauerkraut
- beet kvass
I would recommend you aim for one to two tablespoons of fermented vegetables with each meal, plus a half-cup of kombucha or kvass and a half-cup of yogurt or kefir per day.
Prebiotics provide a food source for the good bugs that already live in your gut and increase their numbers significantly over time. Prebiotics are fermentable fibers from food sources like vegetables, fruit, starchy tubers, nuts, seeds, and legumes. Because it’s hard to get a diverse amount of fermentable fibres in our modern day diet, it is recommended you include prebiotic supplements as well.
Most prebiotics are best avoided if you have SIBO, fungal overgrowth, or a parasite infection, and/or you are in the first 6-8 weeks of an anti-microbial protocol. Once the anti-microbials have reduced the levels of harmful bacteria or yeast, prebiotics can be consumed slowly and gradually.
You want to include a wide range of prebiotics as each different type of fiber will stimulate the growth of different types of bacteria:
Here’s a list of prebiotic supplements and where you can order them to make it easier for you:
- Unmodified potato starch**: Bob’s Red Mill All Natural, or other certified gluten-free brand
- Galactomune powder (Klaire Labs)
- Biotagen powder (Klaire Labs)
- Glucomannan powder (Now brand)
- Psyllium husk powder: (Now brand)
- Acacia fiber (Now brand): may be used as an alternative to psyllium husk
- Partially hydrolyzed guar gum (Healthy Origins)
You want to start slowly with both probiotics and prebiotics. Increase your dose as tolerated based on symptoms of GI distress. Increased gas and bloating is expected as you begin this rebuilding phase, but usually improves after a few days.
Other important considerations to prevent a SIBO relapse
If constipation (gut motility problem) has been an issue with you, I would recommend you take a supplement on an ongoing basis to support your gut motility. Iberogast is a blend of 9 botanical “bitters” that help improve gut motility. (35, 36) Some patients respond well to MotilPro as well.
Gut motility is also reliant on getting good nerve messages from the brain. Getting regular chiropractic adjustments helps keep your nervous system working at a peek level. Regular adjustments could mean once per week to once every two months depending on the person and their state of health. You can also get your ileocecal valve checked and treated if necessary.
I will stress the importance of lifestyle factors again. Getting a good amount of physical activity, getting enough sleep, and especially managing stress are vital to help prevent a relapse.
You may also require taking periodic herbal antimicrobials to control relapses as well.
What about diet?
A lot of patients will change their diet to treat SIBO. Rebuilding your healthy gut flora, for example, may not be enough if there is SIBO or other gut infections involved. Starving SIBO out with a low carb diet also has negative long-term results. This is why making changes to your diet, although very important in the treatment process, isn’t enough to treat conditions like SIBO, parasites, fungal overgrowth, and H. Pylori infection.
A nutrient dense diet, like using the Paleo diet as a template, is recommended. You’re going to have to experiment with all of the nutrient dense whole foods to see what you can tolerate while you are treating your SIBO and afterwards when you are recovering.
When all else fails try the elemental diet. The elemental diet can be very effective and worth a try in IBD patients with severe inflammation and presentation. (37) The elemental diet contains only foods that are absorbed high up the small intestine. So it gives the gut a rest. It decreases inflammation and leaky gut and allows the cells of the small intestine to regrow.
The problem with the elemental diet is it will completely starve the beneficial bacteria in the colon as well. If you have a small number and diversity of good gut bacteria you’re setting yourself up for many types of diseases.
FODMAPs are carbs that can be metabolized by bacteria in the small intestine. A low-FODMAP diet can be used to provide relief for your gut symptoms. The diet may even help prevent a recurrence of SIBO, but I wouldn’t do it for long periods of time. Low-FODMAP diets over a long time will also decrease the diversity of your good gut bacteria. (38)
Low-FODMAP diets are also not recommended during SIBO treatments. Remember, antimicrobials are more effective at killing off SIBO when the “bugs” are dividing. Otherwise, if you’re not feeding the “bugs” (with a soluble fiber like PHGG) they can go into a dormant state (go into “hiding”) and it’s harder to kill them. This is why low-FODMAP diets work to relieve symptoms of IBS, because they stop feeding the bacteria.
I hope these two articles (Part 1 and 2) have provided you with a better understanding and framework to treat your SIBO. There’s still a lot of unanswered questions regarding SIBO which is why it is hard to treat and why there is such a high recurrence rate. Good luck with your quest to achieve a better state of health. Keep trying and never give up hope!