Diets For SIBO Management

Two common small intestinal bacterial overgrowth (SIBO) diet treatments include the elemental diet, a type of liquid diet, and the low-FODMAP diet, which focuses on limiting certain types of carbohydrates that are difficult to digest.

The goal of treating SIBO is to restore a normal balance of gut bacteria. A SIBO diet can help:

• Hinder multiplication of gut bacteria
• Reduce inflammation
• Address nutritional deficiencies

Other aspects of your SIBO treatment plan may include antibiotics such as Xifaxan (rifaximin) and management of the underlying condition (e.g., Crohn's disease or irritable bowel syndrome).

This article reviews use of the elemental diet and low-FODMAP diet for SIBO, and includes what to eat and what to avoid on a SIBO diet.

How the Elemental Diet Works for SIBO

The elemental diet is a liquid diet, or a powder mixed with water, typically used for individuals who have compromised digestive systems. The diet gets its name from the fact that nutrients are introduced into the body in as close to their elemental—or primary— form as possible.

The elemental diet is being looked at as a possible adjunct treatment to antibiotics for the following reasons:

• Its nutrients are believed to be completely absorbed in the very first part of the small intestine, which reduces the number of food components available to bacteria.
• It reduces the number of overall gut bacteria, which may mean a reduction in bacteria in the small intestine.
• It's theorized to increase the amount of bile released from the gallbladder, which may strengthen the small intestine's cleansing wave and reduce bacteria levels.
• It may impact the immune cells within the lining of the intestines, which may also serve to eradicate small intestine bacteria.
  

What to Eat

The elemental diet is administered either as a beverage that you drink or through a feeding tube. The amount of liquid is slowly increased over the first few days to reduce unwanted side effects, such as diarrhea or abdominal pain.

Each formulation contains nutrients in an easily digestible form. Typical formulations include:

• Essential and non-essential amino acids
• Glucose, an easily digested carbohydrate
• Vitamins, fat and water-soluble
• Minerals
• Electrolytes
• A small amount of fat (less than 1%)

Different commercial variations of the elemental diet can be purchased online. The powdered mixes contain only essential nutritional ingredients and provide 150 to 300 calories or more. Your healthcare provider will help you determine how much to use to get adequate nutrition.

No artificial flavors or colors are added to elemental diet mixes (which are combined with water), so the beverage has a bland taste that many people find unpalatable. Some experts suggest adding ice to give it texture, which may make it easier to consume.

Duration

The length of time that you stay on an elemental diet depends on your symptoms and on your compliance with the program.

One of the biggest challenges of the elemental diet is giving up solid food:

• According to one published report, only about 25% of patients are willing to restrict their nutritional intake to liquid feeding for long enough to see results.
• Several studies report that those who are compliant see results in two to three weeks.

Some people who aren't able to adopt a full elemental diet may, with their healthcare provider's okay, use a partial elemental diet that combines liquid feeding with foods that are known to be tolerable. In some cases, this approach is used for long-term maintenance.

How the Low-FODMAP Diet Works

The low-FODMAP diet is more commonly used to treat SIBO symptoms. FODMAPs are a group of carbohydrates that include:

• Fermentables
• Oligosaccharides (comprised of fructans and galactans)
• Disaccharides (milk sugar lactose)
• Monosaccharides (fructose)
• Polyols (sugar alcohols such as sorbitol, mannitol, xylitol, and maltitol)

On this diet, you'll avoid high-FODMAP foods during an elimination phase. At the end of this phase, you slowly introduce each FODMAP type back into your diet—one by one—to accurately pinpoint which FODMAPs cause your SIBO symptoms.

With SIBO, two FODMAP types—lactose and fructose—may be absorbed poorly due to inflammation along the lining of the small intestine. In addition, other non-absorbed FODMAPs may be fermented by the bacteria residing in the small intestine, leading to uncomfortable symptoms.

Following a diet low in FODMAPs may lead to symptom-relief in certain individuals.

What to Eat

During the elimination phase, avoid foods that are high in FODMAPs, meaning they contain one of the five types of FODMAPs:

• Fructans: Non-digestible, fructans are found primarily in wheat, many vegetables, and some food additives, including inulin.
• Fructose: Fructose is the sugar found in many fruits, honey, and high-fructose corn syrup.
• Galactans: Also called galactooligosaccharides or GOS, galactans can be found in legumes, including beans, chickpeas, and lentils.
• Lactose: Lactose is the sugar found in milk and other dairy products.
• Polyols: These are sugar alcohols with names that typically end in "- ol." They're found naturally in some fruits (like blackberries) and vegetables (such as cauliflower and mushrooms), and are often used as artificial sweeteners.

Almost every food group contains options that are high in FODMAPs and those that are low in FODMAPs.

Duration

The elimination phase can last from two to eight weeks. During this time, you're likely to experience a decrease in symptoms.

The next phase, called the reintroduction process, is extremely important. The time needed for this phase varies widely, depending on your symptoms.

Keep in mind:

• Not every FODMAP type is a problem for every person.
• You may want to pick one FODMAP sub-group at a time to test the effect one on your body.
• Plan to test each group for a week before moving onto the next group.

Most experts recommend keeping a food diary. This will help you get a better sense of the relationship between the foods that you eat and the symptoms that you experience.

This diet is not intended for long-term use. Many high-FODMAP foods are actually very good for overall health. A lot of them are considered prebiotics, meaning that they enhance a healthy balance of gut bacteria.

Recommended Timing

The timing of your meals and snacks is not a factor when following either the elimination or reintroduction phase. You can consume food according to a schedule that works best for you.

However, since re-introducing FODMAP foods may cause symptoms to occur, you may want to introduce them at a time when you are at home and can be comfortable.

SIBO Diet Considerations

Many people with SIBO have other conditions, including:

• Celiac disease, an autoimmune condition that causes an immune reaction when gluten is eaten
• Chronic pancreatitis, long-term inflammation of the pancreas
• Cirrhosis of the liver, long-term liver damage that leads to scarring
• Crohn's disease, a type of inflammatory bowel disease
• Diabetes, a long-term condition that impacts the body's ability to control blood sugar

It's very common for people with these conditions and SIBO to experience malnutrition. For example, if you have SIBO, fat-soluble vitamins (vitamins A, D, E, and K) may not be properly absorbed. You may also be deficient in iron or vitamin B12.

For this reason, it is strongly advised that you work with your healthcare provider and a nutrition professional to manage SIBO and any underlying condition. Your treatment will be tailored to accommodate your specific symptoms and may include supplements.

Summary

Diet changes are likely to be part of your SIBO treatment plan. SIBO diets include the elemental diet and the low-FODMAP diet, which focuses on limiting high-FODMAP foods that are difficult for the body to process.

Both of these diets aim to restore a normal balance of gut bacteria. SIBO treatment may also involve antibiotics and management of any underlying condition.

If you have SIBO, it's essential to work with a healthcare provider and/or trained nutrition specialist before making any dietary changes to ensure you're meeting your nutritional needs.