In SIBO TREATMENT: BEYOND DIET PART 1, we discussed prescription antibiotics and herbal antibiotics that target the bacteria that have overgrown in the small intestine. Here, we will discuss additional supplements and lifestyle changes to help treat the root cause, and associated complications of SIBO, while preventing recurrence.
Taken away from meals, various substances can help to break down the protective wall or ‘biofilm’ that bacteria build around their colonies. Left intact, this wall enables bacterial resistance to therapies, including both conventional antibiotics and herbal. Examples of substances that disrupt the biofilm include lactoferrin (found in goat’s and cow’s milk whey), NAC, garlic, dandasa, green tea, and fibrinolytic enzymes especially nattokinase (1-5).
Issues with gut motility can be a large contributor to the development of SIBO. In cases where dysmotility is a concern, a motility agent may be prescribed following eradication treatment. Lifestyle changes, including eliminating snacking, daily movement, acupuncture, and bodywork can also help in ensuring healthy motility.
Probiotics must be used with caution during the treatment of SIBO; some patients find probiotics exasperate their symptoms, particularly if the supplement includes prebiotic starches such as FOS, inulin, MOS, GOS, arabinogalactan, or ingredients that may irritate the gut lining such as soy or lactose. However, a probiotic must be considered if using an antibiotic that has systemic effects, such as metronidazole.
Additionally, certain probiotic strains such bifidobacterium animalis, Bifidobacterium lactis are prokinetic and may aid in improving movement through the gut (6,7). Research utilizing probiotics as the main treatment for SIBO has shown good results with Lactobacillus casei, Lactobacillus plantarum, streptococcus faecalis, and bifidobacterium brevis, particularly when combined with a restricted diet (8,9). Further research is needed to determine why probiotics are helpful in certain cases of SIBO and exacerbate symptoms for others.
Since issues with digestion and absorption tend to accompany SIBO, supplements to support digestion, such as digestive enzymes, bile salts, and substances that increase hydrochloric acid may be helpful. A full gut healing protocol may also be indicated, depending on the condition of the gut lining (5 Steps To A Healthy Gut).
Partially Hydrolyzed Guar Gum
Increased efficacy with rifaxamin has been noted when it is combined with partially hydrolyzed guar gum or PHGG. It is suspected that this is due to its effect on gut motility as well as its prebiotic nature favouring the gut microflora balance. Improvement on rifaxamin alone was observed in 62.1% of patients, while 85-87% of those on rifaxamin alongside PHGG experienced improvement (10).
Resistant starch ‘resists’ digestion; since it is not broken down in the small intestine, it travels to the large intestine where it is consumed by bacteria (11). This consumption leads to the production of short-chain fatty acids such as butyrate, an anti-inflammatory component (12,13). Food sources of resistant starch include green bananas, plantain, and potatoes that have been both cooked and cooled. Due to individual response and tolerance of starch, resistant starch may or may not be tolerated.
As bacteria are killed off, they release toxic by-products such as endotoxins and lipoteichoic acid. An increase of inflammatory mediators are released in response to this increase in toxins and may explain why certain patients worsen following treatment with antibacterial substances, a phenomenon known as the Jarisch-Herxheimer reaction (14). Due to the potential severity of this reaction, it is always advisable to work with a trained physician when treating infections. In an effort to guard against these reactions, caution with dosage, timing, and length of antimicrobial treatments should be taken, as well as utilization of methods to support the body’s ability to clear toxins such as infrared sauna, liver supportive supplements, and adequate hydration.
Due to the effects of bacteria on nutrient absorption in cases of SIBO, levels of certain nutrients may have declined, leading to a wide variety of symptoms. As bacteria are eradicated during treatment, it is beneficial to support these nutrients, such as B12, vitamin A, D, E, and K, via supplementation.
Fungal overgrowth may accompany bacterial overgrowth. As well, antibiotic treatment with metronidazole can lead to candidiasis (15). In these cases, it is helpful to address both bacterial and fungal dysbiosis.
Everything these days seems to be caused by stress, and SIBO is no different. Stress increases inflammation, decreases gut motility, and weakens our immune system. It can also lead us to practice habits that are detrimental to our health such as alcohol use, poor sleep hygiene, consumption of processed foods, and rushed eating.
Stress reduction will look different for everyone, but a basic rule of thumb is to remove the stressors that you can, reframe those that you can’t, and include stress-relieving practices. This can include anything from mindful eating, getting a massage, exercise, scheduling time to yourself, setting a bedtime, playing a musical instrument, dancing – the possibilities are endless! Remove stress where you can, reframe a situation that feels out of your control, and add in a few new habits that you’ll enjoy (you’re much more likely to practice them if you do!).
Treatment is a long-term process. And no matter which treatment is tried initially, it may not be tolerated. We are all different, and it may take a bit of trial and error to develop the best treatment plan for you. You may feel a bit worse before you feel better, you may lose weight, or you may experience immediate improvement. However, you respond, keep track of your symptoms and how things are changing. This will help your doctor monitor your progress and determine if/when the treatment plan needs to change course. Work closely with a doctor you trust who listens closely to how you are experiencing the treatment process. Commit to working with them for at least a few months, ensuring that your treatment plan eradicates SIBO and that you are provided with long-term guidance as to how to prevent recurrence.
Your treatment plan should address the root causes, symptoms, complications, as well as eventual maintenance. Prognosis of SIBO can be serious; ensure that you are working with a doctor who understands this, and who is intent on understanding you as a whole person, and not just the SIBO you are experiencing.