Perhaps it’s been a long journey for you and you finally got diagnosed with SIBO (Small Intestinal Bacterial Overgrowth). You have to celebrate because getting to this point might have been a very long and painful process so well done for not giving up and investing time, money and effort to go and find answers to improve your health!
You are now super excited that you are finally going to get your old life back and feel great again. You’ve just figured out the root cause of your health issues that might have been elusive for a very long time even from your doctors. The SIBO diagnosis was a huge progress and now that you are finally here, the question is what happens next?
Getting the correct diagnosis is 50% getting there, the other 50% is receiving the right treatment for you. If you are lucky, you will get your SIBO root cause correctly diagnosed by your functional medicine practitioner and if that happens, you are indeed very lucky! If you cannot figure out what is causing it, however, that’s a problem, because you run the risk of it relapsing after each treatment. So, getting to the root cause (or causes because it may be more than one!), is key to successful healing from SIBO!
So, here I have put a list of all the causes I could compile to help those of you who are stuck in a cycle of repeated antibiotics or herbal antimicrobial treatments and as soon as your treatment stops, the infection returns within a few months or within a year. Or perhaps you are new to this and you just got diagnosed with SIBO and you are starting to learn about how to treat it, so this is a good starting point to get it right first time and heal quickly.
To avoid getting recurring SIBO infections, please check with your practitioner if they suspect what the root cause is for you. Here is a list so that you can go to your appointments equipped with some knowledge and information and can ask them some questions about your treatment plan which should have hopefully included investigating and treating the possible causes:
1. LOW STOMACH ACID
This is a natural antiseptic which prevents us from having bacteria in our small intestine. Proton pump inhibitors (PPI), or anti-acid medication, is bad news for SIBO sufferers. Whether you have been put on PPI or possibly other medication, regular medication usage can contribute to the overgrowth of unhealthy bacteria in your small intestine and even the stomach because it can disrupt the natural acidity in the stomach which usually protects us.
The low stomach acid changes the natural environment in your gut because it cannot eradicate dangerous pathogens. Often, PPI is overprescribed for indigestion and reflux. The fact is that it is the gas/belching which causes stomach acids to come up which is mistaken for high stomach acidity. So, in fact, reflux is quite often a sign of low stomach acid.
In many cases when people don’t have enough hydrochloric acid (due to various reasons which need to be investigated), this can cause SIBO to develop. This will eventually cause bloating, gas, irregular heart beats, nausea, excessive belching, IBS which will lead to indigestion and reflux and they might end up being prescribed PPI for “possible” high stomach acidity. This PPI medication will make their SIBO so much worse, especially if it is used long term so make sure you check with your practitioner what the best course of treatment is going forward to support your healing from SIBO.
If your practitioner suspects low stomach acidity, they might possibly recommend supplementing with either apple cider vinegar (ACV) or hydrochloric acid (HCL). Your practitioner might suggest a trial of low amount of HCL of around 100mg per capsule per meal (possibly with digestive enzymes) and then move up to 250mg per capsule per meal and finally to 500mg per meal with a larger meal/portion of protein if you have successfully tolerated the lower doses and you are finding it helpful. Or, you could simply try adding ACV and see if it works for you. If you notice that this is helping you break down proteins better and you have less bloating and more energy, then you may have found you root cause of your SIBO.
Important note: if you get pain when you try apple cider vinegar (ACV) or hydrochloric acid (HCL), you need to discontinue and tell your practitioner immediately. This is an indication of gastritis or stomach ulcers and you should not be taking ACV or HCL if you have them. You might be able to introduce them later when you have healed your gastritis/stomach ulcers. Once healed, your stomach cells might start producing sufficient HCL again naturally and you may not need to take any supplements for low stomach acid (See point 5 below on gastritis/stomach ulcers). It is best to work with a practitioner to support you on this.
2. INFECTION IN THE STOMACH - apart from medication as discussed in point 1 above, some infections can also alter the stomach acidity and cause an environment for unwanted bacteria to proliferate. Discuss with your practitioner about testing for infections (H. Pylori is the common one that causes ulcers but also some fungal overgrowths can alter PH levels).
It is common for people to develop SIBO after having a bad case of gastroenteritis/ food poisoning. The immune system will start making antibodies for the toxins the bacteria are releasing but also might create an autoimmune antibody to the cleansing wave (see section 6. Motility disorder). This could be the major cause of autoimmune IBS/SIBO as the body releases antibodies for its own cleansing wave so you cannot clear those food and bacteria particles any more. Your practitioner will most likely give you prokinetics to stimulate the motility in your gut which will aid the healing process and speed up recovery.
3. REGULAR/FREQUENT USE OF ANTIBIOTICS
This is one of the biggest causes of small intestinal fungal overgrowth (SIFO) and small intestinal methanogen overgrowth (SIMO). Once the antibiotics kill a lot of bacteria, they create space for other species to overgrow because they are unaffected by antibiotics themselves and are free to multiply and spread quickly. That’s why people often get UTI/thrush/skin, etc infections after antibiotics because the candida/fungal population has overgrown.
Cutting out simple sugars from your diet is key and also taking probiotics during the antibiotic treatment and for at least a few weeks afterwards may help. Frequent antibiotics use can cause dysbiosis (which is an imbalance of good and bad bacteria in your gut) and if you already had SIBO/SIFO/SIMO prior to that, the antibiotics could make it so much worse. That’s why when going on a treatment plan, whether antibiotic or herbal antimicrobial, you may have to ask your practitioner if they could give you a combination which includes antifungal treatment to prevent overgrowth of yeasts/fungi while you are on antibiotics/antimicrobials. You will also need supplements to prevent the overgrowth of methanogens, so it is best to have all these 3 bases covered to avoid further dysbiosis (imbalance of good and bad bacteria in the gut).
4. PANCREATIC INSUFFICIENCY
This is a very common issue in SIBO sufferers which is often missed out. Not everyone with SIBO has low pancreatic elastase but quite a large number do. Whether you are genetically predisposed to have lower pancreatic enzymes or the SIBO infection spread to the duodenum and is affecting its alkaline environment making it highly acidic so your enzymes cannot get activated, either way, this can lead to your food not being digested and absorbed properly which ends up in bloating and feeding bacteria/fungi and methanogens allowing them to increase their populations quickly. If you get bloated from everything you eat, you need to get your digestive enzymes checked.
One of the easiest and relatively inexpensive ways to find out if you do not have enough enzymes is to ask your doctor to run a “faecal elastase” test – quick, simple and cheap (your insurance will most likely cover it). You will be amazed to find out that most doctors don’t test for this, even having been to 4 different gastroenterologists myself, they all got surprised when I asked them to test me but all tests came back confirming insufficiency of pancreatic enzymes, so definitely get this checked as it might be your root cause of SIBO. You will be prescribed digestive enzymes which can make a whole world of a difference to your healing journey and the underlying cause of your SIBO.
The reality is that if you have insufficient enzymes, you cannot absorb nutrients from the food so….even though you eat, you are actually STARVING YOURSELF!!! Your body is so deprived of nutrients that all sorts of health problems start popping up like heart palpitations, anaemia, low mood, insomnia, depression, severe exhaustion, brain fog, concentration problem, issues with your vision, frequent infections, joint pain, etc the list goes on as you can develop issues with your whole body and every organ if you are starved for so long because your immune system weakens. Digestive enzymes and bile acids are responsible for digesting fats and if you are not taking digestive enzymes, you run the risk of not absorbing very important fat soluble vitamins such as vit A, D, E and K. Ever wondered why you don’t see well in the dark when you drive? Its most likely vit A deficiency which can be easily corrected with digestive enzymes and a good quality multivitamin which contains these important fat soluble vitamins.
That’s why your functional medicine practitioner should give you nutrient support during and after the treatment to correct the mineral and vitamin deficiencies that may have occurred due to low enzymes and SIBO infection. If you are lucky and your pancreatic digestive enzymes are OK, then you might still have nutritional deficiencies caused by the SIBO as it feeds on your food and leaves you depleted of essential nutrients. So, getting a multivitamin and mineral support during your healing is important to support your recovery.
5. GASTRITIS / STOMACH ULCERS
These conditions can cause problems with the stomach production of HCL so it can lead to low stomach acids generally and also a lot of pain when eating, drinking or pain can be triggered when your stomach acids are produced at mealtimes even without any food! This can contribute to making your SIBO worse or cause SIBO in the first place. See point 1 above what happens with low stomach acids.
So make sure you find out what caused your gastritis/stomach acid (was it medication that damaged the mucosal lining or an infection or both?) and treat your gastritis quickly. If this was the root cause of your SIBO, you might be able to treat both gastritis/stomach ulcers and SIBO at the same time.
During the healing period you should try to avoid coffee as it is very acidic and can be irritating to the stomach. Also, all acidic foods such as tomatoes, fermented foods, lemons, vinegar, mayonnaise, ketchup may all cause pain. So best to adapt your diet for a few weeks to help speed up healing and then you can safely re-introduce them. A nutritionist experienced with SIBO will be very helpful on your healing journey.
Once your gastritis is healed, you could trial HCL with your practitioner’s guidance, of course, if you pain returns that it is too strong to take for you and you should try to naturally stimulate more stomach acid production.
If you can tolerate fermented foods, then try a tablespoon of sauerkraut juice before a meal – it is full of beneficial probiotics and also naturally stimulating your stomach to produce more stomach juices to help digest your food! If this is too strong initially while your mucosal lining is healing and you feel pain, you can just drink half a cup of homemade bone broth 30 mins before each meal and it will have the same effect of stimulating your stomach acid production while it is actually quite healing and soothing for your mucosal lining as it contains amino acids essential for your gut healing.
Important: If you are on digestive enzymes and you have gastritis/stomach ulcers, please make sure you don’t buy digestive enzymes which have hydrochloride acid (HCL) added to them while you are healing from gastritis/ulcers.
6. MOTILITY DISORDER
We usually have a migrating motor cleansing wave which means after we eat food, this movement shifts food down the small intestine into the large intestine. It essentially sweeps all the remaining food particles and bacteria out and gets the body ready for the next meal. There are some motility conditions which mean that this cleansing wave is damaged so the food just sits there and ferments.
This can become a common chronic problem especially with our busy lifestyles. We tend to eat on the go these days rushing from home to work, school pick-ups, after school clubs, personal appointments, etc, a long to do list every day which means we tend to have small meals and often eating them less than 4 hours apart. By the end of the day we are so tired and stressed that we find it hard to fall asleep. Frequently, our lifestyles do not have enough time built into it to sleep/rest and for exercise to aid the natural motility in our gut.
So, to naturally stimulate your MMC, try to stick to 3 meals a day only WITHOUT any snacks (2 meals a day would work even better if you can manage and you dont have insulin resistance!) and start practising intermittent fasting (IF). IF and 4 hours between meals is one of the quickest and easiest way to kick start your healing journey, allowing the MMC to work naturally and your body to heal. For more complex cases or in the early stages of healing from an advanced SIBO, your practitioner may give you natural herbal supplements called prokinetics to stimulate the MMC so that all the SIBO infection is flushed out of your system! This is an important root cause to treat SIBO and prevent a relapse. You can contact us if you need nutrition coaching advice.
7. STRESS – you have probably already heard about this from your practitioner. When you have a lot of stress in your life which is over a prolonged period of time and you live in a constant stage of “fight or flight”, it is bad news for SIBO. Stress activates the sympathetic system which helps the body activate the “fight-or-flight” response, it pumps cortisol into your body and shuts down digestion (so basically if you have just eaten a sandwich on the go, got a call from work and you are super stressed and also had a coffee to keep you awake all afternoon, you are not in the best place to heal your SIBO). The digestion shuts down when we are stressed so your food will end up fermenting and rotting in your gut and feeding your SIBO and making you feel sick. And if you have had coffee or any caffeinated drink, this will further make your body produce more cortisol and it also prevents the absorption of nutrients (coffee can especially affect iron absorption so if you cannot quit coffee, try to drink it away from food!). Did you know that caffeine can slow down your migrating motor complex? So, not good news for SIBO. This whole situation can create a cycle of sleeping difficulties and not getting sufficient sleep is associated with overgrowth of unfriendly bacteria in our gut.
How to improve the stress situation, walk out in the fresh air for 5 mins if you can or breathe in, hold for a few seconds and breathe out and repeat for a few times. Your breathing sends a signal to your cells that you are not under attack any more and it will reduce your cortisol production and levels by almost 50% with just breathing deeply for a minute!
Another quick way to destress your body is to lie down if you can and make sure your legs are at the same level or higher than your heart, this is the quickest way to activate your digestion system, if you hear the gurgling of your stomach, great, you have activated you parasympathetic system which helps with your digestion. So, if you can lie down just before a meal and straight after a meal, it will greatly improve digestion and decrease bloating. Some cultures have even built this into their daily lives! Have you heard of afternoon “siestas” in the Mediterranean countries?
Other helpful tips: Try eating your meals slowly without looking at a screen, chew 15-20 times, practise mindful eating (chewing your food many times, looking at it, smelling and enjoying the wonderful flavours). Have you felt your mouth watering when you see something you like? These are your initial enzymes being released in the mouth. The digestion of carbohydrates starts in the mouth before the food has even reached your stomach so take your time with your meals and enjoy them.
Try listening to a relaxing music while eating or sharing your meal with family and friends in a happy atmosphere and also try to have your coffee before midday away from food which will greatly improve your sleep, regulate your cortisol and stress levels which is good news for healing from SIBO! If you can quit coffee for a about a month, it would be even better for your health. You can have 2-3 cups of green tea instead throughout the day to give you low doses of caffeine while enjoying the anti-oxidant benefits of green tea. If you try this, cut down on coffee slowly each day to avoid migraines from a sudden caffeine withdrawal.
8. SLEEP – probably every practitioner you see will probably tell you that sleep is paramount to good health and healing, however, when your gut is infected and your neurotransmitters are produced in the gut and they are disrupted, that means the brain is not working well and our hormones are out of balance. The cortisol and melatonin can be out of synch too which leads to serious sleep deprivation which makes SIBO so much worse. So, the vicious cycle is that you cannot improve your SIBO until you start getting 7-8 hrs of sleep per night but you cannot improve you sleep until you treat your SIBO. So, make sure your practitioner gives you some herbs to calm down your nervous system by using adaptogens which work wonders for your much needed night-time recovery sleep.
9. EXERCISE -Yes, fresh air and exercise are super healthy, we all know it but if you are fighting SIBO, chances are you feel absolutely knackered before you have even left the house or you might even feel exhausted in the morning when you get up! So, increase your exercise slowly, even if you start from 5 mins walking a day and go up to 30 mins a day. The exercise will support your healthy bacteria in the colon which produces short chain fatty acids which are anti inflammatory and super important for our healing. Also, our lymphatic system counts on exercise in order to get drained, so exercise, no matter how little each day, is very important indeed for our immune system and healing from SIBO.
10. DIET – I know we have heard it all before but all these highly processed foods are no good for our health at all. They cause alarming levels of chronic illnesses, so it is time to take a look at how we eat. Once you make a decision to avoid processed foods, you will by pass plenty of aisles in the supermarket and wont even stop to shop from there when you realise what processed foods can do to your health and why we need whole foods to thrive.
With SIBO, however, it is a completely different story. You can go on a very healthy diet and get worse. You can follow a healthy diet plant and feel worse. Yes, this is because a lot of the healthy foods are high in FODMAPS (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) which are incredibly good for us if the bacteria we are feeding with FODMAP is in the colon, not in the small intestine. High FODMAP foods can make SIBO worse, so make sure you follow your nutritionist advice on how long you should follow low FODMAP diet and how and when to re-introduce a variety of foods back into your diet. Going on a low FODMAP diet, or any diet for a long time can be dangerous as it can have a long term impact on your microbiome diversity so best to work with a nutritionist/practitioner experienced with SIBO.
Wishing you best of luck in your journey towards healing from SIBO so that you can enjoy all healthy foods again!!!
If you have recovered and you had a different root cause from the ones mentioned here, please comment or email us with your story, would love to hear from you!
For more information on SIBO, you can read about the steps to healing here: Diagnosing and Healing from SIBO (Small Intestinal Bacterial Overgrowth) (nutritionjourney.co.uk)
For SIBO diets, you could discover more here: What is the best SIBO Diet? (nutritionjourney.co.uk)
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