HOW TO PREVENT SIBO RELAPSE
SIBO is the new Candida - it seems everyone with a gut problem thinks they have SIBO. And, indeed, given the increased incidence of Irritable Bowel Syndrome (IBS) where SIBO is thought to form part of approximately 60% of cases, they may be right.
But, as with every health craze (particularly one that falls more within the Functional, Integrative Health space rather than within the conventional medicine remit), where there is a latest fad there follows a whole host of myths surrounding the condition.
Two of the most common stories about SIBO are that it is a) difficult to treat and b) that even after it is treated successfully it is likely to come back - also known as SIBO Relapse. Then there’s the third conversation about SIBO: testing. Validity, accuracy, breath tests, urine tests, glucose or lactulose… the whole world of testing seems to be rife with confusion and differing opinions.
Much of my work in the first consultation with a SIBO client is about dispelling these myths. I lose count of how many SIBO enquiries come through which include the question, “do you have any success treating SIBO”, as if this is one of the most complicated and challenging digestive conditions to tackle.
In my practice, I have found that this simply isn’t true. I don’t think it’s because I work miracles - I just use common sense, practical application of different approaches to SIBO (because there are differing opinions for a reason) and - most importantly - a really calm, rational and positive approach to tackling this condition.
In a very direct way, the stress about SIBO being tough to get rid of and constantly coming back can be the very ingredient that MAKES it recalcitrant and difficult to treat. I don’t encourage dramatic paranoia in my practice for any condition, but especially for gut wellbeing. The nervous system informs so much of our gut health that to endorse anxiety is precisely the worst thing to do.
However, instead of taking this article down a segue which is entirely psychological… there really are practical steps to understanding how to treat SIBO to ensure that relapse isn’t part of the picture.
THE BASIC REASON FOR SIBO RELAPSE
As with all internet-myths, there is some truth to the fact that SIBO can be prone to relapse. This is because the very nature of SIBO is that it is an overgrowth of bacteria due to some form of dysfunction of motility and gastrointestinal flow. Treating SIBO is, therefore, not just about killing bacteria. It’s also about restoring motility - and that requires understanding why the motility has been interrupted in the first place. More often than not, UN-successful SIBO treatment happens because the reason behind the interrupted flow has not been accurately identified and addressed.
Now, it stands to reason that the main way to prevent SIBO relapse is to establish what has interrupted motility and fix it - and I honestly do believe that this is what most practitioners are aiming to do. However, it is often not simple to identify - and in these cases where it is impossible to pinpoint the precise ‘reason’ for the interrupted motility, simply treating bacteria using antimicrobials isn’t typically going to be enough.
That doesn’t mean that just because we don’t have a ‘why’ we cannot prevent relapse, however. Using an holistic understanding of all of the factors that influence motility in the gastrointestinal tract we can still prevent SIBO relapse, even without fully understanding the ‘cause’.
FLOW & MOTILITY
Interrupted, slowed and impaired flow or motility is the most obvious and widely discussed reason/cause for SIBO - and therefore the most highly-leveraged technique for keeping SIBO at bay.
Many practitioners will utilise supplements to support motility and GI transit both during SIBO treatment and beyond. Sometimes just magnesium is enough to ease constipation in the large intestine which is the lead domino for the development of SIBO. Often, more upper gut motility is required and specific herb complexes or medications known as prokinetics are used. You may have heard of some of these: Iberogast, MotilPro, Prucalopride - even Low Dose Naltrexone has been used as a motility agent.
These are, of course, a good idea, particularly between SIBO treatment finishing and re-testing.
However, within my practice I question the long-term use of assistance to ensure motility. Moreover, they’re difficult to get - I have found that even with the evidence (i.e. randomised control trial data) some doctors and gastroenterologists are extremely resistant to prescribing motility agents. And getting Low Dose Naltrexone, now a fairly common therapeutic agent for all manner of inflammatory conditions in the US, prescribed in the UK is near to impossible.
When it comes to motility, we really shouldn’t need ‘help’. Our diets and our microbiomes are supposed to take care of this in and of themselves. And yet, the whole nature of getting SIBO in the first place suggests that something in this milieu has gone awry.
Instead of focusing on herbs or drugs to influence motility, therefore, I try to focus my clients on the things that assist with gastrointestinal function anyway: fibre, fluids and gut bacteria. Both fibre and probiotics are typically viewed with horror by those with SIBO because they aggravate symptoms… however, after SIBO has been treated these lynchpins of gut function are often the very thing that can help keep SIBO from coming back.
Low-fibre diets do have a place and the scientific literature is starting to support their use for interventional therapeutics in gut conditions. However, I am also a strong believer in the benefits of fibre to maintain and nurture the natural ecosystem of the gut. The key here is balance. Fibre feeding the wrong gut bugs equals digestive symptoms. Fibre feeding the right gut bugs equals harmony.
This is where the probiotics come in. I don’t use probiotics in my practice to ‘re-seed’ the gut (more on this and specific probiotic therapies in the coming weeks). However, I do use probiotics to shift the gut. Recent meta-analyses and reviews have reported that whilst probiotics are not great at colonising (i.e. the strains in the pills we take do not take up residence inside the gut) they can act almost as an ANTI-biotic… and, actually, we don’t really grasp all of the synergistic impacts that they have inside the gut.
What we do know about the microbiome is that certain bacteria make fuel for other bacteria, they also make vitamins for themselves - and they work to keep populations of not-so-great bacteria in check. All of this means that when I am dealing with a patient who, for any reason, has had some gut dysbiosis and then gut treatments, I know that it is important to shepherd their microbiome into a place where it is self-regulating again. I use certain probiotics to help with this…
And no, I’m not going to tell you what they are … because every single patient is different. One of the greatest breakdowns of the data on this subject which can help you navigate the tricky world of probiotics is Dr Michael Ruscio, whose new book “Healthy Gut, Healthy You” contains a complete breakdown of the probiotic classes (4 of them) and how to trial these types to work out what suits you. Probiotic experimentation is not cheap - and a good practitioner will be able to guide you to the right place to start… but it is possible with resources such as Dr Ruscio’s book to navigate this self-experimentation and find the right probiotic to support your microbial balance…
Which then makes consuming more fibre much more possible. And the combination of these two, plus enough fluids, keep stuff flowing ‘lower down’.
UPPER DIGESTION
The other factor when it comes to SIBO is that there is every possibility that it originally occurred due to issues with upper gut digestion, rather than lower gut motility.
Here we are talking the acidity of the stomach, the release of digestive enzymes and the production and concentration of bile from the gallbladder. The human digestive system really is like a line of dominos, with each step having to be in place to release the right products from the next step. Without this streamlined process, the solution that leaves the stomach isn’t acidic enough, doesn’t get broken down enough - and largely undigested food arrives in the small intestine where it proves to be ripe fuel for any bacteria to feed off and create fermentation, gas and the bloating that is so distinct a feature of SIBO.
To ensure that SIBO relapse does not occur, getting these upper dominos to line up is important. This is NOT a case for mainlining HCL tablets - and the science behind the ‘too low stomach acid’ is, as far as I am concerned, slightly questionable. We used to believe that low stomach acid was more often a cause of acid reflux than high stomach acid.
I know that many of my colleagues are much more conservative on this now. Sometimes we will recommend the ‘take as many HCL tablets as you need to feel the burn’ approach. More regularly, however, I am using other techniques: bitters, enzymes on their own, bile supplementation alone and mindfulness techniques (see below) to ensure that the body is working to produce the right concentration and quantity of digestive aids at all times.
When digestion works well from the stomach down there is far less potential for SIBO to regrow. Sometimes simply restoring bile production (which can be affected through issues as broad as gallstones to a genetic SNP which affects synthesis of phosphatidylcholine) is enough to ensure transit and flow and prevent SIBO from coming back.
DIETARY INTAKE TO SUPPORT GUT HEALTH
Beyond the components we need to have in place digestively - from acid to enzymes, bacteria to bile - there is another important factor when it comes to gut bacterial health and harmony. Our gut needs to be nourished in order to retain accurate functioning and powerful flow. This means that everything we know of that supports gut health can also help reduce the likelihood of SIBO recurrence.
Here, I focus on polyphenols and fat soluble vitamins. Both are renowned for their ability to help the body as a whole (antioxidant potential, heart health - general wellbeing etc.) But actually polyphenols literally affect gut bacteria and influence overall wellbeing. Which means that whilst we don’t really (again) understand all the mechanisms and the ‘how’, we do know that polyphenols are never going to be a bad thing.
As for fat soluble vitamins - Vitamin A, in particular, has a large role in the health of the lining of the gut and the secretory IgA levels (part of the immune barrier of the gut). Vitamin D is pretty universally wonderful too, but in gut-centric terms it plays a large role in the modulation of both serotonin receptors in the gut lining (responsible for motility) and also the regulation of immune system activation through the gut. All in all, making sure there is enough of these in the diet and supplement regimen may seem completely immaterial to gut health and SIBO, but actually plays a fundamental role in supporting overall functioning of the gut.
And, as I’ve said many times in this article, prevention of SIBO recurrence is very little about paying attention to the small intestinal bacteria itself and everything to do with ensuring that overall gut function. Here, fat soluble vitamins and plant polyphenols play fundamental roles.
How to get these in is dependent on tastes and dietary preferences, as well as where you live! Adding in polyphenolic compounds as supplements is probably not necessary, though broccoli sprout powders are all the rage and can be quite effective. Ensuring that the dietary intake has a variety of plant matter should be plenty. With Vitamin A and D the situation is slightly different. Organ meats, especially liver, will provide a good quantity of Vitamin A but are an acquired taste. The sun should provide the Vitamin D but is very location dependent. For that reason, I often do supplement with a Vitamin D Complex which contains the right ratio of the other fat soluble vitamins.
ADHESIONS AND THE NERVOUS SYSTEM
Beyond the bacteria, digestive compounds and dietary intake the other elements of SIBO relapse revolve around contraction. This is, in fact, one of my greatest areas of interest when it comes to health in general: the way the biology of the body responds when in a state of contraction.
In SIBO circles it is common now to hear ‘adhesions’ discussed. Adhesions are made up of thickened tissue which occurs in response to damage, either through impact, trauma or surgical procedures. Abdominal surgeries and injuries can prove incredibly impactful on the overall tension within the gastrointestinal tract and directly affect the flow of the internal organs. This can interrupt flow and motility and ultimately give rise to SIBO.
I have referred several patients for myofascial release and other associated abdominal massage therapies throughout the last few years as this has become a more recognised element of recalcitrant SIBO cases. I have to say that this has had mixed success. I am conflicted about the nature of these therapies because there is one company which are the world leaders and yet charge such phenomenally large amounts of money that I cannot, in good conscience, refer my clients there. For that reason I cannot rate their methods and do not know if, done in their way, abdominal adhesion release is a vital key for SIBO treatment.
I have no scientific links to validate this, but it is my perspective that a degree of myofascial and abdominal scarring release may be important for those who have had really disruptive surgical procedures. However, in other patients I feel that the digestive system is highly, highly malleable and would (should?) have adapted around scar tissue.
What I feel IS important, however, is the neurological rewiring that might be required to assist those for whom abdominal surgeries or trauma have resulted in abdominal tensions.
I feel that it is less the scar tissue that is the priority, and more the muscle/neurological memory of the trauma. Wounds leave tension and trauma creates contraction. In the abdominal cavity, any tension and contraction is a response which affects motility, flow and transit… and we are back again at the propensity for SIBO due to decreased gut flow.
The more I work in Functional Medicine, the more I realise how illnesses are so often (if not always) created as the human body contracts away from a stressor, a stimulus with which it cannot cope, or a trauma (physical, immunological, psychological, emotional) which it cannot immediately process.
The patterns we create in response to such stressors tend to become ingrained. For those with SIBO who have had historic abdominal traumas, I believe that an important tool in the armoury of preventing relapse are therapies such as cranial osteopathy which can pacify and reset the central nervous system, through which much of the trauma and contraction is laid down.
Working with the nervous system of the human body is a way to unwind and re-calibrate patterns of contraction. As with the polyphenol/fat-soluble vitamins, the effect of this is far more broad than just helping with SIBO. For those with frequent SIBO relapses this piece is often a game-changer.
THE POWER OF THE MIND - THE SIBO PERSONALITY
A discussion of nervous systems (and, let’s be honest, any article that I write) would not be complete without covering perspective, mindset and psychology…
Contraction and tension are a function of the body, certainly - as explained above.
But they can also result through the stresses of the mind and holding oneself in a state of anxiety. Anxiety creates an activation of sympathetic nervous system activity and a tension throughout the body that is precisely designed to halt gut motility and reserve energy for the heart and the muscles. Being in a parasympathetic state is what safeguards gut function and digestion. Anything which distracts from this state is a risk factor for SIBO.
The complication with gut health is that when your intestines are in distress it creates anxiety. When you are then told about the hoops you need to jump through to treat that gastrointestinal distress (extensive supplement lists, incredibly restrictive diets, endless retesting and repetitive treatments) you can find yourself in a catch-22 situation. You become stressed about your gut - and stress creates gut issues.
This is, in part, why I spend a lot of my time writing articles which aim to minimise how overwhelming human biology can seem. Fuelling stress and anxiety about health conditions is precisely the wrong way to help. Referring to “recalcitrant, tough-to-treat SIBO” means people stress about not getting better - and in SIBO in particular this is enough to create the very tension that will stall the progress of healing.
This is, in no way, to state that all SIBO is caused by anxiety. However, I have seen enough cases now to know that gut motility can be so affected by neurological distress due to emotional or psychological conflict that this does actually cause SIBO. Those for whom the psychological piece is a dominant part tend to be very driven, carry-on-regardless individuals who, to some degree, fuel themselves using their tension and adrenaline.
Using stress to get stuff done is actually quite a good strategy, but it comes with consequences. The major consequence is that it interrupts the neurologically necessary ‘rest and digest’ phase for gut wellbeing. This can be perfectly fine for years, even decades - but if SIBO takes hold for any reason it is sometimes the living in a state of sympathetic overdrive which prevents healing and permanent remission of this condition.
With my clients for whom this forms part of their presentation a big key to SIBO remission is about taking the time in their day to actually eat. The most important tool for unwinding a nervous system that is prepped for sympathetic activity is to insist on relaxation. Breathing is one of the most important tools here - using box breathing techniques prior to eating, for example.
This works in the moment, on the microcosmic level. So does chewing thoroughly, minimising external inputs whilst eating, lighting candles and really taking the time for meals.
But there is a macrocosmic element that I like to remind my clients of. Sometimes tackling conditions which emerge out of running our bodies using just the sympathetic drive requires a re-evaluation of the way we live our lives. It sounds melodramatic to radically re-evaluate life choices because of recalcitrant SIBO… but it really does work.
For many of my clients, my gentle insistence has been to redress the balance of their energy. Instead of holding themselves tense and ready to attack against every element of life, I have recommended grounding/earthing/meditation/mindfulness/journalling and all sorts of other techniques which empower them to drop the tension and the anxieties and relax a little more into life.
Yet again, the impact of these shifts is profound and broad-spectrum. But specifically when it comes to SIBO, it is in the relaxation of the tension of the GI tract that natural flow of movement and motility is restored. GI function SHOULD be unconscious and natural, left to its own devices during a relaxed state. Often it is simply allowing our body to spend time in such a state that really is the magic that prevents constant SIBO relapse.
I have personally found that whilst all of the above techniques can help and have benefit - this final piece is the cornerstone to GI wellbeing. Healing from all manner of GI conditions, but especially SIBO, requires really being in a place where we are neurologically attuned to receiving, digesting and assimilating our food.
***AUTHOR'S NOTE: It is very important to state that there are some very real conditions which are rife with risk factors for SIBO and will place people in the unfortunate situation of having repeated SIBO issues. I can speak personally to this as I have one of the major risk factors - a connective tissue disorder. However, all of the above tips and tricks still hold true for individuals who face this challenge. Everything in this article is about paying attention to factors which influence gut health overall and predispose to SIBO. Even if you have a condition which makes SIBO relapse more unavoidable - the above tools may help to decrease frequency of recurrence, delay time between recurrence, decrease the stress of a recurrence and aid with speedy treatment of refractory SIBO.***