Just as we must consider all the components that contribute to obesity, we must also look into our overall GI health and complications that may arise in that body system.

GI doctors and GI folks know about Small Intestinal Bacterial Overgrowth (SIBO) and indeed treat it, but I think it is one of the least discussed and explained problems in all of medicine despite high incidence. I struggled against it for close to 2 years, so I know it pretty well.

• Dukowicz Andrew C, Lacy Brian E, Levine Gary M. Small Intestinal Bacterial Overgrowth. Gastroenterol Hepatol (N Y). February 2007;3(2):112-122.
• Avelar Rodriguez David, Ryan Paul MacDaragh, Toro Monjaraz Erick Manuel, Ramirez Mayans Jaime Alfonso, Quigley Eamonn Martin. Small Intestinal Bacterial Overgrowth in Children: A State-Of-The-Art Review. Front Pediatr. September 4, 2019;7. doi:10.3389/fped.2019.00363.

The treatment is all over the place and confusing. I essentially put together my own protocol based on the presumed etiology and the limited research.

Prevention: Avoid helping Bacteria invade and live in the small intestine.

1. Enhance and don’t limit stomach acid
   • Avoid calcium
   • Avoid H2 blockers
2. Avoid probiotics
   • Probiotics and SIBO. If the goal of stomach acid is to kill bacteria, why are you adding them?
   • Probiotics are ineffective in general anyway. Just feed the good ones via pre-biotics targeting the large intestine.
3. Don’t kill the good bacteria
   • Natural antibiotics
   • Avoid any PO antibiotic

Treatment for Existing SIBO: Needed to Recover 

1. Control bacteria – antibiotic to kill off small bowel bacteria
2. Increase water intake and intestine motility to keep bacteria from migrating back from the large intestine
3. Deal with bloating, gas, abdominal pain
4. Don’t feed the bacteria – dietary changes to monoglycerides and certain carbs (FODMAP diet)
5. Digestive enzymes to support better digestion
6. Support bacteria in the large intestine – pre-biotics are not useful until SIBO is under control
7. Avoid probiotics

1) Control Bacteria

• Hot water with:
  • A mixture of one tablespoon apple cider vinegar, one cup warm water, and one tablespoon honey will ease indigestion and may alleviate cramping and gas in your upset stomach.
  • Green tea
  • Lemon water
  • Manuka honey Pure New Zealand Certified UMF 15+ Manuka Honey (8.8 oz) – All Blacks Official Licensed Honey
    • Is a medically-active honey harvested from the tea tree family. The honey may kill off potentially infectious bacteria such as Escherichia coli (E. coli), Enterobacter aerogenes, Salmonella typhimurium, and S. aureus in the gut and relieve digestive symptoms. Manuka honey may also help protect the digestive lining and relieve symptoms of disorders like IBS (ref).
    • C Diff
    • Measured by 3 different numbers: UMF MGO KFactor. MGO is the one that matters 450+ MGO or Or 15-20+ UMF
  • Apple Cider Vinegar (vs. regular)
• Pills and Spices
  • Ginger – NOW Foods Ginger Root, 100 Capsules / 550mg – anti-biotic – research – 0.5 to 2gm $4.50 for inflammation (mild effect, strong evidence). 1 to 3/day with food. 1000 [550×2] Ginger increases gastric motility and supports proper bile release into the small intestine, improve fat assimilation and digestion. Stopped because it upsets my stomach.
  • B6, Vitamin B6, and ginger can help relieve nausea
  • Dysbiocide [$28/120, 2 caps BID] – preferred – Herbal Therapy Is Equivalent to Rifaximin for the Treatment of Small Intestinal Bacterial Overgrowth
  • Note: standard medical treatment is rifaximim which costs about $1500 or about 1/2 that if the insurance company pays up. Basically, it is the only antibiotic that isn’t absorbed centrally so it only acts in the gut (and is thus pretty useless and they don’t make a lot of money from it so they overcharge)
  • FC Cidal [$28/120, 2 caps BID] – composition
  • Candida Cleanse 120 Capsules Veggie Caps with Herbs, Antifungals, Enzymes, and Probiotics– Oregano Leaf Extract, Caprylic Acid, L.Acidophilus, Protease, Cellulase, Aloe Vera Gel, Arabinogalactan, Anise Seed, Black Walnut Hulls Powder, Wormwood Leaf Powder, Reishi Mushroom
  • Oregano Oil – 125mg – washing – 500 mg, four times per day – SIBO and more – Key element is Carvacrol
• Consider
  • Candibactin-AR (oils) [$82/180, 2 caps 2-3x/day] and Candibactin-BR [$82/180, 2 caps 2-3x/day] – review not as positive. Metagenics Candibactin-AR Soft Gels, 120 Count
  • NutribioticGse Capsules Caps, 250 Mg, 60 Count – take 1 – anti fungal – not absorbed
  • SUPER Colon Cleanse Detox by Perk – – Pill
    • 11 different natural ingredients

2) Increased Water Intake and Intestinal Motility

• MotilPro [in 3 caps – – 3-6/day – $48.70/180. Motilpro contains vitamin B6, ginger extract, acetyl-L-carnitine, and 5-HTP. Help increase motility, improve gastric emptying, relieve nausea, and help relieve symptoms of chronic constipation and SIBO-C.
• Nutricost 5-HTP 100mg, 240 Capsules (5-Hydroxytryptophan) – Veggie Caps, Gluten Free, Non-GMO, and si motility. 5-HTP 50mg which increases serotonin production in the brain and gut that can help encourage proper motility by inducing proper migrating motor complex (movement of stomach and small intestines during fasting) (MMC) function and muscle contractions in the digestive tract. ^1234567
• Acetyl L-Carnitine Capsules 1000mg Per Serving – 500 mg each L Carnitine Supplement 120 Vegetarian Capsules [white]. Helps improve the neuronal health of brain and colon and improve the MMC. It also increases acetylcholine which is an important neurotransmitter for proper muscle contractions, nerve conductivity, and motility in the gut. Side effects are headache and insomnia of which I had both.

3) Deal with Bloating, Gas, Abdominal Pain

• Atrantil (90 Clear Caps for $33.55 – 2 TID – Ingredients:
  • Peppermint, peppermint leaf extract calms the small bowel.
  • Quebracho Colorado (South American hardwood tree) flavonoids soak up hydrogen and create an unfriendly environment for the archaebacteria. They weaken the cell walls setting the stage for Atrantíl’s third botanical.
  • Horse Chestnut, a natural antibacterial from horse chestnut seed extract, binds to the reductase enzyme in the weakened archaebacteria stopping the methane production.
• Ibergast – STW 5 (Iberogast®)—a safe and effective standard in the treatment of functional gastrointestinal disorders – safe for IBS and dyspepsia. 20 drops BID. Yucky taste.
• Core element of Ibergast is Berberine: Berberine as an antibiotic – 450 BID: Berberine 900mg 180 Capsules Best Value Berberine Supplement – $20. Lots of side effects, including insomnia and headache [yellow]. Research for IBS on berberine.

4) Don’t Feed the Bacteria

Dietary changes to monoglycerides and certain carbs (FODMAP [Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols] diet)

• A huge topic in itself. But the basic theory is to avoid sugars that aren’t immediately absorbed and that are really attractive to bacteria.
  • Disaccharides (lactose, sucrose)
  • Fructose – a monosaccharide that requires modification to absorb
  • Some more complicated carbohydrates – Oligosaccharides
  • Those artificial sugars that are based on alcohol – the bacteria love them and you can’t digest them, thus the reason they are low calorie
  • Fats and protein are ignored by bacteria

5) Digestive Enzyme

Only take before meals.

• Doctor’s Best Digestive Enzymes, Non-GMO, Vegetarian, Gluten Free, 90 Veggie Caps – $17.22 for 90
• Source Naturals: Essential EnzymesUltra 60 Vegetarian Capsule – $20
• Simethacone for gas
• Best Naturals Fast Acting Lactase Enzyme Tablet, 3000 Fcc Alu, 180 Count – take 3 or more – some folks need a ton. Competitor is cheaper but requires opening foil
• Integrative Therapeutics – Similase – Physician Developed Digestive Enzymes for Women and Men – Relieves Occasional Gas and Bloating – Vegan – 180 Veg – 1-2 with meals
  • Sucrase

6) Support Bacteria in the Large Intestine 

Potentially need PolyPhenol, since rebuilding. I would take with food. They also have anti-oxidants.

• Polyphenol foods and role in the biome
• Life Extension Applewise Polyphenol Extract 600 Mg Vegetarian Caps, 30 Count – $13/30 – 600mg recommended so you need 2
• Puritan’s Pride One A Day Cranberry -120 Capsules – take 1 $12/120
• Nutribiotic Grapefruit Seed Abstract Capsules Caps, 250 Mg, 60 Count – Proanthocyanidin-rich extract from grape seeds given to healthy adults for 2 weeks was able to significantly increase the number of bifidobacteria – weak support

7) Avoid Probiotics

Taking these from the top of the GI track buys you nothing! Skip them and don’t use. You can’t put them there, you need to “feed” using prebiotics. If you try and put them there then you are creating SIBO since you have to go through the small intestine to get to the large intestine.

• SIBO Success using Bifidobacterium bifidum, Bifidobacterium lactis, Bifidobacterium longum, Lactobacillus acidophilus, Lactobacillus rhamnosus, and Streptococcus thermophilus
• Bifidobacterium breve
• Bifidobacterium Bifidum helps the gastrointestinal tract function. It reduces the chances of acute diarrhea and might even help fight E.coli infections. It might increase the immunity function, fight Candida and other yeast overgrowths if present.
• Lactobacillus casei strain Shirota (Yakult®) can alter small intestinal bacterial overgrowth (SIBO). Yakult may persist after suspension of therapy in lactose-intolerant patients
• Lactobacillus acidophilus is used for treating and preventing diarrhea. Some people use it for general digestion problems; irritable bowel syndrome, colic in babies, Crohn’s disease, inflammation of the colon. It is also used for infection with Helicobacter pylori, vaginal infections and skin disorders.
• Lactobacillus rhamnosus is claimed to colonize the digestive tract and to balance intestinal microflora. It may prevent rotavirus diarrhea and can stop respiratory tract infections in children. It has been found to reduce intestinal permeability in children who suffer from irritable bowel syndrome. Lactobacillus rhamnosus may increase weight loss in women who are dieting.
• Lactobacillus casei as a lactic acid producer has been found to assist in the propagation of desirable bacteria. It is documented to complement the growth of L acidophilus.

Some studies do indeed look at probiotics, but I admit I discount them based on the reality that it simply doesn’t make sense to treat bacterial overgrowth with bacteria. Sure, perhaps they “compete,” but the reality is that the small intestine is supposed to be mostly sterile and the bacteria in SIBO are generally found to be “good” bacteria – that aren’t supposed to be there.

• Kwak Dong Shin, Jun Dae Won, Seo Jae Gu, et al. Short-term probiotic therapy alleviates small intestinal bacterial overgrowth, but does not improve intestinal permeability in chronic liver disease. Eur J Gastroenterol Hepatol. December 2014;26(12):1353-1359. doi:10.1097/MEG.0000000000000214.
• Leventogiannis K, Gkolfakis P, Spithakis G, et al. Effect of a Preparation of Four Probiotics on Symptoms of Patients with Irritable Bowel Syndrome: Association with Intestinal Bacterial Overgrowth. Probiotics Antimicrob Proteins. 2019;11(2):627-634. doi:10.1007/s12602-018-9401-3. PMCID: PMC6541575. PMID: 29508268.
• Soifer Luis Oscar, Peralta Daniel, Dima Guillermo, Besasso Horacio. [Comparative clinical efficacy of a probiotic vs. an antibiotic in the treatment of patients with intestinal bacterial overgrowth and chronic abdominal functional distension: a pilot study]. Acta Gastroenterol Latinoam. December 2010;40(4):323-327.
• Vitetta L, Vitetta G, Hall S. Immunological Tolerance and Function: Associations Between Intestinal Bacteria, Probiotics, Prebiotics, and Phages. Front Immunol. 2018;9:2240. doi:10.3389/fimmu.2018.02240. PMCID: PMC6189397. PMID: 30356736.

Breath Tests

There is much useless banter about breath tests to make the diagnosis of SIBO. The reality is they don’t catch all SIBO. There are two versions (based on the bacteria), and the work may be analyzed differently as people disagree on how to interpret them. So, the definition of a positive result is mostly useless unless it is really positive. At that point (rotten egg burps), it’s pretty darn obvious.

Imagine if we diagnosed depression this way and told people who were suffering that, according to this marginally useless test, you don’t have depression. Sorry. Maybe in a few months, we can test again.

• Mattsson Johanna, Minaya Maria Teresa, Monegro Milka, et al. Outcome of breath tests in adult patients with suspected small intestinal bacterial overgrowth. Gastroenterol Hepatol Bed Bench. 2017;10(3):168-172.
• Banik Gourab Dutta, De Anulekha, Som Suman, et al. Hydrogen Sulphide in Exhaled Breath: A Potential Biomarker for Small Intestinal Bacterial Overgrowth in IBS. J Breath Res. May 10, 2016;10(2):026010. doi:10.1088/1752-7155/10/2/026010.
• Rezaie Ali, Buresi Michelle, Lembo Anthony, et al. Hydrogen and Methane-Based Breath Testing in Gastrointestinal Disorders: The North American Consensus. Am J Gastroenterol. May 2017;112(5):775-784. doi:10.1038/ajg.2017.46.
• Avelar Rodriguez David, Ryan Paul MacDaragh, Toro Monjaraz Erick Manuel, Ramirez Mayans Jaime Alfonso, Quigley Eamonn Martin. Small Intestinal Bacterial Overgrowth in Children: A State-Of-The-Art Review. Front Pediatr. September 4, 2019;7. doi:10.3389/fped.2019.00363

Much of wasting in third-world societies is associated with SIBO. We need to also investigate the findings in third world countries that imply that disadvantaged individuals in this country suffer from higher levels of intestinal disorders and that the finding seen in third-world countries may actually apply to individuals in this country.

SBIO is a complicated illness and much more research is needed to fully understand effective testing and treatments that will work.