How to Prevent SIBO Recurrence

Episode Summary

In this episode of the Empowered Nutrition Podcast, we dive deep into the complexities of Small Intestinal Bacterial Overgrowth (SIBO) and its recurrence. Our host, with years of professional experience in treating SIBO and co-founder of the SIBO Academy, shares invaluable insights on why SIBO often returns after initial treatment and how to prevent it. We discuss the importance of addressing underlying root causes and present a comprehensive protocol to ensure SIBO does not come back. This episode is packed with practical advice for both patients and practitioners.

Episode Highlights

1. Understanding SIBO Recurrence: Explanation of why SIBO often returns after initial treatments and the importance of addressing root causes.
2. Key Components of a Post-SIBO Protocol:
   • Prokinetics: Importance of stimulating gut motility to prevent bacterial overgrowth.
   • Digestive Enzymes: Role of high-quality digestive enzymes in aiding proper digestion and absorption of food.
   • Probiotics: Use of specific types of probiotics to create an environment unfavorable to harmful bacteria.
   • Replacement Therapies: Addressing deficiencies in stomach acid, bile, and overall nutritional status.
3. Ancillary Strategies: Additional strategies to prevent SIBO recurrence, including:
   • Vagal Tone Improvement: Techniques to stimulate the vagus nerve and enhance gut motility.
   • Trauma and Stress Management: Addressing chronic stress and past trauma that can impact gut health.
   • Abdominal Adhesions: Identifying and treating adhesions that can slow down gut motility.

Resources Mentioned

• SIBO Academy: Courses and resources for practitioners to become experts in treating SIBO.
• Prokinetics:
  • Motility Activator from Integrative Therapeutics
  • Prescription options like Motegrity
• Digestive Enzymes:
  • Transformation Enzymes’ Digest and DigestZyme
• Probiotics:
  • MegaSporeBiotic from Microbiome Labs
  • ProFlora 4R from Biocidin
• Bitters for Stomach Acid and Bile Flow:
  • Gaia Herbs
  • Quicksilver Scientific
• Nutritional Supplements:
  • Multivitamins
  • Protein-rich diets
• Vagal Tone Improvement:
  • True Vega Nerve Stimulation Device
• Visceral Therapy:
  • The Barral Institute Directory for Visceral Manipulation Practitioners

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SUBTITLES:

Well, hello Empower Nutrition podcast listeners. So happy to have you in this episode. Although if you clicked on this episode, it might mean that you either have SIBO or you have sibo. And if that’s the case, I’m sorry because it’s something that I’ve worked with professionally for many years. I’ve worked with hundreds of patients that have have sibo, and if you don’t already know, I also have a company called the SIBO Academy that I co-created with another dietician named Alicia Galvin. And she also, she and I at the SIBO Academy have also trained hundreds of practitioners on how to be experts at working with SIBO patients. And over many years of what I doing this, I’ve seen it go wrong many times. And so if you’re frustrated with your SIBO journey, let me just say it’s not your fault. It’s hard to figure out what to do.
Most practitioners dunno what to do. It used to be that practitioners didn’t even know how to start. Now the problem that I am seeing a lot is that practitioners do know how to start. They’ll either give a prescription antibiotic like Rifaximin or Xifaxan or they’ll give an herbal antimicrobial protocol and then it’s over. They’ll just kind of drop the ball and let it go. And the unfortunate thing about that is that SIBO will usually come back if that’s what’s done. So the purpose of this episode is to just kind of give a quick overview of what I do and what I teach practitioners to do in terms of preventing SIBO from coming back. Because the majority of not, I won’t say every time, but the majority of the time when someone has sibo it, there is some underlying root cause. It’s not addressed just by getting rid of sibo, that that underlying root cause still exists.
And so the SIBO will probably come back if the root issue isn’t addressed. So we’ll go through sort of my top four or five suggestions of what I put into protocol for right after a SIBO intervention. And then I’m gonna go over my top three sort of like ancillary things to make sure you’re doing to prevent recurrence. So after SIBO intervention. So that could be either again, a prescription antibiotic, an herbal antimicrobial protocol or or an a superior on a exclusive elemental formula one, probably the most top critical thing to have is what’s called a kinetic. Now this isn’t a laxative, it’s something that is gonna stimulate the nervous system in the gut that coordinates motility. So it’s called, this system is called the migrating motor complex. And it does this pretty complicated process where it kind of sits still for about 90 minutes on average.
And it does this whole sphincter wave thing where it kind of pushes all the food down in one in a big wave and then it sits for another 90 minutes. Well, digestion happens and then does this coordinated complicated neurological thing. Again, a lot of times with sibo, big risk factors, if there’s impairment of that migrating motor complex to where it’s not running the pulse often enough or it’s not coordinated enough so that the pulse is basically weak and not effective. And then you have where your gut kind of goes from being this, you know, fast moving system that doesn’t allow a lot of bacterial overgrow. And now in the small bowel you have this slow moving thing that where the food is just kind of sitting there, it has more time for bacteria to chow down and eat on it and thrive in the small bowel.
And then you have the beginning of sibo. So slow motility is a big, big risk factor for sibo. And so during a SIBO intervention, which isn’t the topic of today, but we do also do it during, but definitely after someone has had a SIBO intervention, we always give a pro kinetic. So there are prescription versions of this, like motte for example, but most frequently we’re I’m talking about is a dietary supplement. So that would be something like motility activator from integrative therapeutics is the one that I like to use the most, but there’s some other versions of this. So that’s really important to include. And then the second thing that’s really important to have, whether you think your digestion is great or not, is really good quality digestive enzyme. And the reason for this is that when someone has sibo, which I should have maybe said this earlier, but you’re, you’re here, you probably know SIBO being overgrowth of bacteria in the small bowel, whereas it should be mostly sterile when you have that, that bacteria in the small bowel damages the gut lining and specifically it makes it, one of the problems of that is that the little fingers are villi this and the lining of the small bowel normally secrete a lot of digestive enzymes that help to break down and digest your food.
But when they’re damaged, they’re impaired and how much of these enzymes they can release in a similar fashion to what happens in celiac disease. The problem with that is that you now have where the food isn’t getting broken down and digested very well, and so therefore it can’t be absorbed in the small bowel very readily. So you end up with more food sticking around in the small bowel longer because it’s not, it’s like the trash pickup isn’t coming. It’s like you missed taking your trash can out and now it’s sitting there for two weeks and it’s getting rancid. It’s kind of an analogy to that there’s not enough breakdown in the food. So just sitting there and guess what bacteria, there’s always bacteria in the small bowel. So it’s, it’s not that SIBO is like this freak thing where bacteria got in the small bowel.
They’re always there. It’s just that normally your body has these mechanisms whereby it prevents those small, those bacteria from colonizing the small bowel. But if you, one of those mechanisms is the production of these enzymes so that the food can get broken down in a expedited fashion and brought and absorbed so that it’s not just sitting there in the gut. But when you don’t have that enzyme release, then the food hangs out for too long, starts to feed bacteria too much, and the bacteria can then become sibo. And especially when if you’ve just had a SIBO intervention, it’s common to still have a little bit of sibo. That’s pretty common. So that’s a, so it’s a really sensitive time. It’s really important to really ramp up on your preventative measure so that your body can kind of fight off the last remaining sibo or you like start giving it a fighting chance.
So you want to help break that food down and get it absorbed asap. So that really good quality digestive enzyme with every meal does that. So that’s a big mistake I see is that people aren’t given these enzymes because they say, oh, I don’t think I need an enzyme. I feel like I’m digesting my food fine. I don’t care. It doesn’t matter. Everybody needs to do this for the initial period after a SIBO intervention. Typically I’ll be doing a prevention protocol for three months at least. And then reassessing, another common mistake I see with this is just giving a poor quality enzyme. There are even good quality brands that make poor quality enzymes. So just because you’re getting it from a professional supplement line doesn’t mean it’s a good quality enzyme. I used to make that mistake in my earlier days of using enzymes like that. Most practitioners, including myself that are, that are, I know they’re doing a lot of SIBO work, are using a company called Transformation Enzymes. And the product that I use the most is just called Digest and it’s a enzyme product. They also have a product called Digest, digest Zyme. That’s a gentler version if your patient is more sensitive and can’t tolerate digest. But that’s from transformation enzymes.
A third thing that is really important is to help to make the environment in the gut more amenable to commensal or healthy bacteria and less amenable to dysbiotic or unhealthy gut bacteria. And the reason for that is that most SIBO bacteria is comprised of gram-negative or unhealthy gut bacteria. And so SIBO can really often be a migration of these unhealthy bacteria either up from the colon and that would be the more of a distal SIBO that’s further from your mouth basically. Or it can be a more proximal SIBO where it’s coming from the oral cavity. So it’s also, as an aside, really important to work on oral health if, if you’re challenged there, but in any case during a SIBO protocol is a little more controversial, but I, I still do it during, but then definitely after, it’s important to have a very specific type of probiotic, not a classic probiotic that has like lacto, bacillus and bifidobacteria.
That’s not what I’m talking about. I’m talking about a bacillus type probiotic that could be a spore based. But now there’s the most commonly available of these, these bacillus types are not actually coming from spore. So the top two that I like to use are make a spore biotic from Microbiome Labs or like pro Fluora four R from Biocidin. Those are both great options. And what again, what those are gonna do is they’re gonna think of ’em not as a, not as a classic probiotic that’s gonna come in kinda like a prosthetic of a healthy microbiome and do the thing that a healthy microbiome should have been doing in the first place. It’s not that it’s coming in more as like a competitor against the bad bacteria. So it changes, for example, the pH and the gut, it, it interrupts the quorum sensing that these unhealthy bacteria have between, or the communication channels that these bacteria have between each other and makes it so that the, the environment is not as healthy for the bad bacteria. It’s kinda like if you had a bad house, guess that wouldn’t leave and you start to think, well what if I stop cleaning? What if I stopped buying groceries? What if I stopped turning on the air conditioning? Maybe they would leave a little bit faster. It’s a little bit like that you’re making the environment to where the bad bacteria don’t really thrive so that, so that they’re less likely to overgrow and and contribute to SIBO recurring.
The fourth thing is not really one thing, it’s a a collection of things because it’s more customized for the person, but it’s basically a replacement of what that person is missing in. Because a lot of times when someone has sibo, either all or part of the problem is that they were missing something important in the first place, something that was involved in preventing sibo. So I have four things here that I’ll go through. Okay, I just thought another one. So no, there’s four. So the first one is stomach acid. So it’s very uncommon to have high stomach acid. A lot of people are told they have high stomach acid and they’re put on PPIs and stomach acid lowering medications. But that’s almost never the case that they have high stomach acid. It’s normal stomach acid that’s, that’s inappropriately getting too much into the esophagus because of a problem with that lower esophageal sphincter between the esophagus and the stomach.
But in any case, low. So high, high acid is is unlikely, but low acid is fairly common. For example with age pernicious anemia, nutritional deficiencies are some common examples, but you can re, the problem with that with SIBO is that stomach acid is a natural that antimicrobial. So it’s one of your body’s natural defenses against SIBO is that okay, your food comes in your stomach, it mixes with all this acid and it goes into the small bowel. Now you have this acidic kind that’s like going down and through there and like the bacteria can’t live in that low pH. If someone has low stomach acid, we know from research that they’re given for example A PPI stomach acid blocking medication, they’re at increased risk si because of that very reason. So you can either provide them with some between HCL with meals if you’re confident that they don’t have ulcers, that’s really important and if they tolerate it, meaning they don’t have reflux and they don’t have a history of bar esophagus.
So you gotta think about the safety of that. But you can provide them with betain HCL with meals. A more gentle thing that I usually prefer to do is to have them take bitters before meals. So you can get that from judge as a brand that’s gluten free, that’s made by a dietician may Gerber. And I think a partner, there’s also, I love the Quicksilver line of bitters is great, so they take the bitter before they eat and that bitter flavor really stimulates stomach acid and also stimulates digestive enzymes and bile flow. So it’s a great digestive support. And also guess what, the enzymes help prevent sibo. The stomach acid prevents SIBO and the bile does as well. Bile is actually antimicrobial. People may have an impaired bile release, maybe they’ve had a cholecystectomy or maybe they have bile stone or maybe they are postmenopausal and have low estrogen and that’s associated with slower, more sluggish bile.
So in any case, the bitters are gonna kind of hit all three of those fronts. So that’s why like teas bitters. So if you feel like your, if you suspect that your patient is lacking in either stomach acid or bile, you should replace with with, with bitters to help with bile flow. There’s also other supplements like LVGB for example that help with bile flow in, in separate ways that you could look at the other category of sort of like replacement things relates to nutritional status. So I have seen this many times where someone has an overly restrictive diet, especially if it’s a vegan diet or nearly vegan diet, they, I’ve, it’s, it’s much like more likely in common in those people that they’ll have SIBO in my experience. And the, the reason for that is that it’s, like I said before, your body has a number of ways of preventing all this bacteria that’s coming into your mouth through your food and your drinks and the world preventing it from colonizing the small bowel. One of those ways that we haven’t talked about is the immune system. So you’ve got like 70% of your immune system cells living in the gut lining and part of what they’re doing is they’re attacking this bacteria when it tries to colonize and become sibo.
However, that complex and like high demand immune system in the gut does have high nutritional demands. It’s like an elite athlete. It has like high, high nutritional needs unlike a maybe an elderly lady that doesn’t need much. So when someone’s on a restrictive diet and they have nutrient deficiencies, especially in my experience protein, inadequate protein intake, but also micronutrients, they’ll struggle to maintain the health of that immune system in the gut and they’ll struggle to defend from this, these bacteria that wanna grow in the small bowel. So I’m gonna always give a multivitamin almost what during after SIBO prevention or SIBO intervention and then we’re gonna be definitely working on meeting protein needs, like really meeting them. So not, not the person just thinking that they’re getting enough protein, we’re actually calculating their needs and and measuring how much they’re getting to and helping them with what they can do to try to meet their needs, which is are, is gonna vary based on the person, but usually it’s gonna be for women a minimum of 70 grams and for minimum, minimum of 90 grams if they’re an adult with some maybe exceptions obviously they have renal disease or something like that, but it’s, it’s typically gonna be in that range.
But I’ll, I’ll actually do more of like a calculation of like grams per kilogram and all that and adjust for activity level and all this, but it’s gonna, it’s not like they’re gonna be able to have like 50 grams of protein and that’s gonna work. It’s gonna be at least that 70 female 90 male. So that working on that is really important. So those are the main four things of what to make sure someone has in their their like short of like three month at least prevention protocol. The other second big category of this of preventing SIBO o is ancillary things. So this is getting back to more of what I was saying about addressing root causes. So some of what we already talked about were root causes like inadequate nutritional status, maybe they have dysbiosis in the first place, maybe they have low stomach acid, low bile, those are, those can be root causes but in my experience there’s, there’s often other root causes as well.
So I’ll go through three. The top three that I see, the first one and by far the most common actually is that they have low amount of signal in what’s called the vagus nerve. So the vagus nerve is a nerve that goes from the brain and and down all the way next to the spinal cord, all the way down to innervate among other things, the gut, it also innervates the adrenal. So it’s really interesting nerve, but it innervates the gut and it’s the thing that sends, there’s a gut that’s the thing that it’s like the road that the gut brain axis runs on. So when you, you might have heard like okay if if, if someone is like calm, they’re in a rest and digest state, if they’re stressed, they’re in a fight or flight state and, and that what that’s telling you is that the level of stress is impacting what’s happening and with respect to the gut, if they’re under stress and they’re in fight or flight that through this VA nerve that the signal will be low and there will be like little digestion and little motility.
And that is a big risk factor for sibo as we’ve talked about. When you have slow motility whereas rest and digest is just what it sounds, you’re calm, you’re relaxed through that, that feeling that you have in your brain is signaling through the vagus nerve that more signal to actually increase motility and like digest your food more. So the problem that’s common is that people have too much stress either in the short term or from past trauma, can also kind of lock people into like a chronic stress state so that they have a chronic low tone in their vagus nerve that is kind of keeping motility chronically slow and making SIBO happen not just once but over and over again. Every time they get rid of it it comes right back.
So it’s really important to stimulate this nerve so that it, it’s kind of, to me kind of counterintuitive When you’re calm the nerve is stimulated is opposite of what you may think and when it stimulated it stimulates digestion. So it causes your bowels to be doing the thing I talked about earlier with the migrating motor complex where it has its big strong wave every 90 minutes, things that can improve this vagal tone go from more simple to more complex. So more simple things. It’d be like a daily meditative practice. It might be daily prayer, it might be daily meditation, might be meditative yoga, it’s for the individual, it might be with an app or it might be self-directed. It’s kind of for the individual to decide. But that’s the more, most entry level thing is to have a practice like that every day going up from there.
I would say someone with a recent history of SIBO should at least go one level higher than that and that would be actual directed like vagal tone exercises. So that would mean things like gargling water, definitely like research this if you’re interested ’cause there’s specific protocols but it’s like long gargling, like frequently daily, very loud singing is another example of something that stimulates the vagus nerve directly. So, and again these, these practices need to be done daily. And then the next, or like kind of third tier of this is to do something called vagus nerve stimulation. So this is a research thing, there’s the FDA approved device for doing this. You basically hold the device up along the side of your neck where your vagus nerve goes down and it, the device actually stimulates the nerve directly. So the one that we use and recommend the most is called true vega.
And you turn, each time you turn on it’s a two minute stimulation, you just hold it there for two minutes and then you’d work with your practitioner, decide how many of those each day. But I’ll do usually two of those. So four minutes total, either once or twice a day. So those are the things about vagal tone. And again, it could be that your current situation is very stressful, but it’s also very common that there was past trauma. So that would be the second thing is working more around the sort of chronic fight or flight state that’s induced by that. And it can be very diverse trauma experiences. It can be more of like what you might think of like, oh, a woman who was like assaulted for example would be, could be have that kind of trauma. But it could also be growing up with like a narcissistic parent growing up in poverty, growing up in a a dangerous home environment.
Those kind of like chronic micro stressors across childhood have also been shown to cause this sort of like, it’s like a, it’s like your neurological system is kind of like stuck in the wrong gear. Like when you’re riding a bike and you can’t get it to like you’re like clicking the thing on the handlebars to change the gears but the chain’s not actually moving to the different gear. It’s kind of like that you’re just kind of stuck in the fight or flight gear. Even if you like seem to the outside world to be in a pretty low stress situation, you’re actually not in terms of what your nervous system is doing. And that is a big risk factor for SIBO and SIBO recurrence. So first of all it’s just kind of assessing, you know, if that might be applied to you. And then the initial thing would be sort of talk therapy and getting started with that if you don’t already have it.
Beyond that there’s online programs like for example the Gupta program is one that we sometimes recommend and that our patients use. And then the next level above that is something called EMDR, that there’s a website for EMDR. You can find a practitioner and get this type of therapy that I do recommend doing in person where you basically kind of work with this practitioner to sort of like rewire your nervous system responses to the trauma trauma and have it be where it’s no longer triggering this fight or flight response sort of chronically in your body. This might sound really woowoo to you, but I can tell you I’ve seen this be a major factor and a lot of people see Bo journey and I’ve seen it be really just the, the main thing that led to their ultimate like long-term recovery. So if you’re, if you have had SIBO recurrence multiple times and you do have some kind of fast trauma, I encourage you to to go there.
And then the final thing on ancillary things is abdominal adhesions. So a lot of, for a different variety of things I’ll talk about, you can get basically scar tissue that builds between the, the different parts of your small bowel. Like we’ve all seen in the movies how the small bowel like course it’s gross movies, but how it looks, it’s like a ball, it’s, you know, it’s about nine feet of tube, it’s all balled up and like it’s the, this parts of the tube are like touching each other but they need to be like slippery against each other so that your, your body can move the food through effectively. But if they get stuck together with scar tissue, then they can’t move the food through effectively and that will cause the slow motility, that’s the big risk factor for sibo. So things that can cause that will be things like a history of like sports that involve like maybe you got kicked, maybe you got ball like hit you like soccer for example, like hit you in the stomach, football, rugby, baseball, even like anything that’s gonna cause you to have like contact with like, you know like things hitting you in the stomach can do this.
Another thing can be abdominal surgery. So like a past history of a C-section or some other type of surgery is a big one. And then the third one is like a traumatic like violent injury. So maybe it was a car accident, maybe it’s falling from a horse, but some kind of traumatic injury that that that’s also been associated with these adhesions. There are specialized therapists, like usually physical therapists that perform visceral therapy to help with these adhesions. And so we will often send our patients to an online directory for those practitioners. It’s hosted by the Bral Institute and so you can look, just Google the Bral Institute visceral therapy, find a practitioner and then look in your local zip code and see who comes up. Now there are practitioners in that database who don’t do visceral therapy and because they also list in that database, people that do like craniosacral therapy, that’s not really what I’m talking about.
You want somebody that does visceral therapy where they’re just manually like basically palpating for these adhesions and trying to like stretch them out. They can also sometimes look for a related problem, which is impaired closing of the ileocecal valve. So there’s like a valve or like a little door that should be closing between the small and the large intestine and sometimes that valve isn’t closing all the way and so it’s just letting the stool basically backwash into the small bowel and that’s causing the sibo. So these visceral therapists can help with that as well, like assessing for it and trying to work on it. So that can be a great way of finally getting a breakthrough. If you are having recurring SIBO episodes and you have a history that might match that, I would definitely recommend finding a practitioner. So hopefully that helps if you either as a patient have had recurring SIBO and you wanna prevent it. Or if you are a practitioner, wanna just get more effective with sibo. And if that’s the case, feel free to check us out@siboacademy.com. We have lots of practitioner education courses for dieticians, include CEUs, and we teach you all about how to be really effective with sibo. So hope this helps and have a great rest of your day.
Hi there, Aaron here. One of the things that I really wish people knew is how often it is that people have a damaged metabolism and it’s not their fault. It’s this is really a feature of the food environment that we live in and that we’ve even been raised in. And the reason why I wish people knew that is that a damaged metabolism I find really impacts people’s health and is connected to most of the the health goals that I see people usually have. So things like weight loss, weight loss resistance, high blood sugar, problems with cholesterol and blood pressure hormone imbalances. So PCOS, infertility, loss of of sex drive, all relate to metabolic health problems and inflammation. Mental health, for example, is another one where anxiety and depression can be connected to inflammation and metabolic health really profoundly. So I wish that people knew the power of healing their metabolism and how common it is that people need an improvement of their metabolic health to really achieve the health and wellness goals that they have.
This topic is so important that I developed a full program to help people heal their metabolism and the name of that program is Lean for Life. And now I’m thrilled to announce that Lean for Life is available via an app both in the App store and on Android. Via the Lean for Life app, you can access all three, four week phases of the program. Phase one is all about the pattern of eating and what to eat to have a healthy metabolism. Phase two is all about the timing of eating. So we talk about concepts around intermittent fasting, time restricted feeding, fasting mimicking diets, and how to optimize that. And then in phase three we learn about the cyclical pattern of macronutrients that I recommend to keep your metabolism healthy and fine tuned over time so that you can achieve your health goals without restricting, without having to stay on the diet cycle, without having to continuously be on a either diet restrict versus binge cycle and basically break breaking free from Diet culture.
If you’d love to check out the Lean For Life program again, you can go ahead and get the app either on the Apple iStore or on Android, and you can check out the link for the app in our show notes. I’d love to hear what you think. It comes with a free trial of the first phase. Feel free to get in touch with us if you have any questions or feedback on the Lean For Life app and our contact details are in the show notes as well. Good luck on your health journey and best of best of luck to you in healing your metabolism. Thank you so much for taking the time to listen to the Empower Nutrition podcast. We love offering insight to help you optimize your wellness. If you enjoy this episode, feel free to leave us a rating on whichever platform you stream from and consider subscribing. Also, you can learn more about our practice at www dot Empower Nutrition Health and that link is also in your show notes. Take care and talk to you soon.

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