SIBO, FODMAPS, & GP
If you are brand new to gastroparesis and/or just getting started with the general gastroparesis-friendly diet, this post may not be for you right now. But if you have a comprehensive management plan and are still struggling with symptoms — particularly bloating, distention, stomach pain, burping, or gas — the information below might be the missing piece of your puzzle!
What is SIBO?
SIBO stands for small intestinal bacterial overgrowth. It's also sometimes called small bowel bacterial overgrowth or SBBO. It all means the same thing: there are bacteria in your small intestine that are not supposed to be there.
What causes SIBO?
One of the biggest risk factors for SIBO is slow gut motility. Muscular contractions within the gut are supposed to sweep things, both food and bacteria, through the GI tract. When it doesn't, bacteria can take hold and multiply in places where they don't belong. It’s also thought that protein pump inhibitors (PPIs) may encourage the growth of bacteria by limiting (or even eliminating) the anti-bacterial effects of acid in the stomach.
For these reasons, many people with gastroparesis may also have SIBO.
What symptoms does SIBO cause?
The symptoms of SIBO are largely a result of the gas that bacteria produces when it "eats." (See below for more about how what you're eating affects bacteria.) Excessive bloating, distention, burping, and passing gas are common symptoms.
Bowel changes, either diarrhea or constipation, as well as malabsorption and unintentional weight loss may also result. For people with functional GI disorders like gastroparesis or visceral hypersensitivity, the excess gas in the GI tract can also cause abdominal pain or cramping.
How is SIBO diagnosed?
The most widely available test for SIBO is a Hydrogen Breath Test. At the beginning of the test, you drink a solution that will "feed" bacteria if they are present, causing them to release gases. Your breath is measured for these gases over the course of several hours (usually 3). That's it! The drawback is that this test is not 100% accurate and may be even less so for those delayed gastric emptying, as the test counts on the solution being in the small intestine after 3 hours.
Some doctors will treat SIBO empirically, meaning based on symptoms and presentation alone. If symptoms improve with treatment, it's likely that SIBO was an issue.
How is SIBO treated?
Most of the time bacterial overgrowth is treated with antibiotics, preferably Xifaxin (rifaximin), which works only in the intestine and therefore has fewer potential side effects. There is also an herbal protocol for the treatment of SIBO, which was developed by Dr. Gerad Mullin at Johns Hopkins.
Aside from medical treatment, dietary changes are an important part of managing bacterial overgrowth. If the underlying cause of the overgrowth, slow motility, for example, isn't resolved, then the bacteria may regrow. Eating foods that feed bacteria will make this more likely.
How do FODMAPs fit in?
FODMAPs are highly fermentable carbohydrates that are often poorly digested and absorbed, particularly by those with functional gastrointestinal disorders. According to Registered Dietitian and FODMAP expert Kate Scarlata, "FODMAPs are fast food for gut bacteria." For those of us who have an imbalance of bacteria in our gut, have bacteria growing in the wrong places (SIBO), or have an increased sensitivity to sensations in the gut (visceral hypersensitivity), feeding those bacteria causes gas, bloating, pain, and bowel disturbances.
Unfortunately, some of the foods highest in FODMAPs are the ones that many people think of as GP-friendly staples. The things your doctor probably told you to eat when you were first diagnosed. Low-fiber wheat products (white bread, crackers, pasta, cereal, pancakes, etc.), applesauce, pears, and dairy products like skim milk, low-fat yogurt, and frozen yogurt. Many of the meal replacement drinks also contain FODMAPs in the form of FOS, inulin, or chicory root.
Does everyone with gastroparesis have SIBO and/or need to follow a low-FODMAP diet?
No. If your comprehensive management plan is working for you and you're feeling good, then this likely doesn’t apply to you. But if you feel like you're doing everything "right" in terms of managing gastroparesis but your symptoms remain -- or continue to get worse -- testing for SIBO and/or a FODMAP elimination diet may be something to consider.
Is it possible to follow a low-FODMAP GP-friendly diet?
It takes some extra effort and attention, but it is possible to follow a GP-friendly diet that's also low in FODMAPs. What's more, addressing SIBO and reducing the FODMAPs in your diet may actually reduce your overall symptoms and allow to eat a wider variety of foods.
Should one follow the low-FODMAP diet indefinitely?
No, the low-FODMAP diet is meant to be a short-term elimination diet followed by a series of reintroduction challenges. Eliminating all high-FODMAP foods indefinitely is not recommended for several reason.
First, it further limits the variety in the diet. This can make it more difficult (and more stressful) to figure out what to eat. Restricting variety also further restricts nutrition. Many high-FODMAP foods, particularly the fruits and veggies, have nutrients that we may not get from other sources. What's more, higher-FODMAP whole foods may help to properly balance overall gut bacteria (not to mention our digestion).
When followed properly, the elimination phase of the diet removes all high-FODMAP foods for 2-8 weeks. Once symptoms have improved, a specific food from each FODMAP group is re-introduced one at a time to determine whether or not there is a reaction. Those FODMAP groups that do not provoke symptoms can be added back into the diet, while those that do will continue to be off-limits for the time being. The length of the re-introduction phase, which is best supervised by an educated nutrition professional, will vary depending on how many groups of FODMAPs a person reacts to. It's necessary to be symptom-free for 3 days before trying the next group.
Of course, the idea of being "symptom-free" is a little tricky in the context of gastroparesis. Whereas the low-FODMAP diet often significantly and very noticeably reduces symptoms for those with IBS, the effect on those with gastroparesis may be less easy to tease apart from the general ebb and flow of GP symptoms. I think the key is being really purposeful about eliminating FODMAPs in the first place and paying close attention to any changes you may notice in the weeks after, primarily as they relate to pain, gas, bloating, and bowel habits.
I also think it's important to implement the low-FODMAP diet, or any other dietary protocol, in the context of gastroparesis. That usually means avoiding raw veggies, whole nuts and seeds, excessive amount of fat, and too much total fiber. Just as important, in my view, is to implement the diet as part of a comprehensive management plan.
FODMAP Q&A with Kate Scarlata
I recently contacted Kate to ask if she'd be willing to do a Q&A for my group program participants, as they had a lot of FODMAP-related questions. She kindly agreed and we chatted for over 45 minutes about the low-FODMAP diet, and it may help those with gastroparesis, IBS, reflux, and even fibromyalgia.
The information was so good that I've decided to share it here on the blog rather than just with the members of the group. I hope you find it as helpful as they did!