Could you clarify the current SIBO protocol guidelines? Is it best not to recommend low-FODMAP alongside antimicrobials, or is it okay to do both simultaneously?

There’s some history here. Initially, when I first started out treating patients with SIBO, I was doing low-FODMAP with the antimicrobial protocol, and then I even went a step further and I was doing the microbial reset diet, which I think I shared with you, which was a combination of low-FODMAP plus low-fermentation potential diet from Norm Robillard. We were seeing pretty good results with that and particularly with patients’ symptoms reducing. And then, after talking with Dr. Pimentel a few different times, he was pretty convinced that doing low-FODMAP and other diets that restrict the substrate that bacteria can feed on was a bad idea because of the principle of microbiology “You gotta feed them to kill ‘em,” which suggests that if you do these diets that restrict the substrate, then the bacteria will into a dormant state and become harder to kill. That made sense to me mechanistically, and so I decided to give that a try.

There was also this study that showed that using partially hydrolyzed guar gum in conjunction with rifaximin increased the efficacy, which I think I also shared with you in the course, and that seemed to support that idea that because it’s a prebiotic, a prebiotic would actually feed the bacteria and if doing that increased the efficacy, then it seemed to support that argument.

Over time though, I came to notice that the results we were getting from the treatment protocols were not only not better; if anything, I would say they were worse, and the patients were really having a difficult time tolerating the protocols, particularly those who already knew they had a sensitivity to FODMAPs. At this point, we’re recommending that the patient follow a kind of Paleo template reset-type of diet. If they know already that they have sensitivity to FODMAPs like garlic and onions, for example, then we say go ahead and avoid those. We don’t want you suffering during the protocol on eating all these foods that you know trigger you. I don’t think that having a lot of inflammation and GI discomfort during the protocol is going to help it because we know that inflammation and other exacerbation of other GI symptoms can affect the microbiome, so that’s currently where we’re at.

I think if you’ve been following my work the last six months, you know how I feel about SIBO right now. It’s just such a black box, so murky in so many ways. I wish we had better answers, but we just have to keep digging and try to get to the bottom of this. It’s a challenging clinical puzzle for sure.