Laura Schoenfeld: SIBO is one of those really tricky conditions that you actually have to switch back and forth between approaches, which patients always love that—and that’s sarcasm. It’s pretty frustrating when a patient finally learns how to do a low-FODMAP or SCD diet, and then when they start their antimicrobials, you’re like, “All right, now you can eat whatever you want.” So I would say that FODMAPs, for sure, tend to be an important component. I think there’s a lot of overlap with low FODMAPs and low fermentation potential. I think low fermentation potential takes it a little bit further. An example of a food that is low FODMAP but that might not qualify as low fermentation potential would be basmati rice. Basmati rice is a higher-fermentation-potential rice than something like jasmine rice, which is a very-low-fermentation-potential rice. I’ve seen some clients that rice, in general, was fine and they didn’t have any problems with it and they were able to eat it. I’ve seen other clients that only could tolerate jasmine rice from a symptom perspective, and basmati rice caused them to bloat. This is going to come down to where the patient is coming from. If they’re coming from a Standard American Diet, eating whatever, then maybe a low-FODMAPs diet is a little bit of an easier transitional diet to stick to. Low fermentation potential is a little bit more complicated, and it requires a lot more dedication, so if you’re worried about compliance, then the low-FODMAPs diet might be a better choice. Fermentation potential is great, but again, it might be overkill for certain people, especially if you’re going to be using any sort of antimicrobials for treatment.
Chris has a really awesome Revolution Health Radio podcast with Dr. Pimentel. He’s one of the most knowledgeable experts on SIBO out there, and a lot of what they talk about is how people on these low-FODMAPs, low-fermentation-potential, SCD, GAPS diets with SIBO, they don’t get treated as effectively because they stay on the diets throughout the antimicrobial or antibiotic treatment. What’s most important for the diet side of things is while the person is not on any sort of antimicrobials to find the approach that, from a symptom perspective, allows them to have the most limited symptoms but also isn’t so restrictive that they’re avoiding foods that are either not causing symptoms or it’s just too complicated and they can’t follow it. Definitely start with low FODMAPs. If you want to add in low fermentation potential, I think that should just expand the low-FODMAPs approach. Dr. Siebecker in Washington—I forget what her clinic is called—but she has an approach that is a combination of low FODMAPs and the Specific Carbohydrate Diet, which is, again, pretty restrictive. That might be a good place to start with someone who is dedicated and also has very severe symptoms, but eventually the treatment is going to come from antimicrobial/antibiotic use.