SIBO and Leaky Gut: What the Science Says

54-20 Are Small Intestinal Bacterial Overgrowth (SIBO) Tests Valid?

Gastrointestinal symptoms like abdominal pain and bloating account for millions of doctor visits every year. One of the conditions that may be considered for such a nonspecific presentation of symptoms is SIBO, small intestinal bacterial overgrowth, a concept that has gained popularity on the internet in addition to certain clinical and research circles. SIBO’s broadly defined as the excessive growth of bacteria in the small intestine, and so it’s typically treated with antibiotics, but dispensing antibiotics to patients with the nonspecific, common symptoms not without risks—you could be fostering antibiotic resistance, there could be side-effects, or wiping out your good bugs could set you up for an invasion of bad bugs like C. diff––especially for a condition that may not even be real.

Even alternative medicine journals admit that SIBO is being overdiagnosed, creating confusion and fear. SIBO testing is overused and overly relied upon. Diagnoses are often handed out quickly and without adequate substantiation. Patients can be indoctrinated into thinking SIBO is a chronic condition that cannot be cleared and will require lifelong management. This is simply not true for most ,and is an example of the damage done by overzealousness. The “monster” that we now perceive SIBO to be may be no more than a phantom.

The traditional method for diagnosis was a small bowel aspiration, an invasive test where a long tube is snaked down your throat to take a sample and count the bugs down there, but this method has been almost entirely replaced with breath testing. See normally, a sugar called glucose is almost entirely absorbed in the small intestine so never makes it down to the colon. And so if there is bacterial fermentation of that sugar, that suggests you have bacteria up in your small intestine, and you can detect that fermentation because the bacteria produce specific gases that get absorbed in your blood stream and are breathed out from your lungs, which you can then be detected with a breathalyzer-type machine.

 Previously, a sugar called lactulose, but lactulose breath tests were found to not reliably detect the overgrowth of bacteria, so they switched to glucose, but when glucose was finally put to the test, it didn’t work either. The bacterial load in the small intestine was similar for those testing positive or negative, so that’s not a good test either. It turns out glucose can make it down to your colon after all. They labeled the glucose dose with a tracer, and found that almost half of positive results from glucose breath tests were false positives because they were just fermenting it down in their colon where your bacteria are supposed to be. So then patients are incorrectly labeled with SIBO may undergo multiple courses of antibiotics for a problem they don’t even have.

Then why do experts keep recommending breath testing then? Oh, you mean the experts at the conference supported by a breath-testing company, most of whom had personally received funds from SIBO testing or antibiotic companies? And even if we could properly diagnose it, does it even matter? In those with digestive symptoms, there is a range of positivity for SIBO from approximately 4% to 84%—all over the map, and there may be no difference in symptom scores between those testing positive versus those testing negative, so testing positive may mean anything. Who cares if some people have bacteria growing in their small intestines if it doesn’t necessarily correlate with symptoms?

 Now antibiotics can make people with irritable bowel-type symptoms diagnosed with SIBO feel better, so doesn’t that prove SIBO was the cause? No, because it can make just as many people feel better who are negative for SIBO. Currently rifaximin is most often used for SIBO, but it’s not FDA-approved for SIBO, and so the cost can be prohibitive. If fact no drug has been approved for SIBO, so even if you have good insurance, you may be shelling out-of-pocket as much as $50 a day, and you typically take it for two weeks.

And while antibiotics may help in the short-term, they may make things worse in the long-term. Those are given a course of antibiotics are more than three times as likely to report more bowel symptoms four months later than controls. OK so what can we do for these kinds of symptoms? That’s exactly what I’m going to turn to, next.

54-21 Fiber vs. Low FODMAP for SIBO Symptoms

 If you test more than a thousand patients suffering with irritable bowel-type symptoms such as excess gas, bloating, diarrhea, and abdominal pain for longer than six months who don’t appear to have anything more serious going on, such as inflammatory bowel disease, a significant percentage were found to be suffering from lactose intolerance––intolerance to the milk sugar lactose. In infancy we have an enzyme in our small intestine that digests milk sugar, but most of us understandably lose it after weaning. Although a genetic mutation has led to persistence of the enzyme in a minority of adults, about 75% of the world’s population malabsorb lactose, have lactose intolerance after age 30. A third, though, were diagnosed with SIBO, small intestinal bacterial overgrowth.

 The evidence for SIBO and IBS symptoms is shrouded with controversy, predominantly because of the fact that these breath tests used in clinical practice to diagnose SIBO are not valid, as I explored in the last video. And it’s not even clear what the implications are of having more versus less bacteria growing in your small intestine, since the number don’t seem to correlate with symptoms. It turns out it’s not the number but the type. It’s the kind of bugs you have growing in your small intestine. So small intestinal microbial dysbiosis, not overgrowth in general, but the wrong kind of growth that appears to underlie symptoms associated with functional gastrointestinal disorders like irritable bowel syndrome.

How can you prevent that from happening? Well the symptoms appeared be correlated to a significant drop in the number of Prevotella species. Remember them? Prevotella are healthy fiber feeders, suggestive of a higher fiber intake in healthy individuals while the bugs found more in symptomatic patients ate sugar, which may reflect a higher dietary intake of sugars. Yeah, but correlation doesn’t mean causation. To prove cause-and-effect you have to put it to the test, which is exactly what they did.

Switching a group of healthy individuals who habitually ate a higher ­fiber to a more typical standard American low-­fiber diet with lots of sugar produced striking results within just seven days. First, 80% developed new gastrointestinal symptoms out of the blue, such as bloating and abdominal pain that resolved on resumption of their habitual healthier higher-fiber diet. And the diet-­related changes in the small intestinal microbiome were predictive of symptoms and linked to an alteration in intestinal permeability––in other words, they developed a leaky gut within seven days. And while some went from SIBO positive to SIBO negative, or SIBO negative to SIBO positive, it didn’t matter, since the number of bacteria growing didn’t correlate with symptoms. It was the type of bacteria growing.

 And no wonder their guts got leaky. Short-chain fatty acid levels plummeted. Those are the magical by-products that our good gut bugs make with fiber, which play an important role in epithelial barrier integrity, meaning the keeping our gut from getting leaky.

 So while we don’t have sound data that something like a low FODMAP diet has any benefit for SIBO-symptom patients, there have been more than a dozen randomized controlled trials putting fiber to the test. And overall, there was a significant improvement in symptoms among those randomized to increase their fiber intake. That may actually help explain why the effect such diets have on the composition and metabolic activity of our microbiome. Our good gut bugs take the plant residues like fiber and produce health-promoting and cancer-suppressing metabolite like those short-chain fatty acids, which have profound anti-inflammatory properties. All the evidence points to a physiological need for about 50 g fiber per day, which is the amount contained in the traditional African diet, and associated with the prevention of Westernized diseases. That’s approximately twice what’s typically recommended, and three times more than what most people are getting day-to-day. Perhaps it should be no surprise we need so much. Even though we split from chimpanzees millions of years ago, there is still broad congruency in the composition of our respective microbiomes to this day. While they’re still eating their 98-99% plant-based diets to feed their friendly flora with fiber, we’ve largely removed fiber-rich foods from our food supply.

56-5 Avoid These Foods to Prevent a Leaky Gut

Intestinal permeability, the leakiness of our gut, may be a new target for disease prevention and therapy. With all the tiny folds, our intestinal barrier covers a surface of more than 4,000 square feet—that’s bigger than a tennis court, and requires approximately 40% of our body’s total energy expenditure to maintain.

Mounting evidence implicates the disruption of intestinal barrier integrity in the development of numerous ailments such as inflammatory bowel disease. Here, researchers measured intestinal permeability using blue food coloring. It stays in your gut if you’re healthy, but can be detected in the blood of the extremely sick as their gut barrier breaks down. You don’t have to end up in the ICU to develop a leaky gut, though. It can be as simple as taking some aspirin or ibuprofen.

Taking two regular aspirin or two extra-strength aspirin just once can increase the leakiness of your gut. These results suggest even healthy individuals should be cautious with aspirin use, as it may result in gastrointestinal barrier dysfunction.

What about buffered aspirin? Doesn’t matter; both regular aspirin and Bufferin produced multiple erosions in the inner lining of the stomach and intestine. Stick a scope down people’s throats, and you can see extensive erosions and redness inside 90% of people taking aspirin or Bufferin in recommended doses. How many hours does it take for the damage to occur? No, within five minutes. Acetaminophen, sold as Tylenol in the U.S., would be a better choice, unless you have problems with your liver. And rather than making things better, Vitamin C supplements appears to make the aspirin-induced increase in gut leakiness even worse.

Interestingly, this may be why NSAID drugs like aspirin, ibuprofen, and naproxyn are involved in up to 25% of food-induced anaphylaxis––in other words, increasing the odds of life-threatening food allergy attacks by more than ten-fold, presumed to be because these drugs increase the leakiness of the intestinal barrier causing tiny food particles to slip into the bloodstream. Okay, but why can exercise increase risk too?

Strenuous exercise, like an hour at 70% of maximum capacity, can divert so much blood to the muscles away from your internal organs it can cause transient injury to your intestines, causing mild gut leakiness. But this can be aggravated if athletes take ibuprofen or any of the other NSAID drugs, which is, unfortunately, an all too often practice.

Alcohol can also be a risk factor for food allergy attacks for the same reason, increasing gut leakiness. But cut out the alcohol, and your gut can heal up.

What other dietary components can make a difference? High saturated fat consumption, found in meat, dairy, and junk, can cause the growth of bad bacteria that make the rotten egg gas hydrogen sulfide, which can degrade the protective mucus layer. It is said to be clear that high-fat diets in general negatively impact intestinal health by disrupting the intestinal barrier system through a variety of mechanisms, but most of the vast array of studies they cite on the negative effects of a high-fat diet on gut leakiness were done on lab animals or in a petri dish. You don’t know for sure, until you put it to the test.

Rates of obesity and other cardiometabolic disorders have increased rapidly in parallel with a transition from traditional lower-fat diets to higher-fat diets. We know a disturbance in our good gut flora has been shown to be associated with a high risk of many of these same diseases, and studies using rodents suggest that a high-fat diet unbalances the microbiome and impairs the gut barrier, resulting in disease.

But to connect all the dots we need a human interventional trial, and here we go: a six-month randomized controlled-feeding trial on the effects of dietary fat on gut microbiota, and indeed, higher fat consumption appeared to be associated with unfavorable changes in gut microbiome, and proinflammatory factors in the blood, and note this wasn’t meat and dairy. They were just swapping refined cards for refined fats, white rice and white flour for oil. These findings suggest countries Westernizing their diets should advise against increasing intakes of dietary fat, while already Westernized countries should consider cutting down.

So far, we’ve discussed things to prevent a leaky gut. What about foods to heal a leaky gut. That’s what we’ll cover, next.

56-6 How to Heal a Leaky Gut with Food

 Our intestinal tract is the largest barrier between us and the environment. More than what touch or breathe. what we eat is our largest exposure to the outside world. Normally, our entire gastro-intestinal tract is impervious to what is inside it, allowing our body to pick and choose what comes in or out. But there are things that may make our gut leaky, and chief among them is our diet.

What happens is the standard American diet can cause gut dysbiosis, meaning a disruption in our gut microbiome, which can lead to intestinal inflammation and a leaky intestinal barrier. Then tiny bits of undigested food and microbes and toxins slip through our gut lining, uninvited, into our bloodstream and trigger chronic systemic inflammation.

To avoid this dysbiosis and intestinal inflammation, plants should be preferred. Vegetarian diet gut bacteria are associated with intestinal microbiome balance, high bacterial biodiversity, and integrity of the intestinal barrier. They tend to suffer from markedly less uremic toxins like Indole and p-cresol, and because fiber is the primary food for our gut microbiome, the gut bacterial of those eating plant-based diets produce more of the good stuff––short-chain fatty acids that fulfill a protective and nourishing role for the cells lining our core, ensuring the preservation of the intestinal barrier. Plant fiber is of prime importance to the preservation of the intestinal barrier integrity, but you can’t know for sure, until you put it to the test.

 People were given whole grains, beans and lentils, fruit, vegetables, and nuts and seeds, and got a significant reduction in zonulin levels.

 Zonulin is a protein responsible for the disassembling of the tight junctions between gut lining cells, and so it’s a biomarker that reflects an impairment of the intestinal barrier. In other words, zonulin is considered as a useful marker of a leaky gut. But since adding all those plants seemed to lower levels, that may imply that appropriate fiber intake helps to maintain the proper structure and function of the intestinal barrier. But whole healthy plant foods have a lot more than fiber. How do we know it’s the fiber? And there wasn’t even a control group. That’s why they say gut permeability might be improved by dietary fiber. To prove cause and effect, it’d be nice to have a randomized double-blind crossover study where you compare the effect of the same food with and without fiber––and here we go.

People randomized to pasta with or without added fiber and, a significant drop in zonulin levels in the added fiber group, so fiber does indeed appear to improve gut leakiness.

Any plant foods in particular that may help? Curcumin, the yellow pigment in the spice turmeric, can help prevent the intestinal damage done by ibuprofen-type drugs, but that’s in rats. Similar protection was noted from the broccoli compound sulforaphane, but that was in mice. No human studies on broccoli yet, but there was a study on three days of the equivalent of about two to three teaspoons a day of turmeric, which did reduce the gastrointestinal barrier damage caused by exercise, but no smaller dose has ever been put to the test.

If you ask alternative medicine practitioners what treatments they use for a leaky gut, #1 on the list, after reducing alcohol consumption, is zinc.

 Zinc doesn’t just protect against aspirin-like drug-induced damage in rats, when put to the test in a randomized trial of humans, the same thing was found. The NSAID drug indomethacin caused a three-fold rise in gut permeability, as one would expect from that class of drugs. But when they were also taking zinc, this prevented the rise in permeability, strongly suggesting a small intestinal protective effect. The dose they used was massive, though. 75mg a day is nearly twice the tolerable upper limit for zinc. What about just down at regular food doses?

 A significant improvement in gut leakiness even with a dose of of just 3 milligrams of zinc, suggesting that even relatively low zinc supplementation may work. You can get 3 extra mg of zinc in your daily diet eating a cup of cooked lentils.

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• abdominal pain
• alternative medicine
• anti-inflammatory
• antibiotics
• bloating
• butyrate
• dairy
• diarrhea
• FDA
• fiber
• flatulence
• FODMAPs
• glucose
• gut flora
• irritable bowl syndrome
• lactose
• microbiome
• Plant-Based Diets
• Prevotella
• short-chain fatty acids
• SIBO
• side effects
• standard American diet
• sugar
• vegans
• vegetarians