Prebiotics and FODMAPs During SIBO Treatment

Should you consume FODMAPs and/or prebiotics during SIBO treatment or should you avoid them? What about probiotics?  Should you avoid or consume them during SIBO treatment?  Let’s discuss what approach makes SIBO treatment the most effective.      

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Prebiotics and FODMAPs During SIBO Treatment

Dr. Michael Ruscio: Should you take prebiotics and/or restrict FODMAPs while treating SIBO?

Hi, this is Dr. Ruscio, and this question has recently resurfaced and come into light, and I’d like to give my perspective on this. There has been one published study that has looked at coadministering prebiotics compared to coadministering probiotics while treating SIBO with antibiotics, and what’s actually been found to be the most effective is the coadministration of probiotics with antibiotics in the SIBO (1) Trusted SourcePubMedGo to source. That’s been found to be more effective than coadministration of prebiotics. What this means is if you’re treating SIBO and trying to have the best treatment results, it appears that taking probiotics while treating SIBO is going to be more effective than taking prebiotics and, we could speculate, more effective than incorporating FODMAPs into your diet.

This is the item, I think, people are the most confused and concerned about: should they or should they not eat FODMAPs while treating SIBO. Again, this study shows that the most benefit would likely be derived from consuming probiotics and that the prebiotic piece, either by prebiotic supplementation or by prebiotics in your foods by eating high-FODMAP foods, is probably not as important as the probiotic piece. So the very straight answer is the FODMAPs probably aren’t that important when we look at them next to the effect of probiotics.

Now, there are many studies that reinforce this position, and I know that there have been some expert recommendations about incorporating FODMAPs into the diet, but I try to make my recommendations data driven, not necessarily expert driven, and while I have very much respect for some of the leaders in SIBO research, I think that there are practice differences that need to be minded here, meaning we have different philosophies on practice.

So coming back to the issue more squarely, having or not having FODMAPs during SIBO treatment, in my opinion, is probably not that big of a deal. What I do personally is I have patients follow a paleo type of diet, and I don’t have them restrict FODMAPs unless they notice fairly dramatic symptomatic relief by avoiding FODMAPs. Then I have them avoid FODMAPs to whatever extent they need to to help with their symptoms.

Now, again, the questionable piece here is, will eating the FODMAPs help enhance the effectiveness of the treatment? And again, when we look at the one study that has tried to ask and answer this question, it looks like probiotics are actually more important than prebiotics and FODMAPs. Now, coming back to my earlier point about the other studies that reinforce this, we see quite compelling data for the use of probiotics in treating the symptoms of IBS, which have very much overlap with SIBO, and much of IBS may be caused by SIBO, so we see that piece there. And then to even drive that further home, we see in a handful of clinical trials that probiotics can actually be a stand-alone treatment for SIBO, and they’ve been shown to reduce gas levels and help to correct the SIBO breath test.

So when we look at all this data together, the take-home, I think, is this: The most important thing out of all the things you could do along with SIBO antimicrobials or antibiotics is probably taking a probiotic. The FODMAP and the prebiotic piece is interesting, and it’s one of these cool theories that we sometimes get super excited about, but it’s important to use science to help us determine if a theory is something that we should actually follow or if the theory is just something exciting and cool and maybe a little bit off the mark or maybe there’s a better form of treatment. In this case, the theory of should you eat lots of FODMAPs or take prebiotics while treating SIBO, I don’t think that’s fully been supported, and I think the better evidence suggests that you’d be better off using a probiotic during SIBO treatment. If at some point that changes, I’ll be the first to conform with that recommendation, but I think a very practical approach, which would be to have someone eat a healthy diet during SIBO and only restricting FODMAPs to the point to which they need to for symptomatic improvement, would be advisable. Most of my patients are able to eat FODMAPs during treatment without any problem. Some patients have a slight restriction based upon what they’ve noticed they don’t tolerate, and it’s really, I think, as simple as that.

Hopefully this helps. I will put one reference in these notes, and we will be doing either a follow-up article or podcast with all the other supporting references. I apologize for not having them in this video, but I just wanted to get this video out there to get this concept out to the people, and again, we’ll follow up with more robust scientific support for this argument shortly.

OK. This is Dr. Ruscio. Hope this helps. Thanks.

If you need help with SIBO diagnosis or treatment, click here

What do you think? I would like to hear your thoughts or experience with this.


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