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.      

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

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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.

Discussion

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54 thoughts on “Prebiotics and FODMAPs During SIBO Treatment

  1. This is cool piece, Dr. Ruscio. I think it makes sense, and my understanding is that in some cases it can actually be quite the opposite. I mean, FODMAPs, can actually make the treatment less effective. Especially if methane is present. Studies on PHGG and rifaximin where only done on diarrhea patients, maybe we would see different picture with constipation. In my personal experience, I’ve tried eating lots of FODMAPS, and starches while taking rifax+neo, and boy was I wrong. They did absolutely nothing in that situation.

    I wonder what’s the mechanism behind probiotics and SIBO? Does it work because it helps to restore GI motility? Or because it works as an antimicrobial? Anti-inflammatory? All of those?
    Somehow the antimicrobial effects of probiotics don’t convince me at all. It couldn’t be that potent I believe.

    1. Also, I heard Dr. Siebecker on an interview, saying that she also heard that many practitioners found that concept of adding more FODMAPs to actually make everything worse, not better.

    2. Thanks Simas. In my book I discuss how the small intestine, because of its lower colonization density, is more effected by probiotics than the large intestine. The mechanism is likely antimicrobial, immunomodulatory and motility. Dr. S and I will be recording a podcast to provide our thoughts on this issue soon. More to come!

  2. Thank you for this helpful video! I’m curious if you’ve seen any suggestions as to the mechanism behind the benefit of probiotics during SIBO treatment. In other words, why are they beneficial – are they in some way counter-acting the bacteria in the small intestine, or just providing transient improvement to the microbiota of the colon, which somehow helps treat SIBO? I am just curious if you know why the benefit seems to be there. Thanks for always providing great information, and looking forward to the talk in London!

  3. Hi Dr Ruscio!
    Thank you! You cleared up much of my confusion about dirt during treaents if SIBO. I find all this facinating and look forward to more info and research on SIBO.
    Question about diet after treatment. do you recommend the same type of diet as during treatment?
    Also, I’ve noticed herbal antibiotics are used for typically 4 weeks. My first round of them didn’t clear the SIBO which I’ve read is common. Would it be beneficial to do more than 4 weeks? Say 6-8 weeks of the herbals?
    Thanks any advice of info would be wonderful. ?
    -Amber

      1. I usually recommend low FODMAP for 4 to 8 weeks after treatment, in addition to the diet used during treatment (often paleo or AIP). Yes, I often have patients use for longer 🙂
        Hope this helps!

  4. Hi Dr. Ruscio,
    Thank you for all the good information on your website. I have been trying to treat SIBO C for over two years now but am unable to tolerate antibiotics or herbal products. I react to everything including most foods. I am wondering if the Silvercillin would help and at what dosage? Have you been able to help others that can not take supplements?
    According to Cyrex lab results I have leaky gut on the inter and intra cellular levels. I know my gut can’t heal unless I get rid of the SIBO, but where do I begin?
    Thank you! Any information that you could offer would be truly appreciated!
    Jutta

    1. Hi Jutta,
      Sorry to hear about your troubles. I don’t know if silver can treat SIBO. The elemental diet might be the best option for you or working with a clinician. Reactions to treatments are not uncommon and this is where personalizing the treatment to the patient comes in 🙂 Hope this helps!

  5. Hi Dr. Ruscio

    My 34 year old son has been suffering from CFS and constipation for months now, which we think is related to SIBO. While waiting for a breath test to confirm this (appointment won’t be until February – UK NHS is overloaded!) he has decided to take max strength Allicin and probiotics anyway, as he’s struggling with energy levels etc. Do you know which probiotics are likely to be most effective?

    BTW he has undergone many blood tests etc to eliminate other likely underlying issues, all negative. His symptoms started immediately following a fever and several days illness last April (?viral).

    I have listened to a couple of your podcasts with Robb Wolf and and like both your website and databased approach, so any advice would be welcomed.

    Thank you

    Christine

  6. Sorry, also should have mentioned that my son has been on a low FODMAP Paleo diet since about April when he developed various food intolerances, including gluten sensitivity (NCGS). These have all been removed.as they were identified. Not much improvement seen though, other than the lack of reactions after eating (tingling, rashes etc).

    Comprehensive stool analysis in May (sent to Doctor’s Data in USA) revealed high yeast but this wasn’t culturable. He certainly had a yeast overgrowth in June, (evidenced in toenails, skin between fingers etc, which we have eradicated (we think) with months of herbal antifungals. Probiotics and home made Kefir included daily all along but can’t be sure anything has really helped/hindered. Sorry this is so long but desperate for an expert’s opinion as here in the UK knowledge appears to be sparse.

    Christine

  7. Hi Dr. Ruscio

    My 34 year old son has been suffering from CFS and constipation for months now, which we think is related to SIBO. While waiting for a breath test to confirm this (appointment won’t be until February – UK NHS is overloaded!) he has decided to take max strength Allicin and probiotics anyway, as he’s struggling with energy levels etc. Do you know which probiotics are likely to be most effective?

    BTW he has undergone many blood tests etc to eliminate other likely underlying issues, all negative. His symptoms started immediately following a fever and several days illness last April (?viral).

    I have listened to a couple of your podcasts with Robb Wolf and and like both your website and databased approach, so any advice would be welcomed.

    Thank you

    Christine

  8. Sorry, also should have mentioned that my son has been on a low FODMAP Paleo diet since about April when he developed various food intolerances, including gluten sensitivity (NCGS). These have all been removed.as they were identified. Not much improvement seen though, other than the lack of reactions after eating (tingling, rashes etc).

    Comprehensive stool analysis in May (sent to Doctor’s Data in USA) revealed high yeast but this wasn’t culturable. He certainly had a yeast overgrowth in June, (evidenced in toenails, skin between fingers etc, which we have eradicated (we think) with months of herbal antifungals. Probiotics and home made Kefir included daily all along but can’t be sure anything has really helped/hindered. Sorry this is so long but desperate for an expert’s opinion as here in the UK knowledge appears to be sparse.

    Christine

  9. Hi Dr Ruscio

    Thank you so much for your responses. I will try your suggestions in your SIBO protocol radio podcast. It was very informative. And I will notify my son that you consult via Skype if we need further help.

    Have a great weekend in London (bring wooly jumpers as it’s cold here!). It’s a pity that I can’t be there as the programme looks interesting. I hope it is well attended by UK medics and that you all benefit from the event.

    Kind regards

    Christine

  10. Hi Dr Ruscio

    Thank you so much for your responses. I will try your suggestions in your SIBO protocol radio podcast. It was very informative. And I will notify my son that you consult via Skype if we need further help.

    Have a great weekend in London (bring wooly jumpers as it’s cold here!). It’s a pity that I can’t be there as the programme looks interesting. I hope it is well attended by UK medics and that you all benefit from the event.

    Kind regards

    Christine

  11. Hi Mr. Ruscio,

    Thanks for all your information, you’ve really helped me alleviate some of my symptoms. however, i thought you said on Rob Wolfe’s podcast that prebiotics and probiotics can proliferate sibo symptoms, so i thought to say clear from them?

  12. Hi Mr. Ruscio,

    Thanks for all your information, you’ve really helped me alleviate some of my symptoms. however, i thought you said on Rob Wolfe’s podcast that prebiotics and probiotics can proliferate sibo symptoms, so i thought to say clear from them?

  13. Incorrect: “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.”

    What the actual abstract says (https://www.ncbi.nlm.nih.gov/pubmed/23244247):

    “Patients were randomly divided into two groups homogeneous for sex and age: group 1 received Rifaximin 400 mg/day for 7 days/month FOLLOWED BY Lactobacillus casei for 7 days more and group 2 antibiotic FOLLOWED BY short chain fructo-oligosaccharides.”

  14. Incorrect: “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.”

    What the actual abstract says (https://www.ncbi.nlm.nih.gov/pubmed/23244247):

    “Patients were randomly divided into two groups homogeneous for sex and age: group 1 received Rifaximin 400 mg/day for 7 days/month FOLLOWED BY Lactobacillus casei for 7 days more and group 2 antibiotic FOLLOWED BY short chain fructo-oligosaccharides.”

  15. Do your recommendations change if someone is suffering both sibo and leaky gut at the same time?

    Also, I’ve been suffering with very bad chronic shortness of breath (all that started after my gut issues). I’ve seen both heart specialists and lung specialists. Done numerous tests to rule out any infections, issues, asthma, deficiencies, etc.

    Is it possible that the SIBO is the cause of the shortness of breath? Have you ever had patients with these symptoms? If so, what do you recommend?

    Thank you!

  16. Do your recommendations change if someone is suffering both sibo and leaky gut at the same time?

    Also, I’ve been suffering with very bad chronic shortness of breath (all that started after my gut issues). I’ve seen both heart specialists and lung specialists. Done numerous tests to rule out any infections, issues, asthma, deficiencies, etc.

    Is it possible that the SIBO is the cause of the shortness of breath? Have you ever had patients with these symptoms? If so, what do you recommend?

    Thank you!

  17. Hello Dr. Ruscio,

    I hope all is well. I was wondering if you could help me. In May of this year I was diagnosed with C Diff. I took a round of Vancomycin which didn’t help. I then took a 10 day course of Dificid which helped. I am currently negative for the toxins but positive for the antigen. Post c diff I started taking Probiophage DF as well as Sacc. Boulardii. I seemed to be feeling much much better. But then I started feeling nauseous. Right now that seems to be my biggest issues aside from occasional gas. I was drinking a lot of kombucha. I would say starting from June to mid August. I would drink 16oz maybe every day. Well I would stop here and there but for the most part I drank a lot. Now I’m afraid I may have giving myself SIBO from the kombucha. I spoke to several doctors and my nutritionist who say that’s highly highly unlikely.

    My doctor says that I am still recuperating from them C Diff infection. That it may take months to fully recover. What do you think? Sorry for the long message. Thank you for your time and help.

    Thank you,
    Paul Rittenhouse

    1. Hi Paul,

      I would probably agree with your doctor and nutritionist, it’s unlikely that kombucha is the culprit here.

      Good luck!

  18. Hello Dr. Ruscio,

    I hope all is well. I was wondering if you could help me. In May of this year I was diagnosed with C Diff. I took a round of Vancomycin which didn’t help. I then took a 10 day course of Dificid which helped. I am currently negative for the toxins but positive for the antigen. Post c diff I started taking Probiophage DF as well as Sacc. Boulardii. I seemed to be feeling much much better. But then I started feeling nauseous. Right now that seems to be my biggest issues aside from occasional gas. I was drinking a lot of kombucha. I would say starting from June to mid August. I would drink 16oz maybe every day. Well I would stop here and there but for the most part I drank a lot. Now I’m afraid I may have giving myself SIBO from the kombucha. I spoke to several doctors and my nutritionist who say that’s highly highly unlikely.

    My doctor says that I am still recuperating from them C Diff infection. That it may take months to fully recover. What do you think? Sorry for the long message. Thank you for your time and help.

    Thank you,
    Paul Rittenhouse

    1. Hi Paul,

      I would probably agree with your doctor and nutritionist, it’s unlikely that kombucha is the culprit here.

      Good luck!

  19. So, PROBIOTICS benefit recovering from SIBO, but what do prebiotics do? If they don’t help, do they hurt? So many probiotic capsules have prebiotics included in them. Is this okay? Will consuming prebiotics make SIBO worse? Should I find a probiotic that does not include probiotics, or does it not matter? Please help!

    1. Hi Nicole,

      I would go by your symptoms. If you feel worse after consuming something with prebiotics, try avoiding them and see if you feel better. The amount of prebiotics usually included in supplements tends to be pretty minuscule and Dr Ruscio isn’t overly concerned about them.

      Good luck!

  20. So, PROBIOTICS benefit recovering from SIBO, but what do prebiotics do? If they don’t help, do they hurt? So many probiotic capsules have prebiotics included in them. Is this okay? Will consuming prebiotics make SIBO worse? Should I find a probiotic that does not include probiotics, or does it not matter? Please help!

    1. Hi Nicole,

      I would go by your symptoms. If you feel worse after consuming something with prebiotics, try avoiding them and see if you feel better. The amount of prebiotics usually included in supplements tends to be pretty minuscule and Dr Ruscio isn’t overly concerned about them.

      Good luck!

  21. This is cool piece, Dr. Ruscio. I think it makes sense, and my understanding is that in some cases it can actually be quite the opposite. I mean, FODMAPs, can actually make the treatment less effective. Especially if methane is present. Studies on PHGG and rifaximin where only done on diarrhea patients, maybe we would see different picture with constipation. In my personal experience, I’ve tried eating lots of FODMAPS, and starches while taking rifax+neo, and boy was I wrong. They did absolutely nothing in that situation.

    I wonder what’s the mechanism behind probiotics and SIBO? Does it work because it helps to restore GI motility? Or because it works as an antimicrobial? Anti-inflammatory? All of those?
    Somehow the antimicrobial effects of probiotics don’t convince me at all. It couldn’t be that potent I believe.

    1. Also, I heard Dr. Siebecker on an interview, saying that she also heard that many practitioners found that concept of adding more FODMAPs to actually make everything worse, not better.

    2. Thanks Simas. In my book I discuss how the small intestine, because of its lower colonization density, is more effected by probiotics than the large intestine. The mechanism is likely antimicrobial, immunomodulatory and motility. Dr. S and I will be recording a podcast to provide our thoughts on this issue soon. More to come!

  22. Hi Dr. Ruscio,
    Thank you for all the good information on your website. I have been trying to treat SIBO C for over two years now but am unable to tolerate antibiotics or herbal products. I react to everything including most foods. I am wondering if the Silvercillin would help and at what dosage? Have you been able to help others that can not take supplements?
    According to Cyrex lab results I have leaky gut on the inter and intra cellular levels. I know my gut can’t heal unless I get rid of the SIBO, but where do I begin?
    Thank you! Any information that you could offer would be truly appreciated!
    Jutta

    1. Hi Jutta,
      Sorry to hear about your troubles. I don’t know if silver can treat SIBO. The elemental diet might be the best option for you or working with a clinician. Reactions to treatments are not uncommon and this is where personalizing the treatment to the patient comes in 🙂 Hope this helps!

  23. Thank you for this helpful video! I’m curious if you’ve seen any suggestions as to the mechanism behind the benefit of probiotics during SIBO treatment. In other words, why are they beneficial – are they in some way counter-acting the bacteria in the small intestine, or just providing transient improvement to the microbiota of the colon, which somehow helps treat SIBO? I am just curious if you know why the benefit seems to be there. Thanks for always providing great information, and looking forward to the talk in London!

  24. Hi Dr Ruscio!
    Thank you! You cleared up much of my confusion about dirt during treaents if SIBO. I find all this facinating and look forward to more info and research on SIBO.
    Question about diet after treatment. do you recommend the same type of diet as during treatment?
    Also, I’ve noticed herbal antibiotics are used for typically 4 weeks. My first round of them didn’t clear the SIBO which I’ve read is common. Would it be beneficial to do more than 4 weeks? Say 6-8 weeks of the herbals?
    Thanks any advice of info would be wonderful. ?
    -Amber

      1. I usually recommend low FODMAP for 4 to 8 weeks after treatment, in addition to the diet used during treatment (often paleo or AIP). Yes, I often have patients use for longer 🙂
        Hope this helps!

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