The Microbiome Connection: Your Guide to IBS, SIBO, and Low-Fermentation Eating

Introduction to IBS, SIBO, and Their Overlap

If you come away with only one notion from this book, let it be optimism! If you have Irritable Bowel Syndrome (IBS), you are not alone, and you can get better. And if you are among the millions of people who have Small Intestinal Bacterial Overgrowth (SIBO), a debilitating condition that occurs when bacteria that normally grow in other parts of the gut begin to grow in the small intestine, we share our expertise along with a unique SIBO diet and treatment plan to help ease your symptoms. We know … it’s already confusing. Are IBS and SIBO the same thing or are they different conditions? Can SIBO occur without IBS? We’ll guide you through the answers to these questions as you read this book.

IBS

The most common gastrointestinal (GI) condition in the United States is IBS, which is characterized by abdominal pain/discomfort, bloating, and altered bowel habits (diarrhea or constipation or both). IBS affects millions of people of all ages, and it appears to be slightly more common among women than men. Economically and socially, the cost of IBS can be significant, as those coping with IBS often miss days of work or school.

Many people who suffer from chronic IBS choose not to travel on planes, trains, and buses, and avoid dates or outings with family or friends for fear of having to explain their bathroom trips and their pain and discomfort. After all, talking about your bowel movements or how bloated you feel is not considered polite conversation in most circles. So the people you spend time with may never know about your struggle.

As IBS becomes a better-recognized disease, it will be easier to discuss. You can and should talk about IBS to your health-care providers, family, and friends. We know so much more about IBS, and we continue to learn more every year. The more you know about IBS, the better equipped you are to talk about it, and the less its burden becomes. By educating your family and friends, you can both broaden support and lessen the stigma of IBS.

Primary care doctors and health-care personnel must keep up with so many illnesses, so it’s important that we educate them about new IBS information. The more doctors—not just gastroenterologists, but all health-care providers—know about it, the better off IBS patients will be. As physically challenging as it may be, IBS gut pain can be alleviated with proper diagnosis and treatment. Yet we often see patients suffer as they bounce between Western medicine and alternative medicine, getting differing opinions and advice from physicians, dietitians, nurse practitioners, and naturopaths. In some situations, the advice or treatment may worsen their symptoms.

What’s Wrong with Me?

The primary problem is that no one answers the ultimate question: What’s wrong with me? Patients tell us, All I hear is what I don’t have. All my tests are negative. Are there no tests to confirm my illness? or I don’t know what’s wrong with me; I’m starting to believe it’s all in my head. And when you don’t know what’s going on, you may be given procedures, tests, or treatments that are potentially harmful.

IBS is not a fatal illness. It won’t lead to cancer. It hasn’t yet killed anyone, the way heart disease or kidney disease can. But let’s be clear … just because IBS isn’t lethal, doesn’t mean it’s not a problem. It’s not a lifestyle condition wherein patients are simply worried about what they eat. Moreover, IBS suffering is intense, as we’ll discuss later. In fact, some studies have shown that people with IBS have a lower quality of life than people with heart disease. The other problem with the notion that IBS is not a deadly disease is that there’s less effort to fund research, and therefore our scientific understanding of IBS has been slow to evolve.

IBS Prevalence

IBS is extremely common. If you’re reading this book on a bus or train right now, look around you: one in seven of your fellow passengers likely has IBS. Just 10 years ago, people with IBS often felt socially isolated; their symptoms were dismissed by family and friends as being imaginary, and there was little hope that the symptoms would ever disappear, or at least lessen and improve. This is not the case today. Over the last 15 years, research into IBS, gut motility, the gut’s immune system, and the vast inner workings of the gut’s microbiome (the trillions of bacteria, fungi, and viruses harbored in the gut) has been groundbreaking. Our work as clinicians and researchers has convinced us that IBS patients can experience an improved quality of life, engage successfully at work, and lead full, active lives. Many, if not most, IBS patients can find partial or complete relief from this often- debilitating disease.

Is IBS a Disease?

Notice that we just referred to IBS as a disease. Doesn’t IBS stand for irritable bowel syndrome? As you read through the chapters of this book you’ll see that IBS is a legitimate disease and that the word syndrome may no longer apply. In fact, we believe there’s hope for a course of action and an IBS-free future. We look forward to a time when IBS is no longer a chronic disease, but a manageable, finite illness that disappears with proper diagnosis and treatment. In this book, we share what we have learned and how we are now treating IBS. Most importantly, we show you how to empower yourself and lead a normal life again—a life, we hope, that is entirely absent of IBS or IBS symptoms.

The SIBO Subgroup

We also wrote this book to increase awareness and understanding among the subgroup of IBS patients who have SIBO. Through our research, we have found that about three-quarters of patients—as many as 30 million Americans—who have met the diagnostic criteria for IBS have taken a breath test that suggests they have SIBO. We hope this book will pave the way to more SIBO research and funding to improve the treatment of this large community. So how do SIBO and IBS intertwine?

Research on the effects of the microbiome on IBS/SIBO was in its infancy when Mark Pimentel, MD, wrote his first book—A New IBS Solution—more than 10 years ago. Since then there have been many new discoveries about the bacterial composition of the small intestine, the autoimmune cause of SIBO, and the treatment for SIBO.

Selected Treatment Options

When Dr. Mark Pimentel’s book was published, there were few treatment options for IBS or SIBO; in fact, 10 years ago there were only a few drugs approved by the Food and Drug Administration (FDA) to treat IBS. Today there are eight drugs for IBS on the market: five drugs to treat IBS with constipation and three drugs to treat IBS with diarrhea. Importantly, none of these drugs are antidepressants or antipsychotics that are designed to relieve the stress that may be associated with IBS, but is not the cause of IBS. One drug, the antibiotic rifaximin, can eliminate or lessen bacteria in the gut. The other drugs alter motility to help move the bowels or to move fluid through the bowels to relieve the constipating symptoms of IBS. With the FDA now on board, pharmacological treatment of IBS is changing dramatically.

Dietary changes to treat IBS/SIBO have also evolved. Twenty years ago, you may have been advised not to eat any fiber or legumes, or to avoid foods that you found through personal experience didn’t agree with you. Then the gluten-free and low-FODMAP diets were introduced. FODMAP is an acronym for Fermentable Oligo-, Di-, Monosaccharides And Polyols. These are short-chain carbohydrates that are poorly absorbed in the small intestine, including wheat and beans. Studies have shown strong links between FODMAPs and the digestive symptoms of IBS/SIBO, including gas, bloating, stomach pain, diarrhea, and constipation.

Certain foods are linked to symptoms of IBS and SIBO, but it’s not that simple. Multiple studies have shown that low-FODMAP diets can provide benefits for some people with these digestive symptoms. If you have IBS, chances are you’ve heard about the low-FODMAP diet. However, you can’t be on a low-FODMAP diet forever. In its most restrictive form, adhering to this diet for three months or more can lead to macronutrient and micronutrient deficiencies (as shown by Dr. William Chey, Ann Arbor, Michigan). Over the last few years, researchers have shown that IBS/SIBO patients can eat a low-FODMAP diet, but must reintroduce the foods that were eliminated within four weeks to prevent nutrient deficiencies.

As outlined above, IBS and SIBO are related, and SIBO may be an important cause of IBS symptoms. In fact, IBS can indeed be SIBO- and microbiome-induced. In this book, we will focus on SIBO, as we have made the biggest leap in understanding the diagnosis and treatment for the SIBO group of IBS patients as compared to those without SIBO. We know the underlying medical cause of SIBO, how to diagnose it—whether it derives from a motility problem or from an imbalance of microbes in the gut—and the role of autoimmunity for those suffering from IBS. We know how to treat SIBO with antibiotics, followed by promotility drugs to help the bowels move and keep the microbiome balanced. SIBO is the most well-defined part of IBS, and we are making significant headway in its treatment.

SIBO Patients, Family Members, and Professionals

This book is not just for patients with IBS and SIBO; it can also be a learning tool for a family member of someone with SIBO to understand the daily struggles with these conditions. Physicians may also use this book to study the principles of how we understand IBS as a microbiome disease and to learn about the tools to handle patients with this aspect of IBS.

If you’re a patient with SIBO, we hope this book will help you understand what’s going on with your body. If you don’t respond to treatment, you will know why your symptoms are sometimes unpredictable. You will be better able to manage your symptoms to achieve freedom from IBS and SIBO and you will also be better equipped to interact with your health-care professionals when they recommend a certain treatment or diet for you.

If you’re the family member of a SIBO patient, you’ll better understand why it’s difficult for someone with this disorder to be comfortable at dinner because of food sensitivities or symptoms. You’ll develop more understanding of the workings of a SIBO patient’s body, which will lead to more empathy for your family member.

If you’re a health-care professional, this book will help you better understand SIBO. Today’s medical precepts change so quickly that you may not be aware of how many of your patients have been diagnosed with SIBO. This book will help you address the SIBO portion of concomitant medical problems.

If you’re a dietitian, you may not be an expert in gastrointestinal diseases. The majority of dietitians help their patients with the nutritional aspects of diabetes, high blood pressure, and heart disease, but not necessarily IBS. Some dietitians only treat celiac disease or inflammatory bowel disease. This book can aid your understanding of what the IBS/SIBO patient needs in terms of diet as well as what has the potential to harm them.

We know of no other book that covers the entire spectrum of SIBO. This book provides simple explanations of what happens to IBS/SIBO patients from diagnosis to the end of treatment. We reveal changes that can occur in the body in terms of the underlying physical processes and symptoms that may develop. We also cite evidence-based management and treatment with both drugs and dietary changes.

Collectively, we have published hundreds of peer-reviewed journal articles on the topics in this book. Here we have transformed our research into a language that we hope is relatable and easy for you to understand. What’s more, the book includes diagrams of how food travels through the digestive system and how bacteria are distributed throughout the gut, as well as a meal plan guide that includes which foods to eat in moderation and which foods to avoid because they will feed bacteria in the gut and potentially lead to more symptoms. We also provide sample menus for breakfast, lunch, and dinner.

You’ll also learn about the three pillars of SIBO management to reduce problem bacteria, ideas to reduce symptoms, and an elemental diet to starve out the non-beneficial bugs. Finally, we bust the 10 myths of IBS.

What’s Next?

We know of no other researchers who have studied IBS/SIBO as intently as we have over the past 20 years. We have observed a sea change in how to think about these digestive disorders, and we hope this evolution continues. We now have significantly better understanding of gut motility and the microbiome as they relate to IBS/SIBO. And we look forward to the development of better IBS drugs and interventions that can affect the microbiome in ways that benefit you.

Bugs as Drugs and Drugs for Bugs

Because IBS and SIBO may be a microbiome disease, it is important to explain how practitioners and/or patients can use bugs as drugs. Examples include probiotics and other live microorganisms intended to normalize the microbiome. A lesser used treatment, known as fecal transplantation, involves an infusion of stool (feces) from a donor to treat IBS/SIBO that is refractory to other treatments.

We hope that by following the instructions this book provides, you can achieve the same positive changes we see every day in our IBS and SIBO patients.

CHAPTER 1

IBS and You

I developed irritable bowel syndrome (IBS) last year after getting sick on vacation. Now I’ve gained 15 pounds. How can that be when I have diarrhea?

My family doesn’t seem to get it. I can’t eat that because I know I will be in pain and bloated. And still every day they try to encourage me to eat everything.

I’m bloated. I’m full. I’m gaining weight. I’m fatigued. I feel foggy in the head after eating. My doctor told me I’ll just have to learn to live with it.

My belly is flat in the morning, but by the evening it looks like I am 6 months pregnant!

These are just a few of the complaints and concerns we often hear from our IBS patients. Equally disheartening is the lack of compassion, the insufficient information, and the endless unhelpful solutions and suggestions they have been given before coming to see us: The tests didn’t show anything. Try this prebiotic. Try this probiotic. You’re allergic to gluten. Relax and you’ll get better. You’re drinking too much coffee. You’re not exercising enough. Sound familiar?

As practicing gastroenterologists and longtime IBS researchers, we’re a group of IBS specialists who have published many journal articles and advocated for patients for decades. We have a connection and a commitment to our thousands of patients and to those of you dealing with IBS. We know quite well what you’re going through and what you’ve been dealing with. We know now that IBS affects people both physically and psychologically. We’ve seen first-hand how IBS adversely affects both the family life and the professional life of our patients.

Before getting into the science of your gut and its microbiome, the small intestinal bacterial overgrowth (SIBO) in those of you afflicted with IBS, and all the different ways we have dealt with this disease, let’s talk about the impact of IBS, its symptoms, its history, and the issues surrounding it.

IBS by the Numbers

The first step in understanding the impact of IBS is to comprehend how common it is. Globally, about 11 percent of the world has IBS. That’s nearly 1 billion people. In the United States, an estimated 10 to 15 percent of the population has IBS (Figure 1.1). It’s the most common gastrointestinal disorder and one of the most treated disorders encountered by physicians. There are nearly 4 million doctor visits per year for IBS in the US alone, meaning that it accounts for up to 12 percent of total visits to primary care doctors. IBS can start at any age, but most commonly occurs in people between the ages of 20 to 40, and it afflicts more women than men—60 to 65 percent of IBS sufferers are women.

Economically, IBS costs American society more than $21 billion a year in lost productivity at work and in medical expenses, with 13 percent of IBS patients missing at least one day of work or school per month due to their symptoms. (In comparison, building a two-way road from Seattle to Miami would cost $10 billion.) Because IBS is not a fatal illness and is not given priority in research funding despite the high costs to society, the National Institutes of Health allots only $5 million