The NUNM SIBO Symposium is one that always tends to draw a crowd. This year (2017) was the fourth appearance for the annual conference and the third that I have attended. Each year, I am excited to learn about new developments in the SIBO world. Especially those that provide support and solutions for the many individuals suffering worldwide.
In an effort to help those who are suffering, I have made it my mission to provide a quick summary each year of what I believe are some of the important takeaways (you can read last year’s summary here). Not all of them are new to me (or you!), but instead, are important reminders based on major problems I have noticed in the SIBO community.
If you would prefer to watch the symposium yourself, you can purchase recordings of individual talks or the whole conference here.
The majority of the information in this post is summarizing certain points shared by various speakers. However, I do provide context and background research where appropriate so that you do not feel quite as lost if you are a SIBO newbie. If you are completely new to SIBO, consider starting with my About SIBO page.
1) There are now standards for how to go about breath testing.
A breath test consensus paper (see paper) was released about one month ago that sets the stage for consistency in breath testing parameters and interpretation moving forward. Previously, research studies used different criteria (i.e. different cut-off times for division between small/large intestine, different amounts of test sugar consumed, different values for what amount of gas is considered positive, etc.). The differing criteria made it challenging to compare studies and draw conclusions.
2) The low FODMAP diet is associated with an 8x reduction in histamine (see research).
Histamine is a compound involved in the immune response and often cited by SIBO patients to be involved in their symptom picture. The role of the low FODMAP diet in reducing histamine levels is particularly relevant because individuals who believe they are experiencing histamine intolerance sometimes choose to remove high histamine foods from their diet. And if they are sensitive to FODMAPs, they may be trying to layer these two diets on top of each other. The problem with restricting both high FODMAP and high histamine foods is that it leaves individuals with an extremely limited diet full of nutritional deficiencies and lacking in pleasure. For those individuals who have symptoms of histamine overload or intolerance along with digestive issues, it may be more appropriate to recommend a low FODMAP diet (although more research is needed to confirm this).
3) It is important to work on developing peace with food, not fear.
Many individuals following restrictive SIBO diets develop disordered eating patterns surrounding food. They cannot ever eat out, they no longer enjoy food, and/or it is the only thing they ever think about. I get it. I’ve been there. It is a difficult place to be in, but ultimately, health and food is about more than the nutrients on your plate and it is important to seek support of a trained medical professional if you feel that you have an unhealthy relationship with food.
4) Stress is not the cause of IBS/SIBO, but it can play a role.
Pimentel cited a study consisting of US military troops deployed to Afghanistan. The study found that factors viewed as “stressful” such as shooting a weapon or viewing a death were not associated with later development of IBS. Instead, the only factor that was associated with the later development of IBS was getting food poisoning during the time overseas. However, it is important to note that stress can reduce phase 3 of the migrating motor complex (MMC), creating a “stagnant river” in the small intestine and potentially making you vulnerable to infection.
5) At least 60% of people with IBS-D have SIBO.
Not all IBS is SIBO and not all SIBO is IBS, but there is a great degree of overlap. SIBO is believed to be especially prevalent among those suffering from IBS-D.
6) Methane may not be SIBO, it may be “bloom”.
Sorry to drop the ball without much additional info, but there wasn’t really too much said about this, other than that Dr Pimentel’s team is now theorizing that methanogens can blossom and overgrow and it is unclear how much they are coming from the small intestine versus the large intestine (colon). It is unclear at this point what causes Methanobrevibacter smithii or other methanogens to bloom.
7) Methanogens may actually help harvest more energy and nutrition from food by slowing intestinal transit.
Along similar lines, methanogens appear to alter how the body responds to glucose. Interestingly, research has shown that in Sub-Saharan Africa, 75 percent of people have methane on their breath. In contrast, less than 15 percent of people living in the US have methane on their breath and in Japan, methane rates are extremely low. It is theorized that methanogens may actually be beneficial in the Sub-Saharan region of Africa due to the type and scarcity of food that is available. If someone living in this region has high amounts of methanogens and moves to an area of the world where food is abundant, they may be prone to developing obesity and type 2 diabetes due to the presence of methanogens and excessive energy harvesting from food.
8) The higher the result for anti-vinculin on the IBSChek test, the sicker the patient tends to be.
Dr. Pimentel mentioned that it is harder to treat individuals with a higher anti-vinculin level and that for those with an anti-vinculin above 3, Rifaximin will not work. Now, if you don’t know what the heck IBSChek or anti-vinculin are, let’s take a step back…Dr. Pimenetel and colleagues have discovered the mechanism that links acute gastroenteritis (i.e. food poisoning, traveler’s diarrhea) to the subsequent development of IBS and have created a test (IBSChek) that can determine whether this was the case for you. Here’s how it works: a) individual contracts food poisoning, b) bugs that cause food poisoning release a toxin called cytolethal distending toxin B (CdtB), c) the immune system creates antibodies to the CdtB toxin, d) unfortunately, CdtB looks a lot like a protein called vinculin that is found on the nerve cells in your gut and therefore attacks these nerve cells (a phenomenon called molecular mimicry), f) the result is an impaired migrating motor complex that sets the stage for small intestinal bacterial overgrowth.
9) Approximately 70 percent of the world population has lactase non-persistence (see research on this topic– it states 65%).
Let me break that down for you. We are talking about lactose intolerance here. Lactose is a type of sugar that is found in milk and certain other dairy products. It is also added to some food products, medications, and dietary supplements. Lactose is a disaccharide (meaning it has two sugars) consisting of glucose and galactose. In order to break down this sugar (lactose), lactase must be present. If it isn’t present, individuals who drink milk can end up with bloating, cramping, gas, and diarrhea. Lactase is an enzyme produced on the brush border of the small intestine. Inability or decreased ability to produce lactase can have different causes. One of those causes is that approximately 65-70% of people have lactase non-persistence. This means that after being weaned from milk as an infant, 65-70% of people worldwide no longer produce adequate amounts of lactase to be able to digest foods such as milk. Individuals of European descent and those descending from certain dairying cultures in Africa, South Asia, and the Middle East are more likely to have the genetic trait that allows them to produce the enzyme lactase into adulthood. If individuals have the genetic ability to produce lactase, but are still reacting to milk, there can be another reason for lactose intolerance- the brush border of their small intestine has been damaged for some reason (such as SIBO), impairing lactase production and release.
10) The impact of the low FODMAP diet on colon bacteria is still unclear.
In healthy individuals, FODMAPs are nutritious components of food and should not be restricted. Some studies show detrimental effects on the colon microbiota from a low FODMAP diet, while others suggest a reduction in inflammatory metabolites for individuals with FODMAP intolerance who follow this diet.
11) There are currently no published studies examining the safety and efficacy of the low FODMAP diet in pregnancy or while breastfeeding.
However, there is a study currently being conducted at Monash University looking at a low FODMAP diet in breastfeeding mothers whose babies are colicky.
12) Pimentel does not use Ciprofloxacin (an antibiotic) for SIBO.
He said that while it is effective for SIBO and is much less expensive than Rifaximin, the side effects are greater and 75% of the time it will not work a second time meaning that bacterial resistance has occurred (this is undesirable, especially for a condition like SIBO that is often chronic).
13) Women have less serotonin production than men
Specifically, women produce only about 75% what men produce. Therefore women may be more susceptible to mood changes associated with a low carbohydrate diet (carbohydrates play a role in the production of serotonin).
14) A research study being conducted at the National University of Natural Medicine (NUNM) in Portland, OR over the past three years revealed that many of the asymptomatic controls tested positive for SIBO.
More specifically, 64% of controls met the criteria for positive hydrogen and methane levels at 100 minutes. It is unclear if the large number of asymptomatic controls was caused by false positives or errors in study design. Audience members theorized that perhaps the design criteria did not exclude people with “secondary SIBO” (i.e. they have no digestive symptoms, but have other health issues that could be rooted in microbial health).
15) Hydrogen sulfide producers- help is on the horizon!
Read more about this one in the whole post I dedicated to the issue of hydrogen sulfide.