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Whether or not we actually have SIBO might not be all that relevant as SIBO diet management helps both IBS and SIBO. The only way to be certain we have SIBO is testing, but this isn't an accurate science at this point in time.

SIBO, an overgrowth of bacteria in the small intestine, affects both IBS constipation and diarrhea types. Bacteria feed on carbohydrates, and an overabundance of bacteria in the small intestine will result in excess gasses, including methane or hydrogen. Individuals tend to predominantly produce either one gas or the other. Methane is believed to cause constipation, and hydrogen diarrhea.

Many of us find that we can't tolerate too much fibre, starch, FODMAPs or certain fats. SIBO can be the cause of all of these symptoms. A flatulogenic diet which feeds bacteria will make SIBO and IBS symptoms much worse.

Previously IBS was believed to be "functional" and it's often claimed that the colon has a mind of its own. A particular food might produce symptoms one day, but not on another. Inconsistencies in colon behaviour to certain foods might be due to overall gas "threshold". IBS / SIBO symptoms have a direct relation to intestinal gas. The more gas produced, from whatever source, the more severe the symptoms.

Too much fibre can cause hypermotility and the reasons could be because most food has a component of soluble as well as insoluble fibre. If the colon finds fibre irritating, this can cause fast transit, meaning that the carbohydrate isn't digested fully in the small intestine, providing food for bacteria. Bacteria are more likely to feed on soluble rather than insoluble fibre, but most carbohydrates have a mix of the two. Any malabsorbed food will feed bacteria at our expense. Dysbiosis means that bacteria feed on our food.

Certain fats can cause IBS symptoms as well. Bile acid malabsorption is most known for causing diarrhea (bile acid diarrhea). Larger amounts of bile acids in the intestine can stimulate motility, causing flatulence and diarrhea. Bile acids are produced by the liver, and are important for the digestion of fats. Certain bacteria can modify these bile acids by removing amino acids and creating modified bile acids. This process (deconjugation) creates free bile acids, which can cause mucosal inflammation as well as malabsorption.

Good fats include medium chain triglycerides, such as butter, olive oil and coconut oil. Medium chain fats are easier digested, and are absorbed directly to the liver. Fried food, especially take away, should be avoided due to saturated fats which are often rancid. Healthy fats include the omega 3 fats in seafood.

Dietary management for SIBO and IBS:

• Restrict FODMAPs as much as possible. Different FODMAPs will cause different symptoms depending on the individual. The least digestible FODMAPs tend to be galactans (legumes) and brassicas (brussel sprouts, cabbage, cauliflower). Wheat fructans may affect one person but not another. Toast is generally better digested than bread.

• Restrict starches and sugars. FODMAP vegetables, fruits and wheat aren't the only problem food. Non-FODMAP foods, particular non-gluten potato or tapioca flour are very high in starch, which also feed bacteria.

• Elimination diet to identify flatulogenic foods.

• Eliminate saturated or rancid fats from the diet.

Complete evacuation allows you to identify problem foods more clearly. It provides a yardstick to judge the flatulogenic properties of food that you eat. It's hard to judge this when you still retain gas from the previous day.

Soluble fibre is generally better tolerated. Insoluble fibre may be easier digested if eaten with protein, e.g. ham or salmon. Insoluble fibre eaten on its own tends to be more irritating.

The interaction between bacteria and bile

Carbohydrates: Fermentable Sugars and Fibre

Review article: small intestinal bacterial overgrowth, bile acid malabsorption and gluten intolerance as possible causes of chronic watery diarrhea

Idiopathic (Primary) Bile Acid Malabsorption and IBS Diarrhea
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