What is IBD?
Many IBD (Inflammatory bowel disease) patients experience symptoms such as fatigue, bloating, abdominal pain, loose/watery bowel movements frequently with passing blood, weight loss, joint pain, etc. (1)
IBD refers to the inflammation of the digestive system, causing severe gut symptoms. The two most common types are Crohn's disease (CD) and Ulcerative Colitis (UC). Although they have similarities in terms of the symptoms and treatment, they affect various parts of the digestive system. (2)
Crohn's disease can affect any part of the digestive tract between the mouth and anus, while Ulcerative Colitis only causes changes in the lining of the colon, starting at the rectum area and moves upward. (3)
Stool tests can rule out IBD; blood tests seek for elevated inflammatory and antibody markers. Doctors may order a colonoscopy to have a closer look.
How is IBD connected with SIBO?
Many IBD patients have IBS (Irritable Bowel Syndrome) symptoms due to SIBO (Small Intestinal Bacterial Overgrowth). According to research, IBD patients have a 9x more significant risk of SIBO than the overall population. (4).
SIBO (Small Intestinal Bacterial Overgrowth) is defined as excessive bacteria in the small intestine. There are too many and/or the wrong type of bacteria present in the wrong place that should generally be found in the large intestine. The overgrowth of bacteria in the small bowel may cause digestive symptoms such as bloating, gas, reflux, diarrhea or constipation, abdominal pain, etc. (5) Read more about the different types of SIBO in my previous blog post.
The body has several protective mechanisms to prevent a potential bacterial overgrowth, such as:
- Adequate pH of stomach acid is required not just for digesting food and absorbing minerals but also for killing any harmful organisms found in our food, such as parasites, bacteria, etc.
- Bile flow – which also has an antibacterial effect on the intestines
- A well-functioning migrating motor complex – that gets activated during fasting periods and clears any remaining food or bacteria out of the small intestine towards the colon. If you constantly snack, then you inhibit this clearing motion. (6)
- intact ileocecal valve -is a sphincter located in the last section of the small intestine (ileum), connecting to the first portion of the large intestine (cecum). It opens to allow the digested food to pass downwards and closes to prevent the backflow of the colonic content, waste, and bacteria to the small intestines (ileum). (7)
- a healthy microbiome, etc. (8)
In IBD, some of these protective barriers might be compromised, which creates a free way to SIBO. If you have undergone abdominal surgery or had strictures, your risk may be increased.
SIBO and IBD symptoms may produce similar symptoms, so it is better to test for SIBO! According to a study, IBD patients with positive SIBO tests experienced more severe gut symptoms such as bloating, gassiness, and more frequent loose stools than their SIBO-negative peers. (9)
IBD may be linked to an improper immune response triggered by various environmental variables, gut dysbiosis, leaky gut, and genetics. (10)
How to deal with IBD symptoms naturally?
Conventional medicine uses several medicines and immunosuppressants to decrease inflammation and the autoimmune process that might be necessary.
While it is crucial to reduce the symptoms, it is equally important to identify possible root causes of IBD.
In terms of dealing with SIBO and IBD, the main focus should be on:
1. Following an anti-inflammatory diet
Diets may play an essential role in reducing symptoms and inflammation by removing triggering foods and giving a chance for the intestinal wall to heal.
Different dietary approaches have been used for managing the symptoms: Paleo diet, Vegan diet, Specific Carbohydrate Diet (SCD), GAPS diet, low-FODMAP diet, etc. (11)
LOW-FODMAP DIET
The low-FODMAP diet has also been reviewed in the literature as a potential dietary approach for IBD patients. (12)
FODMAP is an acronym for "Fermentable Oligo-, Di-, Mono-saccharides And Polyols." These are short-chain carbohydrates and sugar alcohols that are poorly absorbed in the body. The bacteria ferment these carbohydrates and create gases, resulting in abdominal pain and bloating. Some examples of high-FODMAP-containing foods are cauliflower, mango, apples, onions, wheat, sweeteners like xylitol, and so on. (13)
Generally, a low-FODMAP diet is recommended to help reduce digestive symptoms, including bloating, flatulence, abdominal cramping, and diarrhea. (14) This diet can be beneficial if IBS or SIBO is also diagnosed and other dietary approaches haven't provided improvement. (15) It also has drawbacks because the diet removes some beneficial prebiotics that would improve dysbiosis in IBD patients.
SCD DIET
SCD (Special Carbohydrate) diet is one of the most popular dietary approaches to reduce symptoms and inflammation in IBD patients. (16) (17) Originally, it was created by Dr. Sidney Haas as a treatment for celiac disease, and later, in 1987, Elaine Gottschall published her book "Breaking the Vicious Cycle" as a treatment plan for IBD.
SCD is used as an elimination diet, which aims to remove complex carbohydrates that contribute to the overgrowth of harmful bacteria. The growth of these bacteria produces byproducts that cause inflammation in the digestive tract. In this diet, bacteria's food sources are excluded ( disaccharides and most polysaccharides), such as potatoes, grains (rice, millet, quinoa, wheat, etc.), most dairy products, processed foods, and most legumes, and so on. (18)
SCD is also commonly used among SIBO patients as it removes the complex carbs that bacteria commonly feed on in the small bowel. It can also be helpful for people with a deficiency of carbohydrate enzymes.
The diet also has some pitfalls as it allows dairy, which is often not well-tolerated by many. According to a study, approximately 70% of patients with IBD have lactose intolerance. (19) The diet can be high in nuts, which may cause adverse reactions in some who have oxalate sensitivity.
You can read more information about this diet in Elaine Gottschall's book "Breaking the Vicious Cycle."
ELEMENTAL DIET
When some of the anti-inflammatory diets fail to reduce symptoms, especially when someone is in the middle of a flare-up, then the Elemental Diet can be an excellent reset tool.
An elemental diet is an anti-inflammatory meal replacement formula that is quickly absorbed in the first section of the small intestine and includes all the necessary macronutrients, minerals, and vitamins in a broken-down form. This way, the gut has some pause from digesting whole foods and time to heal. Research showed that it could effectively reduce intestinal inflammation and maintain remission. (20)
An elemental diet is usually used for 2-3 weeks in case of severe digestive symptoms, such as IBD (21), IBD or SIBO (22), or Celiac disease (23).
2. Lifestyle modifications
Stress, especially chronic stress, puts a massive burden on the body by activating the sympathetic nervous system and getting us into the fight-or-flight response. Getting stuck in the fight-or-flight response shuts down digestion and the immune system, among other organs' functions. Healing the body is only possible when you are in the rest-and-digest response when the parasympathetic nervous system is activated.
Flare-ups usually happen when somebody goes through a stressful period. Managing stress & shifting the mindset should be crucial elements in achieving optimal wellness.
According to studies, applying relaxation or stress management techniques can improve the quality of IBD patients' lives and reduce inflammation, anxiety, and pain. (24)
Some of these techniques involve:
- Meditation
- Breathing techniques
- Gentle exercises, yoga, tai chi
- Aromatherapy
- Music or art therapy
- Massage
- Biofeedback therapy
3. Supporting the gut with specific supplements
- High-potency probiotics – different strains were found to be effective in the active phase of IBD and the maintenance of the remission phase. (25)
- Saccharomyces boulardii, which is a beneficial yeast, showed a decrease in symptoms. (26)
- Omega-3 fatty acids coming from sources such as fish oils were found to reduce inflammation effectively. (27)
- Vitamin D – In IBD, low vitamin D levels were associated with increased inflammation (higher fecal calprotectin and higher CRP levels), flare-ups, and medical treatment. (28)(29)
- Curcumin is a potent antioxidant and has anti-inflammatory properties that can be found in turmeric roots. Curcumin used at a high dosage (3g/day) in Ulcerative Colitis patients with mild/moderate disease activity was shown to reduce inflammation and achieve remission. (30)
Conclusion
Many IBD patients may suffer from symptoms similar to IBS. Studies showed that SIBO (Small Intestinal Bacterial Overgrowth) is more common among people with IBD than the general population due to the compromised protective mechanisms.
It is essential to determine whether SIBO contributes to the severity of the symptoms by requesting a lactulose breath test.
A variety of diets can assist IBD patients in controlling their digestive symptoms. SCD or low-FODMAP are among the most popular diets. However, these dietary approaches might not be suitable for everyone with inflammatory bowel disease. Unique health history, intolerances, and sensitivities need to be considered to find the best-customized diet plan.
IBD symptoms can also be reduced with the right lifestyle changes and supplements.
*This post is only for informational purposes and is not meant to diagnose, treat or cure any disease. I recommend consulting with your healthcare practitioner always before trying any treatment or dietary changes.
Perler, B. K., Ungaro, R., Baird, G., Mallette, M., Bright, R., Shah, S., Shapiro, J., & Sands, B. E. (2019). Presenting symptoms in inflammatory bowel disease: descriptive analysis of a community-based inception cohort. BMC gastroenterology, 19(1), 47. https://doi.org/10.1186/s12876-019-0963-7
Ng SC, Shi HY, Hamidi N, Underwood FE, Tang W, Benchimol EI, et al. Worldwide incidence and prevalence of inflammatory bowel disease in the 21st century: a systematic review of population-based studies. Lancet. 2018;390(10114):2769-78.
Ranasinghe, I. R., & Hsu, R. (2021). Crohn Disease. In StatPearls. StatPearls Publishing.
Shah A .(2019), et al. Aliment Pharmacol Thera; Small intestine bacterial overgrowth prevalence drastically higher in patients with IBD. Helalio Gastroenterology. doi:10.1111/apt.15133. https://www.healio.com/news/gastroenterology/20190215/small-intestine-bacterial-overgrowth-prevalence-drastically-higher-in-patients-with-ibd
Bures, J., Cyrany, J., Kohoutova, D., Förstl, M., Rejchrt, S., Kvetina, J., Vorisek, V., & Kopacova, M. (2010). Small intestinal bacterial overgrowth syndrome. World journal of gastroenterology, 16(24), 2978–2990. https://doi.org/10.3748/wjg.v16.i24.2978
Deloose, E., & Tack, J. (2016). Redefining the functional roles of the gastrointestinal migrating motor complex and motilin in small bacterial overgrowth and hunger signaling. American journal of physiology. Gastrointestinal and liver physiology, 310(4), G228–G233. https://doi.org/10.1152/ajpgi.00212.2015
Miller, L. S., Vegesna, A. K., Sampath, A. M., Prabhu, S., Kotapati, S. K., & Makipour, K. (2012). Ileocecal valve dysfunction in small intestinal bacterial overgrowth: a pilot study. World journal of gastroenterology, 18(46), 6801–6808. https://doi.org/10.3748/wjg.v18.i46.6801
Abdul Rani R, Raja Ali RA, Lee YY. Irritable bowel syndrome and inflammatory bowel disease overlap syndrome: pieces of the puzzle are falling into place. Intest Res. 2016;14(4):297-304.
Shah A, Morrison M, Burger D, Martin N, Rich J, Jones M, et al. Systematic review with meta-analysis: the prevalence of small intestinal bacterial overgrowth in inflammatory bowel disease. Aliment Pharmacol Ther. 2019;49(6):624-35.
Ranasinghe, I. R., & Hsu, R. (2021). Crohn Disease. In StatPearls. StatPearls Publishing.
Kakodkar, S., & Mutlu, E. A. (2017). Diet as a Therapeutic Option for Adult Inflammatory Bowel Disease. Gastroenterology clinics of North America, 46(4), 745–767. https://doi.org/10.1016/j.gtc.2017.08.016
Gearry, R. B., Irving, P. M., Barrett, J. S., Nathan, D. M., Shepherd, S. J., & Gibson, P. R. (2009). Reduction of dietary poorly absorbed short-chain carbohydrates (FODMAPs) improves abdominal symptoms in patients with inflammatory bowel disease-a pilot study. Journal of Crohn's & colitis, 3(1), 8–14. https://doi.org/10.1016/j.crohns.2008.09.004
Barrett, J. S., & Gibson, P. R. (2012). Fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) and nonallergic food intolerance: FODMAPs or food chemicals?. Therapeutic advances in gastroenterology, 5(4), 261–268. https://doi.org/10.1177/1756283X11436241
Halmos, E. P., Power, V. A., Shepherd, S. J., Gibson, P. R., & Muir, J. G. (2014). A diet low in FODMAPs reduces symptoms of irritable bowel syndrome. Gastroenterology, 146(1), 67–75.e5. https://doi.org/10.1053/j.gastro.2013.09.046
Zhan, Y. L., Zhan, Y. A., & Dai, S. X. (2018). Is a low FODMAP diet beneficial for patients with inflammatory bowel disease? A meta-analysis and systematic review. Clinical nutrition (Edinburgh, Scotland), 37(1), 123–129. https://doi.org/10.1016/j.clnu.2017.05.019
Suskind, D. L., Lee, D., Kim, Y. M., Wahbeh, G., Singh, N., Braly, K., Nuding, M., Nicora, C. D., Purvine, S. O., Lipton, M. S., Jansson, J. K., & Nelson, W. C. (2020). The Specific Carbohydrate Diet and Diet Modification as Induction Therapy for Pediatric Crohn's Disease: A Randomized Diet Controlled Trial. Nutrients, 12(12), 3749. https://doi.org/10.3390/nu12123749
Damas, O. M., Garces, L., & Abreu, M. T. (2019). Diet as Adjunctive Treatment for Inflammatory Bowel Disease: Review and Update of the Latest Literature. Current treatment options in gastroenterology, 17(2), 313–325. https://doi.org/10.1007/s11938-019-00231-8
Gottschall E. Breaking the Vicious Cycle. Baltimore, Ontario: The Kirkton Press; 2012.
Eadala, P., Matthews, S. B., Waud, J. P., Green, J. T., & Campbell, A. K. (2011). Association of lactose sensitivity with inflammatory bowel disease--demonstrated by analysis of genetic polymorphism, breath gases and symptoms. Alimentary pharmacology & therapeutics, 34(7), 735–746. https://doi.org/10.1111/j.1365-2036.2011.04799.x
Berni Canani, R., Terrin, G., Borrelli, O., Romano, M. T., Manguso, F., Coruzzo, A., D'Armiento, F., Romeo, E. F., & Cucchiara, S. (2006). Short- and long-term therapeutic efficacy of nutritional therapy and corticosteroids in paediatric Crohn's disease. Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver, 38(6), 381–387. https://doi.org/10.1016/j.dld.2005.10.005
Borrelli, O., Cordischi, L., Cirulli, M., Paganelli, M., Labalestra, V., Uccini, S., Russo, P. M., & Cucchiara, S. (2006). Polymeric diet alone versus corticosteroids in the treatment of active pediatric Crohn's disease: a randomized controlled open-label trial. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association, 4(6), 744–753. https://doi.org/10.1016/j.cgh.2006.03.010
Pimentel, M., Constantino, T., Kong, Y., Bajwa, M., Rezaei, A., & Park, S. (2004). A 14-day elemental diet is highly effective in normalizing the lactulose breath test. Digestive diseases and sciences, 49(1), 73–77. https://doi.org/10.1023/b:ddas.0000011605.43979.e1
Olaussen, R. W., Løvik, A., Tollefsen, S., Andresen, P. A., Vatn, M. H., De Lange, T., Bratlie, J., Brandtzaeg, P., Farstad, I. N., & Lundin, K. E. (2005). Effect of elemental diet on mucosal immunopathology and clinical symptoms in type 1 refractory celiac disease. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association, 3(9), 875–885. https://doi.org/10.1016/s1542-3565(05)00295-8
Gerbarg, P. L., Jacob, V. E., Stevens, L., Bosworth, B. P., Chabouni, F., DeFilippis, E. M., Warren, R., Trivellas, M., Patel, P. V., Webb, C. D., Harbus, M. D., Christos, P. J., Brown, R. P., & Scherl, E. J. (2015). The Effect of Breathing, Movement, and Meditation on Psychological and Physical Symptoms and Inflammatory Biomarkers in Inflammatory Bowel Disease: A Randomized Controlled Trial. Inflammatory bowel diseases, 21(12), 2886–2896. https://doi.org/10.1097/MIB.0000000000000568
Pabón-Carrasco, M., Ramirez-Baena, L., Vilar-Palomo, S., Castro-Méndez, A., Martos-García, R., & Rodríguez-Gallego, I. (2020). Probiotics as a Coadjuvant Factor in Active or Quiescent Inflammatory Bowel Disease of Adults-A Meta-Analytical Study. Nutrients, 12(9), 2628. https://doi.org/10.3390/nu12092628
Avalueva, E. B., Uspenskiĭ, I., Tkachenko, E. I., & Sitkin, S. I. (2010). Eksperimental'naia i klinicheskaia gastroenterologiia = Experimental & clinical gastroenterology, (7), 103–111.
Calder P. C. (2015). Marine omega-3 fatty acids and inflammatory processes: Effects, mechanisms and clinical relevance. Biochimica et biophysica acta, 1851(4), 469–484. https://doi.org/10.1016/j.bbalip.2014.08.010
López-Muñoz, P., Beltrán, B., Sáez-González, E., Alba, A., Nos, P., & Iborra, M. (2019). Influence of Vitamin D Deficiency on Inflammatory Markers and Clinical Disease Activity in IBD Patients. Nutrients, 11(5), 1059. https://doi.org/10.3390/nu11051059
Jadhav, P., Jiang, Y., Jarr, K., Layton, C., Ashouri, J. F., & Sinha, S. R. (2020). Efficacy of Dietary Supplements in Inflammatory Bowel Disease and Related Autoimmune Diseases. Nutrients, 12(7), 2156. https://doi.org/10.3390/nu12072156
Lang, A., Salomon, N., Wu, J. C., Kopylov, U., Lahat, A., Har-Noy, O., Ching, J. Y., Cheong, P. K., Avidan, B., Gamus, D., Kaimakliotis, I., Eliakim, R., Ng, S. C., & Ben-Horin, S. (2015). Curcumin in Combination With Mesalamine Induces Remission in Patients With Mild-to-Moderate Ulcerative Colitis in a Randomized Controlled Trial. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association, 13(8), 1444–9.e1. https://doi.org/10.1016/j.cgh.2015.02.019
Alexandra is a Functional Medicine Certified Health Coach & Holistic Nutritionist specializing in IBS, SIBO, and Gut Health. She helps her clients identify the root causes of their chronic gut issues with functional testing, supporting their bodies holistically and implementing the necessary lifestyle changes long-term to regain control of their bodies and enjoy food freedom. Book your FREE SIBO Assessment call now >>>