Chloe Adams, a low FODMAP specialised dietitian from England, explains the relationship between SIBO (Small Intestinal Bacterial Overgrowth) and IBS symptoms.
In this episode, you’ll learn:
- How did Chloe come across the low FODMAP diet?
- What exactly is SIBO and what is its link to IBS?
- Do SIBO and IBS have similar symptoms and does IBS cause SIBO or vice versa?
- How is SIBO diagnosed and is there a cure?
- How does the low FODMAP diet help those with SIBO and how does Chloe use it to treat her patients?
- How and when are probiotics best used to treat IBS and SIBO?
- Why is it essential to use a high-fibre diet in tandem with a low FODMAP diet for IBS-C sufferers?
- Does the low FODMAP diet benefit those who suffer from IBS-C?
- Why does Chloe recommend linseed?
- What to watch out for in gluten free bread
LISTEN OR DOWNLOAD THE LOW FODMAP DIET & IBS PODCAST EPISODE 34 HERE
Can’t listen to this episode right now? Read the transcript below!
My guest, Chloe Adams, is a gastroenterology dietitian from the UK, who has post graduate training in medical conditions affecting the digestive system and accredited training in the delivery of the Low FODMAP Diet at King’s College London.
Chloe loves being able to have such a positive impact on people’s lives and she is very passionate about her job. Something else that Chloe enjoys very much is preparing tasty foods that are also healthy and friendly for our digestive system. This is why she has created a blog called “Tummy Love” where she shares recipes suitable for digestive issues, reviews suitable products, as well as sharing evidence-based information and advice aimed on improving digestive comfort through lifestyle change.
So, here she is.
LARAH: Hi Chloe. How are you?
CHLOE: Hi, Larah. I’m really well. How are you?
LARAH: Very well as well. It’s early in the morning here, but that’s a perfect time to record. There are no noises outside and no planes flying through so I thank you so much for taking the time to be on the podcast.
CHLOE: An absolute pleasure.
LARAH: Okay, so let’s start. First of all, would you be able to tell the listeners a little bit more about yourself and how you came across the low FODMAP diet?
CHLOE: So first a little bit about me. Well I have worked for The National Health Service in Birmingham in the UK for 7 years now.
After putting forwards a bit of a case to my department to develop a new community gastro service, I was appointed to role of Community Gastroenterology Dietitian; this was around 3 years ago. This is kind of a fairly relatively new dietetic role in the UK.
I first found out about the low FODMAP diet in 2012 when I attended a study day on IBS. This was just after the first couple of research papers were published on the diet by Shepherd et al., demonstrating such clinical effectiveness.It instantly sparked my interest.
I was lucky enough to get booked onto one of the very first courses King’s College London ran in the UK for training on the low FODMAP diet. I have since been specialising in the area and now have a great deal of experience in using this, with a diverse range of clients for a range of conditions associated with functional symptoms. I’m really, really enjoying kind of noting the effectiveness of the diet and what a real impact it can have on someone’s life.
LARAH: Thank you, Chloe, for sharing that with us. You started quite early in the UK, back in 2012 at the beginning of the research at King’s College in London. That’s great!
Another question I wanted to ask you because it comes up quite a lot on Facebook groups and also from my readers on the website. I get asked this a few times so I wanted to talk to you about SIBO (small intestinal bacterial overgrowth) because it seems to come up a lot in the context of IBS. So first of all, could you explain what SIBO is?
CHLOE: SIBO and the link with IBS is ever so interesting. SIBO, as you know stands for small intestinal bacterial overgrowth. Essentially, it is what it says on the tin. The small intestine is the part of the digestive system that connects the stomach to the large bowel. There are good bacteria present in the whole of the digestive tract, though usually the bacteria are in much higher in concentration in the large bowel. Also, the types of bacteria differ between the small and the large intestine. SIBO is when the bacteria multiply more rapidly in the small intestine, and particularly with the types of bacteria that are normally found in the large intestine.
LARAH: Okay. You know, when we talk about good bacteria in our gut, there are bad bacteria? So is SIBO the bad bacteria?
CHLOE: I wouldn’t necessarily say that’s the bad bacteria. It’s just too much of the good bacteria and bacteria that you normally associate with the colon being multiplied more rapidly in the small intestine.
LARAH: Yeah, that’s great. That makes sense. Thank you, Chloe.
When we hear about SIBO in the context of IBS, is it because they have similar symptoms? And, also, another question I see quite often, is if IBS can cause SIBO or vice versa and could you please go into detail about that?
CHLOE: SIBO and IBS do in fact have very similar symptoms. Both conditions share the symptoms of tummy pain, discomfort and bloating, excess wind and diarrhoea or constipation. In the UK, the way IBS is diagnosed is by, first of all, ruling out Coeliac Disease and inflammatory bowel disorder, and if a combination of these symptoms are present, the diagnosis of IBS is made. This is what the National Institute of Health Care and Clinical Excellence outlines in the guideline for assessment and management of IBS.
IBS does not cause SIBO, however SIBO can be a cause of, or worsen symptoms of IBS. First I’ll explain a little bit about IBS. In a nutshell, this is an increased sensitivity of the lower bowel. If gas production within the small intestine is so great as a consequence of bacterial overgrowth, this will create a pressure build up in the GI tract. This pressure build up will then press against the more sensitive large bowel and worsen symptoms of pain, bloating and wind.
SIBO can be caused by neuromuscular damage which slows the movement of food and bacteria through the small intestine. This could be as a result of diabetes in some. Partial obstruction in the small intestine can also cause SIBO, as this can also interfere with the transport of food. For example, this could be due to adhesion due to Crohn’s or following bowel surgery. Another potential cause of SIBO is diverticular of the small intestine, which is when food can get caught and that can affect kind of the way that gut bacteria reproduce.
The way SIBO differs from IBS is that SIBO can actually affect the absorption of micronutrients. In advanced cases the bacteria can compete with the food we eat. This can lead to associated symptoms of tiredness, and in extreme cases, weight loss. IBS is simply, as I described, a hypersensitivity. So, here, there is no risk of malabsorption for those with IBS.
A portion of those diagnosed with IBS, will in fact have SIBO, however often, will not get diagnosed formally. There are similarities in treatment for IBS and SIBO, so often the formal diagnosis is not always necessary. If you are diagnosed with IBS, as long as you receive appropriate diet and lifestyle support, you will receive the care you require to treat SIBO, if it is a contributing factor.
LARAH: Okay, that’s interesting. It means that once you are under the supervised care of a specialised dietitian, and when she’s looking at your diet and lifestyle and everything at the same time as treating your IBS, for example, with the low FODMAP diet, that will also improve the SIBO if you have one.
CHLOE: Absolutely. I’ll talk about that in a little more detail in a minute.
LARAH: How can SIBO be diagnosed?
CHLOE: SIBO is commonly diagnosed using a hydrogen breath test. First, to explain a bit of background for us to understand how the test works as the test can be completed using either a small drink of lactulose or a small drink of glucose. So let’s do the science first.
Lactulose is a sugar, which is only digested by bacteria in the large bowel. When this sugar is broken down, hydrogen and methane are released. These gases are then used up by other bacteria in the large bowel. Usually, only very small amounts of these gases move through the lining of the intestine into the bloodstream. Those who have SIBO will release increased levels of hydrogen and methane into the bloodstream. This is because in the small intestine, there aren’t those other colonic bacteria to use these gases that are produced.
So then we go to glucose. Glucose is a sugar which is usually digested and absorbed in the small intestine causing no production of gas. If there is colonic bacteria present in the small intestine, the bacteria will produce gas from the glucose which will be released into the bloodstream.
This is the premise for the breath test. The test involves fasting for 12 hours, then drinking a lactulose or glucose solution. Thereafter, the breath is tested every 15 minutes for 3 or more hours. The breath tests will be analysed for methane and hydrogen. This is how the breath test can identify SIBO.
LARAH: Okay, yeah, that’s interesting. That’s very similar to how the fructose and the lactose malabsorption breath test works. I remember being there for like hours — life 4 or 5 hours and every 15 minutes putting on the alarm.
Okay, so there is a way to diagnose SIBO if people want to. Is there a cure or a treatment for SIBO?
CHLOE: Traditionally SIBO is treated with antibiotics or probiotics. Antibiotics are used to treat infection caused by bacteria in the body. Probiotics are high doses of good bacteria which can be taken to improve the bacteria balance in the bowel. This is why some with IBS will experience an improvement in symptoms after taking antibiotics or probiotics. In those where this happens, it is likely they may be experiencing SIBO as part of their IBS.
In fact, there is only limited evidence for the use of both antibiotics and probiotics in the treatment of SIBO. Often, they are prescribed in short courses, however, recurrence of the SIBO is often happens once the treatment has stopped. There are also risks associated with taking multiple courses of antibiotics. For example, it can increase the risk of developing strains of bacteria resistant to antibiotic treatment.
More recently, through clinical practice, it has been identified the low FODMAP Diet can be used to treat SIBO. However, much more research is needed in this area to understand this mechanism more clearly and for this to be written into national clinical guidelines. Like antibiotics and probiotics, the evidence for these is still small at the moment.
The reason the Low FODMAP diet works to treat SIBO is because FODMAPs are the food of lower intestinal bacteria. So when an individual follows the low FODMAP diet, essentially, they starve the overgrown bacteria in the small intestine causing them to die off. I have used the Low FODMAP Diet in many clients with suspected or diagnosed SIBO now with a really good success rate, which is promising. It is for this reason I choose to use the diet in practice to treat SIBO, because the low FODMAP diet, as we know, is well structured and actually promotes a healthy, well-balanced way of eating. We’re not cutting out any particular food groups because potentially it can work. And for that reason, I just think why not? We might as well give it a go and seemingly, it seems to be working, which is good.
I sometimes combine the low FODMAP diet with the use of a probiotic in cases where prolonged use of the diet might be required. This is to maintain the adequate levels of colonic bacteria in the large intestine, because when starving the colonic bacteria in the small intestine, we don’t want to also starve the large intestine of good bacteria. That’s why the probiotic can be useful in those cases. Again, there’s limited evidence in this area at the moment, but this is something we are noticing is starting to work through clinical practice.
LARAH: Thank you, Chloe, for that. And regarding probiotics, I heard from a few different dietitians that do not recommend that during the elimination phase just to make sure that it is the diet and not the probiotic that is making the person feel better and improve their symptoms. Do you do that as well? Is it something you agree with?
CHLOE: Yes. I do it in kind of a step approach so it makes sure the elimination phase is done initially so you see progress with that. And then, if there are still some lingering symptoms, I’ll then do a trial run of the low FODMAP diet with the 4 short weeks on the probiotic as well, to notice any further improvement. As we know with IBS, it’s really important to change only one thing at a time, so we can work out exactly what is working and what’s not working.
LARAH: Yeah, perfect. Thank you for all the information on SIBO. I think it has made it a lot clearer for me and hopefully for the listeners as well.
Now I have another question that I see asked rather a lot. It’s regarding IBS with constipation, so IBS-C. it seems that people that are suffering predominantly from an IBS with constipation, don’t seem to benefit as much from the low FODMAP diet compared to people like me who are suffering from IBS-D. From your knowledge and experience, is that a correct statement, and if yes, why?
CHLOE: Yes, that’s right. FODMAPs have an osmotic effect on the bowel. What I mean by this is FODMAPs cause water to get drawn back into the lower bowel, and it is this what worsens the symptom of diarrhoea in those with IBS-D. This is why the low FODMAP diet works successfully for this IBS sub-type.
For those with IBS-C, withdrawing FODMAPs from the diet could potentially worsen the constipation, as the osmotic draw can be useful. For those who experience IBS-C, often the pain, bloating and wind can simply be a consequence of the stool sitting in the lower bowel causing discomfort. For those with constipation, it is always important to first focus on increasing dietary fibre and fluid. Introducing whole grains will add to stool bulk, as whole grains are high in insoluble fibre. It is this that helps to push the stool through the large bowel.
Eating your 5-a-day will increase the soluble fibre you consume. This fibre helps to wash the stool through the large bowel. One portion of fruit and vegetables is about the equivalent of 1 handful (80g). Dietary fibre works most efficiently when you consume plenty of fluid and it is recommended to consume 1.5 to 2 litres of fluid a day to help with this. So it’s the insoluble fibre that helps to push everything through. The soluble fibre helps to wash everything through, and it’s the fluid that will help the fibre to work its best.
In some cases this won’t be sufficient in treating IBS-C entirely. So through clinical practice and experience I have found the low FODMAP diet can be used to target abdominal pain, wind, and bloating in this IBS sub-type. However, it is essential to maintain a high-fibre diet in addition to the low FODMAP diet through the duration. Quite often, as well as recommending 5-a-day and 2 litres of fluid, I will recommend the use of linseed. Linseed are potent little seeds packed full of both soluble and insoluble fibre. This can help provide an additional fibre boost to improve gut motility and ease constipation in addition to reducing the pressure build up in the lower bowel to treat the pain, bloating and wind.
LARAH: Okay. That’s interesting regarding the linseed. What about other seeds like chia seeds? Would those work as well or are linseed best?
CHLOE: Chia seeds, and all seeds, actually, include a lot of insoluble fibre. There’s no reason why they might not be able to help. The reason why I recommend linseed is that it is what’s written into the British Dietetic Association Gastroenterology Specialist Group Guidelines, as a useful remedy. However, it is still limited, but there is some evidence there and that’s why I tend to recommend the linseed over the use of other seeds.
LARAH: Okay. And the linseed, should they be ground, or just the whole seed?
CHLOE: It doesn’t particularly matter. So, it’s completely up to the individual and their taste and textural preference and how they’re going to use it, to be honest. They could either stir them into porridge, so that could work with either the whole seeds or the ground up seeds. You can stir them into yoghurts and sprinkle them over salads. The whole ones would work better there. Sometimes, stirring them into cooked dishes in things like bolognese or chili or curry. And sometimes the ground ones work better there. It completely depends on how they’re going to be using it. I’d only recommend 1 tablespoon a day, but they can increase up to 2 tablespoons if they require a little bit more fibre.
LARAH: Okay, yeah, understood. Would that work as well…? For instance, I am IBS-D, but I don’t often get the symptoms because I consume about 80 or 85 percent low FODMAP. So a modified low FODMAP diet which helps me to manage the symptoms quite nicely. I tend to get constipated at times. Would that work even for people who have IBS-D, but then eliminating those FODMAPs that tend to get constipated a bit. Would the linseed work as well — the soluble and insoluble fibre intake?
CHLOE: Potentially. There would be no harm in giving it a go. It can be used for those getting alternating IBS. During those times when they are getting constipated, their fibre requirement may be a little bit higher. It could be used for those occasions, but when you take it, just make sure you take plenty of fluid on board because the fluids help the fibres work. If you suddenly increase your fibre without increasing the fluid, it could make the constipation worse.
LARAH: Yes, perfect, understood. Thank you, Chloe.
Something else that comes up a lot from people starting the low FODMAP diet is about the food that they need to give up, at least temporarily; and inevitably, amongst the food that we need to eliminate during the first phase of the low FODMAP diet is bread. For me, it was a big shock when I saw the list of things I couldn’t eat including pasta and bread. Being Italian, I ate a bit of that.
Bread is such a staple food, and some people find this quite hard. Thankfully we know that there are some breads that are suitable for IBS sufferers, even on the elimination phase, but there are also some other issues and not necessarily are the gluten-free breads also low FODMAP. Could you please explain about what it is in breads that we need to look for, when choosing a suitable bread — one that’s not going to give us IBS symptoms?
First of all, I’ll explain how a grain of wheat, rye or barley is made up. Grains of such are made up of 2 components – the protein which is the gluten, and the carbohydrate which is the fructan, so the FODMAP. Gluten is what is involved in the autoimmune disease Coeliac Disease and non-coeliac gluten sensitivity presenting with neurological symptoms. Gluten is not involved in IBS. Fructans are involved in IBS and functional symptoms, so this is the bit that we want to be focusing on.
Fructans are short chains of fructose which are poorly absorbed in most people. It is for this reason those without IBS often do better with less wheat in their diet. Research suggests fructans are the FODMAP most commonly associated with bloating, and many individuals without IBS report improved digestive comfort when they reduce wheat in their diet. Something to bear in mind when you’re looking at your bread is that with some gluten-free breads, they are specifically designed for those who are only required to avoid gluten, so for example, Coeliac Disease. The wheat grain is processed to remove the gluten, but the remaining part of the grain – the carbohydrate and fructan — is still used to produce the bread. This sort of modified grain of wheat is called codex wheat starch.
For this reason, when you are hunting for a bread to use for the low FODMAP diet, you need to make sure it is wheat-free as well as gluten-free! However, the Low FODMAP Diet is not gluten-free. So, for example, if you pick up a packet of crisps or a soup and it says “may contain gluten”, that is okay on the Low FODMAP Diet. The low FODMAP Diet you’re avoiding the wheat; you’re avoiding the fructan. Gluten is something quite separate. The low FODMAP diet is actually far less restrictive than a gluten-free lifestyle, and I think it’s really important that we remember this.
Another thing we want to be looking for when we look at labels of different breads is if there are any added FODMAPs. Sometimes there can be added fructans that could be in the form of FOS or inulin. Sometimes apple fibre can be used to produce breads as well, so keep your eyes out for these things as well and make sure that the bread you’re choosing is wheat-free.
All wheat-free breads taste very different. I say this to everyone – if you don’t like the first loaf you try, please don’t tarnish all wheat-free breads with the same brush. It is really important to do your research and try different shops and different brands. It can be pretty heartbreaking when you spend over £2 on a loaf of bread and you don’t like it – though if you put the hard work in at the beginning and you find a loaf of bread you enjoy, you are then set up for the low FODMAP diet and lifestyle and it will be more realistic for you to maintain, and therefore, it will be more successful for you. This is something I really promote to people and explain that there is potential and once they do their reintroduction, they may identify that it’s going to do them better to be very low in wheat for the long term, so it’s really good to be looking for your plan B as part of your step 1.
LARAH: Okay. So you mean that after the elimination phase and they try to reintroduce a slice of bread, should they try to reintroduce it or should they not bother with that and continue to get low FODMAP bread?
CHLOE: Once you’ve done your elimination phase of the diet — whether that’s 4 weeks or 6 weeks or 8 weeks — it will be slightly different depending on which dietitian you might see. Once you’ve done the elimination phase, you’ll be popping back to your dietitian. They’ll talk you through how to do the reintroduction phase of the diet. The reintroduction is really important because this is when you identify your true sensitivities. When you do this, it’s a very step-by-step process and a part of that will be reintroducing wheat back into your diet. If, at this point, you’ve identified that you do have a really high sensitivity to wheat and it’s going to do you better to keep it out for the long term, you’re really gonna want to have a backup plan and know the sort of wheat-free bread that you enjoy so you can continue to use this for the long term to improve your symptom control.
LARAH: Yeah, got it, understood. I know that Monash University has tested some bread, especially in Australia, so we do have a few brands that are specifically low FODMAP brands. Alpine Breads in Australia provides low FODMAP breads. I think, in time, those will be seen appearing everywhere in the world or there will be a specific low FODMAP identification on it.
CHLOE: Yes, that will be exciting when it comes to the UK. I think it’s great that Australia is doing that already. Yeah, you’re right. I’m sure FODMAPs will go mad and it will move over to the UK and the rest of the world at some point. When you’ve got that branding and that labelling, it just makes things that much clearer and easier for people when they’re doing shopping.
LARAH: Yes, absolutely. And straight away, you can identify them. There are a couple of certifications; there is the Monash University certification and one is the FODMAP Friendly certification, and straight away, you can see from the logo and know that the product is safe during the elimination phase, so that’s great.
CHLOE: Yeah, nice and easy. Over here in the UK, we still have to read all the ingredients and be careful, so, yeah, that would be great if it comes over here.
LARAH: All right, great, Chloe. That was a lot of really great information and you answered a lot of questions that I get from people. Obviously, I’m not a health professional so I leave those questions for you guys to answer, so thank you for that and explaining it all very well.
LARAH: Is there anything else that we haven’t discussed that you would like to share?
CHLOE: I would say that if you have any extra questions you’d like to ask, I’d be happy to answer them for you.
LARAH: Perfect. So on that note, how can people find you and contact you through your website and social media so I can put down the links?
CHLOE: If you would like to check out my blog, it’s Chloe’s Tummy Love. You can follow me on Twitter, Facebook and Instagram. I don’t have a link in my blog where you can do mail, but I post content on different social media to stay up to date with tummy love content.
I am also freelancing in the Midlands, so if people live in the Midlands in the UK and would like to access my support, click through to my freelance website on the “about” page on my Tummy Love blog.
LARAH: Okay, great! In freelancing, do you mean providing dietary advice or is it something different?
CHLOE: Yes, I’m providing dietetic advice, but outside of the NHS. Private work.
LARAH: And do you do that one-to-one or also by Skype?
CHLOE: At the moment, I’m doing one-to-one and I’m doing that through home visits. I do intend to start using Skype and I’ll update my website when that’s all up and running.
LARAH: Sounds good. Well, I just want to say a big thank again for taking the time to be on the podcast and answering all these important questions. It’s been a pleasure to have you, Chloe.
CHLOE: Thank you very much for asking me. It’s been great.
LARAH: All right. Thank you so much.
Thank you for listening to this episode with Dietitian Chloe Adams from England. I hope that this interview helped you to understand a bit more about SIBO, as this condition is affecting a lot of people, including IBS sufferers.
We also talked about bread and how to find a suitable low FODMAP bread, and also what to watch out for in gluten-free bread and how it may not be necessarily low FODMAP.
To finish, I just want to mention that for those listeners who are participating in the low FODMAP Smoothie Challenge that my friend Clare and I have created, I just wanted to say well done so far. We’re almost at the end of the challenge. You are doing a lot of good to your body by consuming those healthy low FODMAP smoothies.
If you would like to join the next challenge, you can subscribe for free on the challenge page on my website.
Until next time, I wish you good health and happiness. Lots of love from me and goodbye.
Links and resources mentioned in this episode: