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How Stress Contributes to SIBO

on May 24, 2018

by Chris Kresser

Despite following aggressive antimicrobial treatment protocols and making dietary changes, many patients experience ongoing problems with SIBO. In fact, two-thirds of SIBO cases are chronic or relapsing in nature. (1) A growing body of research suggests that stress, trauma, and nervous system deregulation may be to blame for recalcitrant SIBO. Read on to learn about how stress contributes to SIBO and why managing stress is essential for restoring gut health over the long term.


I’ve talked a lot about the function of the HPA axis and its role in health and disease, but for those who are newer to this subject, let’s start with a review. The HPA axis is a dynamic system, comprising the hypothalamus, pituitary, and adrenal glands, that regulates the body’s response to stress. Stress activates the HPA axis and begins a cascade of signals that results in the release of hormones and neurotransmitters like cortisol, epinephrine, and norepinephrine. While the stress response is typically protective in the face of acute stress, it can become harmful over the long term. In fact, chronic activation of the HPA axis may play a crucial role in the development of SIBO because the stress response is closely linked to the gut microbiome.

Researchers have observed several interesting relationships between gut bacteria, stress, and the HPA axis. Gut bacteria can start a stress response by producing metabolites such as lipopolysaccharides (LPS), which provoke inflammation in the central nervous system. Gut microbes also produce hormones and neurotransmitters that are identical to those made in the human HPA axis and thus have the potential to alter HPA axis function. (2) On the flip side, hormones produced during times of stress adversely impact the composition of the gut microbiota and even enhance microbial growth and virulence.

Research suggests stress contributes to ongoing problems with SIBO and managing stress is essential for restoring gut health over the long-term.

Given the complicated relationship between stress and the gut microbiota, infection is only one piece of the SIBO treatment puzzle; chronic HPA axis activation and stress must also be addressed. Gut microbial imbalances and stress will tend to perpetuate each other in a vicious cycle, promoting recurrent SIBO, unless steps are taken to resolve both of these triggers. (3)

How does stress promote SIBO?

Stress and HPA axis dysfunction contribute to SIBO through several mechanisms, including the reduction of gastric acid production, impairment of GI motility and gut mucosal immunity, enhanced bacterial growth and virulence, and the formation of biofilm.

Stress reduces gastric acid production

Gastric acid produced in the stomach serves the important purpose of killing ingested bacteria before they can enter the small intestine. The HPA axis tightly controls gastric acid production. Stress, and subsequent HPA axis dysfunction, significantly inhibit gastric acid secretion. (4, 5) In hunter–gatherer times, this adaptation would have been beneficial; if you were under acute stress being chased by a lion on the African savanna, you wouldn’t want your body to waste precious energy making gastric acid. However, in our modern-day world characterized by 24/7 stress, lowered gastric acid production may become a chronic condition. A chronic insufficiency of gastric acid allows a larger quantity of ingested bacteria to pass through the stomach unchallenged and enter the small intestine, where they can proliferate. Over time, too much bacteria entering the small intestine may promote the development of SIBO.

Stress impairs GI motility

The migrating motor complex (MMC), a pattern of electromechanical activity that sweeps through the intestine during periods between meals, regulates the movement of food through the GI tract. An absent or impaired MMC promotes the development of SIBO by causing food to stagnate in the small intestine, where it creates a breeding ground for bacterial overgrowth. Stress directly inhibits the migrating motor complex. (6) The relationship between stress, the MMC, and digestion was first observed in the early 19th century by William Beaumont, a former surgeon in the U.S. Army who later became known as the “Father of Gastric Physiology.” He noticed that “fear, anger, or whatever depresses or disturbs the nervous system” was associated with the suppression of GI motility and impaired digestion. (7) We now know that stress-induced inhibition of the MMC is mediated by corticotropin-releasing factor (CRF), a hormone central to the HPA axis. Once released by the hypothalamus, CRF binds to receptors in the brain, altering neurotransmission that governs the MMC. (8)

Stress also impairs GI motility by provoking blood sugar swings. High cortisol resulting from chronic stress causes blood sugar levels to fluctuate; these fluctuations promote frequent hunger and snacking throughout the day. Constant eating reduces the amount of time between meals, the period during which the MMC is most active, thus impairing gastrointestinal motility.

Stress reduces gut mucosal immunity

Secretory IgA (sIgA) is an immunoglobulin that helps to maintain immune function on mucosal membranes, including those of the GI tract. Stress decreases sIgA, a situation that may increase the risk of bacterial overgrowth in the intestine. (9)

Stress enhances bacterial growth

Fascinatingly, stress hormones favor the growth of pathogenic bacteria. Catecholamines, which include epinephrine and norepinephrine, enhance bacterial attachment to host tissues and affect the growth and virulence of bacteria. (10) Stress also enhances general susceptibility to infection. (11) These findings represent another important link between stress and the risk of SIBO.

Stress may promote biofilm formation

Biofilm, a community of microorganisms that share nutrients and DNA and undergo changes to evade the immune system, plays an important role in gut infections such as SIBO. Biofilm protects bacteria from antimicrobial treatments, resulting in extremely stubborn infection. Interestingly, stress response mediators, including cortisol and catecholamines, promote biofilm formation by helping pathogenic bacteria access nutrients they need to survive. (12, 13, 14) This is just one more fascinating example of how stress supports the best interests of bacteria in our bodies while degrading our health.

Stress management in the treatment of SIBO

Stress management should be a significant part of any treatment plan for eradicating SIBO. The following list includes strategies that help normalize HPA axis activity and reduce stress, with the ultimate goal of restoring gut health.

Space meals apart and fast overnight. Fasting between meals activates the MMC, which needs to be functional to prevent and reverse SIBO. Encourage your patients to space their meals at least four to five hours apart to allow the MMC to kick in. Ideally, your patients should also fast for at least 12 hours overnight. Intermittent fasting, where the patient compresses food intake into an eight-hour window and fasts for 16 hours each day, can be even more effective.

Find ways to reduce stress every day. I have previously written about the importance of stress reduction in the context of our overall health here and here. Here are a few of my favorite tips for reducing stress that you can pass on to your clients and patients:

  • Learn to say “no.” Know and respect your limits and don’t take on more commitments than you can realistically handle.
  • Avoid stressful people. People who continuously stir up drama drain our stress reserves; limit your time with these individuals or avoid them entirely, if possible.
  • Turn off the news or limit your exposure to it. You can still be well-informed without continually feeding your brain stress-inducing information from the media.
  • Let go of pointless arguments. While discussion and debate have their place, engaging in arguments is also a massive tax on our time and energy. Many arguments only serve to entrench peoples’ worldviews further. Learn to let go and move on.
  • Edit your to-do list. Consider what tasks on your list are most important, and drop less important tasks to the bottom of the list.

Practice meditation or yoga and spend time in nature. These practices reduce HPA axis activation, helping to correct the adverse downstream effects of stress on GI motility, gastric acid secretion, gut mucosal immunity, and bacterial growth.

Measure and learn to regulate heart rate variability. Heart rate variability (HRV) is an objective indicator of the stress response. A high HRV is considered a good indicator of a balanced HPA axis. Your patients can measure their own HRV at home using systems such as Heartmath Inner Balance or BioForce HRV.

Consider methods of “neural retraining,” such as Dynamic Neural Retraining System, Gupta Amygdala Retraining, and Somatic Experiencing. These programs and approaches address deeply entrenched patterns in the brain and nervous system that may persist even after the initial trigger is no longer present, resulting in a more balanced HPA axis.

Try visceral manipulation or massage. Bodywork helps reduce stress and can even enhance GI motility.

Stimulate the migrating motor complex. The MMC needs to be in working order to treat SIBO successfully. Both pharmaceutical and over-the-counter options are available for stimulating the MMC. These include low-dose erythromycin, low-dose naltrexone, Iberogast, and MotilPro.

These treatments are powerful strategies for addressing stress as it relates to SIBO. When combined with antimicrobial treatments and dietary changes, these therapies have the potential to reverse stubborn cases of SIBO.

Now I want to hear from you. Do you feel that stress is an important factor contributing to SIBO amongst your patients? What strategies do you recommend to your patients to assist with stress reduction? Let me know in the comments below.

25 Comments

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  1. Hi Chris,
    All the talk of dysbiosis seems to be about SIBO. Is the problem always or mostly in the Small intestine and is it always or mostly bacteria as opposed to yeast? I’ve had two SIBO tests – both negative but definitely have classic IBS symptoms. Is treatment different if it’s yeast proliferation in the colon as opposed to SIFO or SIBO? Is dysbiosis just dysbiosis when it comes to treatment? Is the Candida diagnosis dead? Curious to know your thoughts.

    • Have you checked into any alternative SIBO testing? The most common gases they look for are hydrogen and methane, but hyrdogen sulfide can also be a be byproduct of the bacteria and SIBO indicator.

    • Hi William,
      I can’t speak for Chris, but for sure the problem could predominantly reside in the colon. At our clinic we use Doctor’s Data three day stool test to parse out the extent and type of dysbiosis. This also helps us determine which intervention is best suited for the microbial imbalance. Good luck.
      Brandon LaGreca, LAc

  2. I think a discussion about mthfr is also appropriate- how can you reduce stress if your methylation process isn’t functional?

  3. Yes, I believe stress has caused my SIBO. Two years ago I was diagnosed with a rare eye disease that causes central vision loss. I am in a study program at UCLA & so far my vision is good. This SIBO is killing me.

  4. Sublingual taking of thyroid hormone – both synthetic & desiccated – caused thrush in my mouth, so what’s it doing to my GI?

  5. I have had a lot of very stressful events in my life and am currently in the process of changing my diet completely due to serious IBS (explosive diarrhea several times every day). It is hard work, but I have achieved great results so far.

    I am so happy to have it acknowledged, that stress and trauma is not something you just “get over”, but that it can have serious physical consequences long term as well.

  6. I’ve been on the SIBO roller coaster for 6 years, treating and relapsing every time. I’ve been to a well known functional MD and another somewhat well known SIBO ND. I alternate the natural MMC supplements, take digestive enzymes with every meal, follow a comprehensive stress reduction program, have done Chris Shade’s mercury detox, and I still have problems! Is there anyone out there that can help?

  7. Hi Chris,
    Thank you for all your work. Would you still recommend a 4-5 hour window between meals for a hypoglycemic? And the 12 hours overnight as well?

  8. As a similar note, I see unresolved SIBO and really HPA metabolic syndrome often has a mechanical causation.
    Where cranial tortious create 27/7 compression on the pituitary hypothalamus and hiipocampus.
    I need to do a study of pre and post markers- as after rebala cling the cranium symptomolgy changes are phenomenal.

  9. No question. My stress which has been chronic, has caused, I am sure, Hashimotos. Stress affecting my bladder – infection- antibiotics- gastritis- Zantac ppi’s- all responsible. Allopathic treating symptoms rather than cause.

  10. Thank you! This makes me feel hopeful! I know I have gut issues that are helped with SIBO treatments but it’s always temporary. I literally decided a week ago to give up on finding the cause and just ‘pulse’ SIBO treatments. Now I’ll look for the root cause.

  11. Yes definitely. Acute stress, followed by chronic high stress that lasted over 12 months (as a result of a major life event ) resulted in a sudden but gradual growth in my stomach until I looked pregnant. I later was tested by a gastroenterologist and was found to have strong methane dominant SIBO. So I know stress was a strong causal factor for me. I’m not surprised therefore that it causes recurrence of SIBO!

  12. I have a similar question–does one need to test for SIBO vs other causes of IBS, and does one need to know if one’s HPA axis is out of whack? What I’m wondering is, what if someone had damage done, in childhood let’s say, that altered the gut microbiome, but since then this person was removed from the stressors that did the damage, and/or they learned to deal with the stressors in a way that did not further disrupt the gut microbiome, might their HPA axis be OK (perhaps they are asymptomatic for HPA axis dysregulation, too), but the gut microbiome be damaged from long ago, and still need attention? Forgive the length of my question; thanks.

  13. My client is responding to enzymatic therapy after not much improvement from anti-microbial’s, digestive enzymes, probiotics, leaky gut support. Doing stress reduction with walking, yoga, punching bag.

  14. Check for hypoxia, a lot of these people have sleep apnea and they need to be treated with CPAP or BiPAP. It’s a $37 test to do an overnight oxygen level.

  15. As a practitioner, and dealing with SIBO myself, I was trained to not recommend IF to those with blood sugar and adrenal dysregulation, because it can worsen these. Over 90% of those I test have both of these, and many have SIBO too. I occasionally have to fast when the SIBO worsens, but my blood sugar gets wonky often, so I feel caught in a viscous cycle.

    What do you recommend? When is the best time to introduce IF to clients? There have to be parameters and priorities for these common issues….

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