On the SIBO diet, patients feel immediate bloating, but now I understand that that the treatment is more effective if they eat fermentable foods. When you start patients on SIBO antimicrobial protocol, when do you expect symptoms of bloating to decrease or disappear? If they’re very uncomfortable, do you tell them to remove the fermentable foods?

Dr. Amy Nett:  I think by “SIBO diet” you just mean a standard Paleo diet where you’re not limiting FODMAPs. That’s how I’m interpreting this because I don’t know that we have a SIBO-specific diet, so I’m going to just interpret that as a standard Paleo diet with a variety of FODMAPs and resistant starch and you’re saying that it causes bloating in patients with SIBO. Yes, we use the FODMAPs, though, to make the bacteria metabolically active so that they’re more vulnerable. In terms of when the bloating in response to FODMAPs improves, that depends so much on what the patient’s response is to the treatment. If patients have really severe and uncomfortable bloating and abdominal distention or gas after eating those foods, what you can consider is have them start the herbal antimicrobial protocol and then I just tell them to add in the FODMAPs, the resistant starch, and the prebiotics to your tolerance. That’s going to look a little bit different for everyone, but if it’s too uncomfortable for them, have them start the GI-Synergy, Lauricidin, and then add the PHGG in. For some people, if it’s a really severe case of SIBO where you’re seeing methane up to 80 or 100, for some of my patients it’s a couple of months before they’re able to tolerate FODMAPs and certain fibers without uncomfortable bloating. So work with your patients, see what’s tolerable to them, and again, there’s kind of a general guideline and a theory on how you want to do this, but then you have to work with each body differently and see how people respond and tweak it for them.