Chris Kresser: I recommended using partially hydrolyzed guar gum during an antimicrobial protocol to make it more effective, and this was based on research, a study that I linked to, showing that the efficacy of rifaximin improved considerably when partially hydrolyzed guar gum was included in the protocol, and it was based on the principle in microbiology that you have to feed them to kill them, where if you go on an extremely low-fiber diet during treatment, then the organisms can go into a dormant state and it might make them more difficult to kill. Then later in the training, I think this week, in the prebiotic and probiotic section, I said to avoid prebiotics during antimicrobial protocols for SIBO. That was a conflicting statement there, and I think what happened is I produced the content for this week earlier and at a time before we started using partially hydrolyzed guar gum and prebiotics during antimicrobial protocols, so that’s the source of the confusion.
I would say the jury is still out on this. We have the study on partially hydrolyzed guar gum, and it was pretty compelling. Then we have some clinical experience that backs this up, where patients who had taken rifaximin or done a botanical protocol while following an extremely strict low-FODMAP diet did not clear SIBO, and then they added partially hydrolyzed guar gum and maybe some of the FODMAPs that they could tolerate back in, and they did clear SIBO. I think there’s definitely something to this, but we don’t have studies on other prebiotics, so we don’t know for sure. Is there something unique to partially hydrolyzed guar gum that has this effect, or is it consistent with all different prebiotics? We need more research to clarify this, and so for now we’re being cautious and just recommending partially hydrolyzed guar gum during the treatment. It’s not because I know for certain that other prebiotics aren’t going to work and have the same effect. It’s just that we don’t have information one way or the other, and I just prefer to be conservative with this kind of thing until we learn more.
Generally we would advise patients to stay away from the full prebiotic rotation protocol that I’m talking about this week, where they’re taking all kinds of different resistant starch and non-starchy polysaccharides and different types of soluble fibers, because first of all, for a lot of patients with SIBO, it’s just going to make them extremely uncomfortable if they do that before the SIBO has been treated. And second of all, we don’t have any research suggesting what the effects of that might be.
I do want to clarify this because there’s been some good discussion on the Facebook group about it, as well, for those who aren’t on Facebook or have missed this. When I said that I don’t recommend a low-FODMAP diet during antimicrobial protocols, what I meant to say if I didn’t say this is I don’t recommend a strict low-FODMAP diet, where all FODMAPs are removed across the board, regardless of whether the patient reacts to them. What we would suggest to a patient is, “Look, if you know that you are really intolerant of onions and garlic, which a lot of people are, and you just don’t respond to those well at all, by all means, don’t eat those during the antimicrobial protocol because it’s just going to make you uncomfortable and those protocols can be uncomfortable enough as it is. But if you can tolerate some of the higher FODMAP fruits or other vegetables or the stuff in the yellow column, like the sweet potatoes or avocados or something like that, then I don’t really believe that there’s any reason to remove those during the antimicrobial protocol.” As I argued, there’s never been a study showing that that improves the efficacy of the protocols, and there’s some reason to believe that it might decrease the efficacy.