Small intestinal bacterial overgrowth (SIBO) affects at least 39 million Americans and can bring about a range of uncomfortable digestive symptoms. The American College of Gastroenterology's (ACG) Clinical Guidelines for SIBO management suggest that dietary manipulation may be beneficial in managing SIBO. One such strategy is the SIBO Bi-Phasic Diet, a comprehensive and structured approach that combines food restriction with reintroduction. This article will delve into the fundamental principles, goals, and guidelines of the SIBO Bi-Phasic diet, helping to empower those with SIBO to navigate their journey to healthier digestion with dietary modifications.
Understanding SIBO
In a healthy state, the bacterial population in the small intestine should be small. SIBO, or small intestinal bacterial overgrowth, is the excessive growth of bacteria in the small intestine. This bacterial accumulation can result from many reasons and may contribute to maldigestion, malabsorption, and a leaky gut. Many digestive and extraintestinal symptoms are associated with SIBO, including bloating, gas, abdominal pain, heartburn, constipation, diarrhea, rashes, headaches, and fatigue. There are three distinct variations of SIBO: hydrogen-dominant SIBO, hydrogen sulfide-dominant SIBO, and intestinal methanogen overgrowth (IMO). The SIBO subtypes are determined through gas patterns measured on breath testing. IMO, previously called methane-dominant SIBO, occurs due to an overgrowth of microorganisms called archaea anywhere within the small or large intestines. SIBO is closely related to irritable bowel syndrome (IBS). It is estimated that up to 80% of patients with IBS have SIBO underlying their symptoms. Furthermore, the type of SIBO present may influence the IBS subtype, with hydrogen- and hydrogen sulfide-SIBO linked to IBS-D and IMO associated with IBS-C.
The SIBO Bi-Phasic Diet: An Overview
The SIBO Bi-Phasic Diet (SIBO B-PD) is a dietary approach developed by Dr. Nirala Jacobi. It combines principles of the low-FODMAP and Specific Carbohydrate diets to help manage SIBO. The diet is divided into two phases (hence the name), each with specific dietary guidelines and objectives. The first phase of the SIBO B-PD aims to restrict dietary fermentable carbohydrates to support the reduction of bacterial overgrowth and their production of metabolic byproducts. Doing so may help manage SIBO, relieve patients of SIBO symptoms, support gut health, and promote optimal digestive function. During the second phase of the SIBO B-PD, antimicrobial agents are brought on board to help manage the remaining bacterial overgrowth. At the same time, the patient begins to reincorporate foods into their diet. A personalized reintroduction approach helps patients identify trigger foods and maintain a healthy and balanced diet that supports gut health and may help prevent the recurrence of SIBO in the long term.
Phases of the Bi-Phasic Diet
The SIBO B-PD starts with Phase 1, the restrictive phase. This lasts 2-6 weeks and aims to limit the bacteria's food supply and support the reduction of their population in the small intestine. The restrictive phase guides the patient through a low-FODMAP (Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols) diet, which involves avoiding or minimizing foods high in fermentable carbohydrates known to ferment in the gut and exacerbate symptoms. High-FODMAP foods include certain fruits, vegetables, grains, legumes, dairy products, sweeteners, and food additives. In addition to FODMAPs, the patient should avoid known trigger foods, even if they are low-FODMAP. This phase of the diet emphasizes eating smaller, frequent meals with adequate protein and healthy fat sources. Phase 2, or the reintroduction phase, starts after Phase 1 and lasts 4-6 weeks. The objective is for the patient to gradually reintroduce foods to expand the diet and identify their individual dietary triggers. Introductions should be performed in a controlled, systematic manner. Each food is reintroduced one at a time, and the patient should keep a food-symptom diary to track symptoms to determine how each food affects their body. Phase 2 naturally progresses into the final phase of the SIBO B-PD - the maintenance phase. The overall goal of the SIBO B-PD protocol is for the patient to create a sustainable, nutritious, and individualized dietary plan based on their tolerance levels.
Implementing the Bi-Phasic Diet Plan
Implementing dietary changes, especially those involving extensive food elimination, can be intimidating and challenging. Here are tips and strategies for people planning to start the SIBO B-PD:
Read also: The Hoxsey Diet
Preparation and Planning
Preparing for the SIBO B-PD ensures a smooth transition and maximizes its potential benefits. As with any dietary change, consulting with a knowledgeable healthcare provider, such as a functional doctor or nutritionist who specializes in SIBO, before starting the diet is important. They can assess your specific condition, recommend and order SIBO testing if needed to tailor the treatment plan to your particular needs, and guide you through the protocol. Meal planning and shopping is another important preparatory step. Familiarizing yourself with low-FODMAP food options and creating a meal plan for the restrictive phase will support success; a healthcare provider can help you do this. Shopping before starting the elimination diet to stock up on the necessary ingredients and clearing your kitchen of high-FODMAP and trigger foods will guarantee you have a clean slate to start the diet and helps you to avoid food temptations. An elimination diet can be emotionally challenging. Food and social eating are a means of community, connection, and happiness for many people. Emotional preparation for the diet and finding a support network in friends, family, or support groups can ease the emotional shock of the diet's restrictive phase.
Navigating Phase 1: The Restrictive Phase
SIBO B-PD Phase 1 focuses on eating low-FODMAP and easily digestible foods. Here are examples of foods to consider including in the diet:
- Protein: poultry, beef, lamb, pork, fish, eggs
- Non-Starchy Vegetables: leafy greens, zucchini, bell peppers, cucumbers, carrots, eggplant, and bok choy
- Healthy Fats: olive oil, coconut oil, avocado, and moderate amounts of nuts and seeds
- Fruits: lemon, lime, berries
- Fermented Foods (as tolerated): cultured vegetables, sauerkraut, kimchi
- Beverages: water, herbal teas, black coffee
It's important to avoid or minimize the consumption of foods that can potentially worsen SIBO symptoms. Here are some foods that might be avoided during Phase 1:
- Vegetables: onion, garlic, artichokes, asparagus, cauliflower, broccoli, Brussels sprouts, cabbage, potatoes, mushrooms
- Fruits: apples, apricots, figs, mango, peach, pears, plums
- Legumes: beans, soy (tofu, tempeh), peas
- Dairy: milk, yogurt, cheese, ice cream
- Grains: wheat (bread, pasta, pastries, cereals), barley, rye
- Sweeteners: sorbitol, xylitol, mannitol, high-fructose corn syrup, agave
As patients begin implementing a low-FODMAP diet, they may experience die-off symptoms as the bacteria are cut off from their food supply. Staying well hydrated; eating smaller meals; chewing and swallowing food slowly and mindfully; keeping a journal to identify and avoid triggering foods; and engaging in stress-relieving activities can help manage uncomfortable digestive symptoms. Your doctor may also recommend digestive aids, such as digestive enzymes, digestive bitters, and carminative herbs, to provide additional symptomatic relief.
Phase 2: Reintroduction and Beyond
During Phase 2 of the SIBO B-PD, patients will systematically reintroduce higher-FODMAP foods into the diet. It is recommended to keep a diet-symptom journal during this process to help identify individual triggers, determine personal tolerances, and track progress. The patient should be instructed to introduce foods one at a time and to begin by reintroducing generally well-tolerated foods that are less likely to trigger SIBO symptoms. These often include lactose-free dairy, gluten-free grains, and small amounts of fruits and vegetables. The introductions will be spaced several days apart, allowing the patient to accurately monitor the body's response to each food. Start with a small portion of each reintroduced food, and gradually increase the portion sizes as tolerated. Remembering that this process is highly individualized, based on the patient's specific symptoms and sensitivities, is important. Staying in communication with their healthcare provider during this process can help patients to navigate the process effectively and guide them on specific foods that should be reintroduced or avoided based on needs and preferences.
Read also: Walnut Keto Guide
Dietary Maintenance Considerations
After completing Phases 1 and 2 of the SIBO B-PD, adopting a long-term maintenance approach to manage SIBO symptoms, support gut health, and potentially help prevent a recurrence is essential. As patients continue to incorporate more diversity into their diet through food introductions, they will naturally transition into a balanced and varied diet that includes a wide range of whole foods. Emphasizing nutrient-dense and anti-inflammatory options, like whole fruits, vegetables, lean proteins, whole grains, and healthy fats, encourages whole-body wellness and healthy digestion. Individual tolerances can change over time, so it can be helpful to occasionally rechallenge previous trigger foods to reevaluate food sensitivities and continue to diversify the diet. Also, remember that how you eat is just as important as what you eat regarding digestive health and function. Practice mindful eating habits, such as chewing food thoroughly, eating slowly, and paying attention to hunger and satiety cues. Certain lifestyle factors can contribute to SIBO recurrence. Getting adequate sleep, staying physically active, avoiding excessive alcohol consumption, and implementing stress management techniques can support gut function and help prevent SIBO recurrence. Regular follow-up with a healthcare provider can also increase long-term success. Healthcare providers should continue to work with patients to address underlying medical conditions that may increase SIBO risk and recommend gut-supporting supplements that support a healthy microbiome balance and intact intestinal barrier.
Monitoring Progress and Seeking Professional Guidance
Managing SIBO and maintaining healthy gut function requires an individualized approach, and everyone's progress on the SIBO B-PD will vary. Working closely with a healthcare professional, registered dietician, or nutritionist specializing in SIBO throughout the process is important to help accurately monitor progress and make necessary adjustments to the treatment plan. Regular, subjective monitoring by the patient of their quality of life and digestive symptoms helps to gauge the effectiveness of the treatment protocol. Improvements in bloating, bowel regularity, abdominal pain, energy levels, mood, sleep quality, and ability to perform daily activities indicate that the treatment plan is working. In some cases, objective measurements with laboratory tests may be required or helpful to monitor patient progress. These often include:
- SIBO Breath Test: The SIBO breath test can monitor SIBO management progress and track changes in hydrogen, methane, and hydrogen sulfide gas levels.
- Comprehensive Stool Test: Other factors besides SIBO can contribute to digestive symptoms. A comprehensive stool test holistically assesses gut health by measuring markers that assess for inflammation, intestinal permeability, dysbiosis, intestinal infection, and maldigestion.
- Food Sensitivity Panel: Definitively identifying food sensitivities and intolerances through observation alone can sometimes be difficult. A food sensitivity panel measures a person's immunological response to specific food proteins to identify foods that should be removed or limited from the diet at any point during the SIBO B-PD protocol.
Recipe Resources and Cookbooks for SIBO
Following a SIBO diet can feel restrictive, but with the right resources, you can enjoy delicious and satisfying meals while supporting your gut health. I can't recommend using cookbooks or online recipes enough. Here are some resources to help you navigate the SIBO Bi-Phasic Diet with confidence:
Free Online Resources
- My SIBO Recipes: Free recipes from Relaena Sindelar.
- Journey Through SIBO: Free recipes from SIBO patient Elena Wistey.
- The Healthy Gut: Free recipes from Rebecca Coomes, SIBO Cookbook author and Nutritionist.
- SIBO Diet Recipes: Free recipes from one of Dr. Siebecker's students, Dr. Sam Johnson.
- Bridgetown Nutrition: Free recipes from one of Dr. Jacobiâs students.
- Elana's Pantry: Elana Amsterdam offers 99 family-friendly classics on Elana'sPantry.com.
Cookbooks and Recipe Collections
- The SIBO Summer Cookbook: Bursting with delicious recipes for people treating Small Intestinal Bacterial Overgrowth (SIBO). All recipes are based on the SIBO Bi-Phasic Diet Protocol developed by Australiaâs leading SIBO specialist, Dr. Each recipe is classified by which phase it is suitable for, making menu planning a breeze. Rebecca Coomes believes in eating food when itâs at its best: in season. This cookbook features gorgeous summer produce, giving you a wide array of meals which are perfect for the warmer summer months.
- SIBO Family Favourites: From Shivan Sarna - SIBO patient and advocate, and Dr. Half cookbook, with delicious SIBO Specific Food Guide recipes (including vegetarian recipes).
- Recipes for the Specific Carbohydrate Diet: For those suffering from gastrointestinal illnesses, Recipes for the Specific Carbohydrate Diet offers a method for easing symptoms and pain, and ultimately regaining health. Includes a diverse and delicious collection of 150 SCD-friendly recipes and more than 80 dairy-free recipes. Easy-to-make and culturally diverse recipes. More than 150 recipes for quick and easy dishes for casual meals and elegant dinner parties alike. Dozens of recipes for snacks, desserts, breakfast dishes, and beverages will help you integrate the SCD way of eating into your familyâs lifestyle with ease, grace, and creativity. Over 275 recipes by Rochel Weiss who found relief and healing through the SCD after having struggled for many years with severe Crohn's disease. Hints and tips, stress management techniques, breakfast lunch and dinner menus, and easy instructions. Over 95 great recipes complying with the SCD, all made from basic, wholesome ingredients. Lucy Rosset regained her life from ulcerative colitis with the SCD. A personal favorite.
- Everyday Grain-Free Gourmet: Breakfast, Lunch and Dinner: Provides delectable, easy-to-digest dishes that appeal to family and guests who have food limitations that simply must be met. Specifically designed to please and inspire all those who suffer from these debilitating intestinal diseases, as well as those who already live happier lives thanks to the Specific Carbohydrate Diet.
Recipe Examples
- SIBO steak frites recipe: Take a trip to France with our SIBO steak frites recipe.
- Herb crusted chicken: This succulent herb crusted chicken is grilled on the BBQ for a perfect summerâs SIBO dinner. Quick, easy, delicious and perfect on your SIBO diet.
- SIBO friendly smoothie bowl: For busy mornings, this SIBO friendly smoothie bowl is ready in minutes.
- SIBO friendly, low fodmap and gluten free pumpkin pancakes.
- Lemon sorbet: This light, luscious lemon sorbet is perfect for hot summer days when you want something to cool you down while sticking to your SIBO diet.
- Berry sorbet: Cool down on a hot summerâs day with a refreshing scoop of berry sorbet.
- Mediterranean salad with pesto dressing: Take a trip to the Mediterranean with this delicious salad with pesto dressing.
- Basic pancakes: Simple yet delicious, these SIBO friendly basic pancakes are perfect for breakfast, brunch, dessert or as a snack.
- Butter chicken: Butter chicken is a hugely popular Indian curry, yet normally contains onion, garlic and cream, making it unsuitable for those treating SIBO. This version packs a flavour punch and tastes just as good as the real thing, without causing any irritation.
- Pumpkin bread: Perfect for breakfast or as a snack with a cup of tea or coffee. Spread slices with some butter or a nut butter of your choice for extra deliciousness. Once sliced, you can freeze your pumpkin bread, and re-heat as required.
Variations of the SIBO Bi-Phasic Diet
Dr. Jacobi has released other versions of the SIBO Bi-Phasic Diet to accommodate different needs and preferences. According to Dr. Nirala Jacobi: The Original Bi-Phasic Diet is the most widely used. Many thousands of practitioners around the globe have used this diet with their patients and seen excellent results. There are also two additional versions: The Vegetarian Bi-Phasic Diet and The Histamine Bi-Phasic Diet. The Original SIBO Bi-Phasic Diet begins with mostly meat and vegetables during Phase 1. When we adjusted the diet to accommodate vegetarians and vegans, we didnât just eliminate the meat. We put a lot of care and attention into developing a diet that would be nutrient-dense and palatable for vegetarians. It includes eggs, tofu, and tempeh as protein sources during Phase 1. It also includes a variety of soaked or sprouted legumes and grains during Phase 1. The download for the Vegetarian Bi-Phasic Diet has some delicious recipes as well as instructions on soaking and sprouting. The Histamine Bi-Phasic Diet is specifically designed for people with histamine intolerance, but itâs also useful for people with other food intolerances. It eliminates foods that are high in histamine and also histamine-liberating foods. Itâs meant to be followed for 2-4 weeks but ideally not longer than that. Sometimes people feel so good when they go on the Histamine Bi-Phasic Diet that they donât want to go off of it. Iâve seen people with histamine intolerance get astounding results with this diet, with their symptoms all resolving in a matter of days. But the diet is restrictive, and I recommend they transition back to the original Bi-Phasic diet.
Choosing the Right Version
Most patients start with the Original SIBO Bi-Phasic Diet. We opt for the vegetarian version if they are opposed to eating meat. The other reason to use the Vegetarian Bi-Phasic Diet is when people are constipated. The original diet contains a lot of meat, which can be constipating. If thatâs a concern, we can mix and match the diets. I recommend the Histamine Bi-Phasic diet if I suspect that a person has histamine intolerance. Histamine is a substance that is produced in the body but is also present in foods. In people who have SIBO, histamine intolerance can occur because of the depletion of the histamine-digesting enzyme, yeast overgrowth, or the prevalence of histamine-producing bacteria. Some of the signs of histamine intolerance include runny nose, itchy eyes, sneezing, hives, joint pain, anxiety, or insomnia. These symptoms donât always mean histamine intolerance, but if they do, the Histamine Bi-Phasic Diet can be miraculous. As SIBO improves, the sensitivity to histamine usually also declines. Thatâs why we only use the Histamine Bi-Phasic for a short period of time and then transition to the original diet.
Read also: Weight Loss with Low-FODMAP
Nutritional Supplements During the SIBO Bi-Phasic Diet
During Phase 1, the focus is on reducing exposure to fermentable starches and repairing digestion. Digestive bitters are a nice way to gently reset normal digestion. Bitters are herbs that stimulate the parietal cells of the stomach to produce hydrochloric acid and stimulate bile flow. That means improved digestion of proteins and fats. Many patients with SIBO also have leaky gut, so supplements to support the integrity of the gut lining may be beneficial. Many people will benefit from l-glutamine or zinc carnosine. Be very careful if you are choosing a combination product because many of them contain herbs like Slippery Elm or Marshmallow. These are demulcent herbs that support the gut lining, but they can also be fermentable, which is problematic for people with SIBO. Another consideration for people with SIBO is nutrient supplementation for vitamins and minerals that may have become depleted because of damaged digestion. The top three to consider are vitamin B12, magnesium, and trace minerals. The overgrowth of bacteria can disrupt iron metabolism as well as B vitamins. However, supplementing these can sometimes lead to an aggravation of symptoms. Use caution and be sure to work closely with a qualified healthcare provider. Phase 2 of the diet is when we transition the overall strategy to eliminating the bacterial overgrowth. This is when a healthcare practitioner will prescribe an antibiotic or recommend antimicrobial herbs. In addition to antimicrobials, supplementation to repair the gut can continue during Phase 2. Pancreatic enzymes as well as brush border enzymes may also be beneficial. Brush border enzymes are specialty compounds, like maltase, isomaltase, alpha-galactosidase, and Dipeptidyl Dipeptide 4 (DPP4). More support for bile flow, like ox bile or herbs, can also be considered.
Managing Die-Off Symptoms
Some people struggle with die-off or detox reactions or what we call the Herxheimer reaction. I recommend doing anything you can to support healthy detoxification. Drink lots of water throughout the day. Encourage sweating by exercising or using a sauna. Encourage circulation by getting a hydrotherapy treatment. Vitamin C can support healthy detoxification pathways, and activated charcoal can bind to toxins in the gut for elimination. All of these things can help to minimize any discomfort as the bacteria are dying off.