SIBO Expert Dr. Pimentel Answers Your Questions, Part 1: Food and Diet

Earlier this month, SIBO expert Dr. Mark Pimentel took over Cedars-Sinai Hospital’s twitter account to answer questions about IBS and SIBO. Although Twitter’s character limit doesn’t lend itself to detailed answers, Dr. Pimentel answered some great questions about SIBO and IBS. You can find all the tweets from the chat by searching the hashtag #CedarsIBSchat on Twitter.

Who is Dr. Pimentel and why do we care that he’s answering SIBO questions?

First, a little more about Dr. Pimentel. Who the heck is he and what qualifies him to answer all these questions?

For those that don’t know, Dr. Pimentel is one of, if not the, leading experts on SIBO. He leads Cedar’s Pimentel Laboratory, which researches the link between IBS, SIBO, food poisoning, and gut bacteria. If you have SIBO and haven’t been following the research being done by Dr. Pimentel and Cedars, you might want to start doing so. Much of what we know about SIBO and how to treat it came from Dr. Pimentel and Cedars. Consequently, I get excited when Dr. Pimentel hops on Twitter to answer SIBO and IBS questions.

On to the food and diet related questions…

First, I have to say that many people asked great questions during the Cedars IBS Chat. So many that Dr. Pimentel did not get to answer all of them (including mine!). However, he did answer over twenty-five questions and provided us a lot of great info in the process.

Because some of the questions covered information already known, I’ll only be recapping those questions that I felt provided new or especially interesting info. But I’d encourage you to go back and read all the responses if you have time. I’ve also broken this recap up into several posts, because there is just too much information to digest in one post (get it? digest? ha!).

Digestion-related puns aside, let’s get started…

What Sugars are OK?

People with IBS and SIBO have all kinds of food-related challenges. It’s very challenging to know what is “ok” to eat and why. Thankfully, Dr. Pimentel cleared up a few more of these questions for us.

One participant asked about eating honey, maple sugar, coconut sugar, ghee, or just plain coconut.

First, Dr. Pimentel references one of the many SIBO diets, the Cedars-Sinai Low Fermentation Diet that his laboratory recommends for SIBO and IBS patients. This differs from the low FODMAP diet often recommended for SIBO, although the diets overlap a lot. So it’s important to remember that when Dr. Pimentel says that certain foods are ok, it doesn’t necessarily mean these foods are low FODMAP (although they might be!). It does mean they will not ferment rapidly in the digestive tract. In other words, these foods get digested easily before the bacteria in the small intestine can get ahold of it.

Sugar and sweeteners can be tricky for IBS and SIBO. Recently, Dr. Pimentel said that Stevia, a zero-calorie artificial sweetener made from plants, interrupts the migrating motor complex and shouldn’t be consumed by SIBO patients. Unfortunately, because Stevia is a low FODMAP food, a lot of SIBO patients probably use it. And because coconut sugar has moderate levels of FODMAPs, many SIBO patients likely avoid it. Similarly, honey has high FODMAP levels.

If you’re following a low FODMAP diet to try and determine food sensitivities or as a short-term part of SIBO treatment or other reasons, then obviously consider FODMAP levels. But for those of us not eating a low FODMAP diet but still concerned about managing SIBO or IBS through diet, it’s great to know that honey, coconut sugar, and pure maple syrup should be gut-friendly!

Dr. Pimentel also answered another diet-related question involving artificial sweeteners.

Coffee, SIBO, and IBS Can Mix Nicely But Beware the Additives

Personally, I love the taste of coffee but it absolutely triggers my symptoms. This happens because coffee (and caffeine) increases peristalsis. Increased peristalsis means that your intestines have less time to absorb the water from the food you’re digesting, making you have to go to the bathroom sooner! So if your symptoms include diarrhea, coffee can trigger this. However, there’s nothing fermentable in coffee, which is what I believe Dr. Pimentel means here when he calls coffee “safe.” Drinker beware, I say.

Coffee aside, Dr. Pimentel again calls out the sweeteners as potentially problematic. These might cause problems, especially sucralose (Splenda). Splenda, another zero-calorie artificial sweetener, cannot be digested by humans. But bacteria digest it, so when you eat it, all the bacteria get fed while you absorb nothing. As a result, if you have bacteria in the wrong place (in your small intestine, for SIBO patients) this causes symptoms to flare.

So before you go adding Splenda or Stevia to your coffee, maybe consider honey or coconut sugar or palm sugar or just plain old table sugar instead.

Low FODMAP: Should it be forever?

This isn’t new, as some studies have shown that eating a low FODMAP diet for longer than a few months can change your gut bacteria. Therefore, many SIBO doctors (mine included) recommend a low FODMAP diet as a temporary measure only. Usually, a temporary low FODMAP diet follows treatment with pharmaceutical antibiotics or herbal antibiotics as part of a SIBO treatment regime. Now every patient has a different case, but generally, if you don’t have to follow a low FODMAP diet, then don’t.

Relatedly…

Do Less Carbs Equal a Better SIBO Diet?

I see a lot of discussion of avoiding carbohyrdrates and/or gluten when talking about SIBO diets. It’s important to remember that there isn’t an virtue in avoiding foods simply for the sake of avoiding them. As Dr. Pimentel reminds us, eating as close to a balanced diet as possible—including carbs—is ideal.

The “quick carbs” he cites here include plain old table sugar (sucrose) and glucose-containing carbohydrates like potatoes, sweet potatoes, and rice. White bread as well. It sounds counter intuitive but multigrain or whole-wheat breads actually take longer to digest, which gives the bacteria more time to feed off them and cause us symptoms. So go ahead and eat some french bread if you can!

Oh, and while we’re at it, have a drink too…

Are Some Alcohols Ok on a SIBO Diet?

Well don’t mind if I do have some red wine, if the doctor recommends it.

Again, another reminder that if something agrees with you and it’s low fermentation, it’s totally ok to have it. Diet restriction solely for the sake of restriction just isn’t healthy. I personally love wine, so I’m embracing this. Wine, an many alcohols like gin and vodka, and beer are also low FODMAP in moderation. Be careful with mixed drinks or alcohols that have lots of additives to them, as those can cause more issues.

What to do if you’re still confused about all this diet stuff or still having problems?

Getting a Dietician Can be Just as Good (or Better) as Low FODMAP Diet.

This one is really interesting. The BMJ Study the participant mentions gave IBS patients a diet tailored to the individual patient’s food sensitivities as measured by a leucocyte activation test. The control group followed a fake elimination diet not tailored to the patient’s results. After four weeks, the patients with individually tailored diets reported statistically significant improvements in their IBS symptoms. It’s worthwhile to note that the control group also saw reductions in symptoms but not to the extent of the individually tailored diet group.

An individually tailored diet allows you to hopefully eat a wider range of food than the standard low FODMAP diet allows. The more foods you’re allowed to eat, the better for your general health. Also, if you know what you’re actually reacting to, you’re more likely to reduce your symptoms. Win-win. Working with a knowledgable dietician can make a real difference.

Dr. Pimentel doesn’t say this in his tweet, but the other takeaway is that testing for food sensitivities can also be helpful. The study mentions that some food the patients reacted to were low FODMAP foods! So it’s important to actually know what you’re reacting to because otherwise you’ll needlessly restrict yourself.

That’s all for now…

Well, I think that covered all the diet and food related questions Dr. Pimentel answered in the Cedars IBS Chat. Were there any other questions about diet you wish he had answered?

Check out my recap of the questions on motility and prokinetics here.