Fruit and Starchy Vegetables with Small Intestinal Bacterial Overgrowth

April 21, 2012 in Categories: , , by

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Small Intestinal Bacterial Overgrowth (SIBO) is a condition in which bacteria, yeast and/or fungi that would not normally reside in the digestive tract thrive in the small intestine (usually the third segment called the ileum, but they can work their way higher up the digestive tract to the jejunum and, in extreme cases, even the duodenum).  They are usually mixed with your normal, beneficial bacteria who are also growing farther up the digestive tract than usual.  SIBO typically goes hand in hand with a leaky gut and can actually perpetuate a leaky gut even after an individual adopts a strict paleo diet (even with the autoimmunity protocol and an effort to eat gut-healing foods).  SIBO is also linked to gut-brain connection problems, especially in individuals who are stressed, depressed and/or not getting enough sleep (although which comes first is up for debate).  Symptoms of SIBO include upset stomach, nausea, acid reflux, heartburn, burping, vomiting, bloating, gas pains, trapped gas, flatulence, diarrhea, constipation, and stomach pain.  And it is very possible that the onset of symptoms was gradual enough that you might not even notice.  Aside from having the bacterial count of your jejunum tested, a good indication that you have SIBO is if you have continued health issues even after adopting a paleo diet (not just gastrointestinal symptoms but also things like arthritis, skin conditions like psoriasis, difficulty in losing weight, or continued mood and energy level issues).

If you have or suspect that you have SIBO, one of the dietary recommendations for treating this condition (besides going paleo) is avoidance of all complex sugars.  This means that starches and even disaccharides like sucrose are off limits.  I have touched on this subject in a couple of posts (How Mood and Gut Health Are Linked, Repairing The Gut, and most recently, Modifying Paleo to Treat Psoriasis), but I felt like further explanation on this aspect of treating SIBO is probably overdue.  The idea behind this recommendation is that by eating these more complex sugars, you are feeding the bad bacteria.  Monosaccharides, like fructose and glucose, are the most easily absorbed sugars we can eat, so they are typically already absorbed by the time that meal gets to the lower small intestine where the “bad” bacteria are growing.  Limiting yourself to monosaccharides helps to starve the bacteria in your small intestine.  By consuming healthy probiotics (either in supplement form or from fermented foods like sauerkraut and coconut milk kefir), you replenish the good bacteria that should be growing farther down your digestive tract.

Obviously paleo baking and anything high in sucrose is out.  But, what does this mean for consuming fruits and starchy vegetables?  There is actually alot of conflicting information out there.  Two great resources are the GAPS (Gut and Psychology Syndrome) diet and the SCD (Specific Carbohydrate Diet) diet, which both limit carbohydrate intake by the type of sugars present in the foods (the books associated with these diets are titled Gut and Psychology Syndrome and Breaking the Vicious Cycle, respectively).  These diets were not developed within a paleo framework, but many of the ideas behind these diets are compatible.  Both of these diets include stages in which you first abstain from nearly all carbohydrate sources and then you slowly add back more and more simple sugars into your diet.  My recommendation to treat SIBO is to use elements of these diets and incorporate them into your implementation of a paleo diet (and I suggest doing the autoimmunity protocol which additionally avoids egg whites, nightshades, nuts and seeds for anyone suffering autoimmune condition and/or skin conditions).

So first, let’s tackle fruit.  In GAPS and SCD, all fruit is restricted at first, but then added back in once the symptoms improve.  Most fruit tends to have the majority of its sugar as fructose and glucose rather than disaccharides like sucrose, which is why most people tolerate them.  Depending on what other health issues you are dealing with, you may want to try a few weeks without fruit or you may want to see if your symptoms improve by simply cutting out the more obvious sugars and starchy vegetables (see below).  If you’re going to leave fruit in your diet, I suggest not going to town on it (although Prof. Loren Cordain is a big fan of not limiting fruit in a paleo diet, he does not address SIBO in either The Paleo Diet or The Paleo Answer, both outstanding books BTW).  Try limiting to 1-3 servings a day and see how you feel.  Dried fruit, except dried apricots, dates, raisins and prunes, is restricted.

Now, let’s talk about starchy vegetables.  Starch molecules are basically long chains of sugar and while they are great for slowing down the blood sugar spike after a meal (especially when the vegetable consumed is also fibrous like sweet potatoes), this also means those sugars are still not fully digested by the time they reach the “bad” bacteria.  Again, all starchy vegetables are avoided in the first stages of both GAPS and SCD.  And again, it’s up to you whether or not you want to approach it this way.  In the symptom-free/maintenance phase, some starchy vegetables are allowed and some are not.  Whether or not a starchy vegetable is recommended has to do with exactly how long the starch molecules are and whether or not it contains other factors that slow down digestion (like alot of fiber).  Here is a table with the allowed and disallowed vegetables (plus a few extra that I thought you might be wondering about):

Okay
Avoid
Artichoke, French
Arrowroot
Avocados
Artichoke (Jerusalem)
Ripe Bananas
Bitter/Black Gourd
Beets
Green Bananas
Carrots
Chestnuts
Celeriac (Celery Root)
Jicama
Ginger root
Kohlrabi
Mushrooms
Okra
Olives (preserved without sugar)
Parsnips
Pumpkin
Plantains
Rhubarb
Sweet Potato
Rutabaga
Taro
Summer Squash (like zucchini)
Tapioca
Turnips
Yams
Winter Squash (like butternut or acorn)
Yucca

Like everything in the paleo diet, this is a starting place.  Really, you will probably just have to end up experimenting on yourself to figure out which foods you tolerate and which you don’t.  Now that my diet is so clean, it is abundantly clear when I eat something I shouldn’t.  For example, I can handle a small portion of fruit, but if I eat some paleo baking or a helping of sweet potato, I get very bloated, to the point where my stomach feels rock hard (and it’s sadly not all muscle, folks!).  I will usually also notice a big drop in energy level and a dip in my mood and patience as well.  Usually, my psoriasis will feel itchier and look redder too.  It can take days to pass the gas (I find a large quantity of ginger tea helps immensely) and recover.  This happens not when I binge on something horrible for me, but simply when I eat something that many people in the paleo community eat on a daily basis.  It can be very frustrating and very discouraging, but I try and focus on the positive:  I now know how to eat for my health issues and even if it’s sometimes hard to comply, I am no longer roaming in the dark taking scads of prescription medications.  I am healing.

Comments

I suspect SIBO. I did a breath test and still waiting for the result… Already 1,5month on the AIP diet. Is it ok to do oilpulling or better not (with coconut oil)? I did it yesterday and the day before (first time) and since yesterday I feel even more tired and have a headache. Should I continue or better stop?
Thanks a lot!

I have the gut bacteria treated with probiotic and AIP but still feel real weak after 7 weeks the Dr, is still doing tests I guess it takes along time I lost 23 lbs which I could not loose for years .I do exercise T-Tap great for getting rid of toxins and detox baths.Thank you for all the great info my husband says I,m indefagagble or something lie that means nothing can stop me no matter how hard it is.Any article on vertigo and dyslexia?

Sarah hasn’t written about vertigo or dyslexia, but they can certainly be associated with AID and the attendant food intolerance, hormone imbalances, or dysbiosis. Healing does take time, especially if you have been diagnosed with SIBO. Sarah recommends a low-FODMAP diet in addition to the AIP to best address that. – Christina, Sarah’s assistant

Would this elimination diet be appropriate for small children (1 to 9 years old) if SIBO is suspected but not confirmed? Two of my six children have confirmed Celiac disease and two more had a positive genetic screen for Celiac genes (along with my self and my husband). My two youngest (the only ones in our family that had a negative genetic screen) have digestive issues though such as constant abnormal stool and my baby also has eczema. My celiac kids seem to be doing well, although my celiac son struggles with impulse/anger control occasionally and my celiac daughter belches repeatedly any time she eats. My two oldest had a positive genetic screen for celiac, but were negative for the celiac disease antibody blood test (my oldest also had an upper endoscopy that was negative to further rule out Celiac because he was anemic despite eating a pretty balanced diet). I’m having ongoing health issues as well, primarily digestive, mood, hormonal, and energy related (and have been struggling with these since I was very young). We’re already mostly doing the Autoimmune Protocol (I have been allowing minimal sunflower and pumpkin seeds) but I’m really struggling with knowing if we should be eating starches and certain fruits. I have an appointment for my youngest with our pediatric GI to discuss testing for SIBO, etc. If it’s not a good idea to apply this plan to young children, could you point me in the right direction of some good recommendations for young children? If their is someone in the Paleo Mom Consulting group that could help with our group of mixed ages, please let me know (if I go that route I hope to find one person who can help me with my kids and myself).

We got our celiac diagnoses almost 4 years ago and have been strictly gluten free since then and slowly moved away from processed gluten free food to grain free with dairy and rice to total Paleo and now to the AIP (we were paleo without dairy, eggs, or nightshades for the past few months and just last week eliminated nuts and cocoa). My children are thriving overall but over these past four years, in addition to the issues I mentioned above, all the kids have dry, rashy skin on arms and legs (my youngest has eczema) and all are pale and lethargic (they need to spend more time outside but complain they’re too tired). I don’t know if I’m being paranoid because of the known autoimmune disease in our family or if all this adds up to being signs that I should being doing more to improve our health.

Any ideas of what direction I should go in would be appreciated.

The AIP and a low-FODMAP diet should be fine for all ages, provided they are eating a wide variety of the allowed foods. Sarah does not recommend starting a low-FODMAP diet unless SIBO has been confirmed. For help troubleshooting problems that linger on the AIP, you could refer to the troubleshooting guide in The Paleo Approach or might consider talking to any one of ThePaleoMom Consultants (any one of whom is qualified to address your concerns about your children). – Christina, Sarah’s assistant

Here is what Sarah had to say about resistant starch in an earlier comment: “I think the research is still very preliminary on resistant starch itself. It binds bile salts and cholesterol similarly to soluble fiber, so I think supplementing with large amounts could potentially lead to the same problems as supplementing with soluble fibers (discussed in my Fiber Manifesto series). There’s some interesting anti-inflammatory effects, but no one has looked at this head-to-head with other fiber types and all fiber is anti-inflammatory. It’s been shown to provide no benefit to cancer risk (whereas other fiber types have) but does benefit in IBD (both soluble and insoluble do too). I think that the research showing insoluble fiber in general is very important (resistant starch is a type of insoluble fiber) and an essential corrective influence on the gut microbiome is very convincing. I just feel uncomfortable will all fiber supplements… as soon as you isolate one type of fiber, you preferentially feed certain types of bacteria. I think that especially when you’re talking about supplements geared at the microbiome, eating real whole foods is the safest strategy.” – Christina, Sarah’s assistant

I’m confused. I have been on SCD a long time– maybe two years, though I never really was able to do the intro portion. My diet has been very dependent on nuts (for a long time I used a lot of roasted but not soaked/sprouted nut butter– I have laid off that for the last 3 months or so) and eggs and I have continued to have problems with gas, diarrhea, constipation and moderate acne. I have started to think that maybe I need to try AIP, but it doesn’t seem possible without plantains, which are not SCD legal. I seem to tolerate the plantains with no problem (though I get symptoms if I eat potatoes or sweet potatoes, or any grain, even rice). (I just had some of your plantain pancakes, btw, which were delicious!) Do you think I should go back and do the SCD intro for real or try AIP and forget about some of the SCD prohibitions, like green plantains?

Sarah does not recommend combining diets unless medically necessary. The AIP is an excellent place to start to try troubleshooting some of those lingering problems. – Christina, Sarah’s assistant

I suspect that I may have SIBO for many of the reasons Sarah mentions – digestive/mood/energy level issues after having done Paleo for several years, plus a worsening of these issues when I eat sugars. I’m considering doing a coconut/MCT oil-only cleanse for a week to see what the effects will be. Does Sarah recommend this and are there any risks I should be aware of?

Sarah recommends speaking to your healthcare practitioner to actually diagnose SIBO before adopting any dietary/lifestyle changes to treat it. If you are diagnosed with SIBO, she recommends a low-FODMAP, low-inulin diet with plenty of coconut oil. – Christina, Sarah’s assistant

There’s some disagreement on this, but most experts would say you need to clear the SIBO (verified by retesting) BEFORE introducing probiotics, otherwise it can worsen the condition. I was diagnosed with a bad case of SIBO and every probiotic I’ve tried has made me worse. I’m getting ready to retest shortly.

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