INTRODUCTION

Small intestinal bacterial overgrowth (SIBO) is defined as a clinical condition caused by excessive numbers of small intestinal bacteria (≥ 10

CFU/mL) that include predominantly gram-negative aerobic and anaerobic species[1]. In the physiological state, there are mechanisms to prevent excessive colonization of bacteria in the small intestine, such as an acidic stomach pH, pancreatic enzymes, the intestinal immune system, small intestine peristalsis, the ileocecal valve and the intestinal barrier itself.However, when changes in any of these mechanisms occur, SIBO can develop[2].

Given the growing knowledge on the intestinal microbiota and its role in health and disease processes, a series of studies have linked SIBO with diseases such as irritable bowel syndrome (IBS)[3],inflammatory bowel disease[4], nonalcoholic fatty liver disease[5], postgastrectomy syndrome[6] and several other conditions that are considered risk factors for the development of SIBO.

The main gastrointestinal symptoms are nausea, diarrhea and/or constipation, flatulence, distension and abdominal pain. Such symptoms may be due to poor absorption of nutrients or changes in intestinal permeability, as well as the inflammation and/or immune activation that result from pathological bacterial fermentation in the small intestine[7].

The noninvasive diagnostic method most commonly used in clinical practice is the measurement of hydrogen gas and/or methane exhaled in the breath after the ingestion of a fixed amount of a carbohydrate substrate. The indication of colonization by methanogens, which are not bacteria but belong to the Archaea domain, led to the proposal of a new term called intestinal overgrowth of methanogens. Given the diagnostic limitations, data on the prevalence of SIBO in the general population are unreliable, and the association of SIBO with the main risk factors is supported[1].

In terms of treatment, the use of antibiotics is currently the gold standard for eradicating bacterial overgrowth[1]. Rifaximin has been shown to be effective in the treatment of SIBO, despite the heterogeneity found in the studies as well as the lack of a recommendation regarding the dose and duration of treatment[8]. The antibiotics used are based on whether SIBO is associated with methane production(M-SIBO) or hydrogen production (H-SIBO). M-SIBO is associated with delayed small bowel and colon motility and is produced under anaerobic conditions. The treatment of M-SIBO tends to be easier than that of H-SIBO and is often associated with constipation. H-SIBO is associated with an overgrowth of gram-positive bacteria in the small intestine and usually manifests with diarrheal symptoms[9].However, the recurrence rate after treatment with antibiotics is high, showing that there are no universally accepted treatment approaches for SIBO[1].

Before long they came to a cat,9 sitting on the path, with a face like three rainy days! Now then, old shaver, what has gone askew4 with you? asked the donkey.

Although it may seem effective, an elemental diet is difficult to follow, and the literature lacks further studies for the clinical applicability of these diets. Regarding the use of medicinal herbs, although a few studies showed promising results in relation to the improvement of symptoms, these studies were of low methodological quality, and further studies are needed to standardize and prove the safety for the clinical applicability of these herbs[11].

DIET AND SIBO: WHAT IS THE EVIDENCE

The principle for treating SIBO involves treating the underlying disease or condition to eradicate the bacterial overgrowth and possible associated nutritional deficiencies[10].

A recent systematic review included studies that evaluated the use of probiotics, an elemental diet,and herbal therapy for the treatment of SIBO[11]. It was observed that in randomized clinical trials that evaluated the use of probiotics, there was heterogeneity between the strains used and the duration of treatment, and regarding the methodological quality, most studies were of moderate quality. These results corroborate the position of the American College of Gastroenterology that treating SIBO with probiotics seems to be counterintuitive and that the studies published thus far are of low quality[1].

Regarding diet, studies have focused on diets with a reduction in fermentable products, involving an approach with few fibers and no gluten. The use of probiotics and phytotherapeutics has also been studied, but the results emphasize the need for well-conducted studies so that the results can be extrapolated to clinical practice[1,9].

Dietary strategies for the treatment of SIBO are based on a reduction in the consumption of fermentable products, which involves a diet low in fiber, sugar alcohols and other fermentable sweeteners such as sucralose. However, the dietary data for SIBO are an extension of nutritional therapy for IBS[3], highlighting diets low in fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs), which are short-chain carbohydrates that are osmotically active and fermentable by small intestinal bacteria[1].

However, it is not clear whether the clinical improvement resulting from dietary changes is the result of a modification of the intestinal microbiota or is simply due to a reduction in fermentation and gas production. Although dietary modification is used in clinical practice for patients with SIBO, its role and effectiveness have not yet been determined[10].

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: http://creativecommons.org/Licenses/by-nc/4.0/

Souza C contributed to the discussion and design of the manuscript; Rocha R and Cotrim HP contributed to the writing, and editing the manuscript.

On the same evening the bride and bridegroom went on board ship; cannons112 were roaring, flags waving, and in the centre of the ship a costly tent of purple and gold had been erected113

A recent meta-analysis in which most articles included were from Western countries, with only one Asian study, assessed the association between SIBO and obesity. It was observed that the risk for SIBO was three times higher among individuals with obesity than among individuals without obesity when evaluated only in the Western population[15]. This result highlights the importance that diet plays in the intestinal microbiota, since a Western diet rich in sugars and fats has been shown to reduce beneficial intestinal microorganisms in obese individuals[18].

In the daytime she sat down once more beneath the windows of the castle, and began to card with her golden carding-comb; and then all happened as it had happened before

However, the causal relationship between SIBO and obesity is not clear, and more comprehensive studies are needed that can consider ethnicity, eating habits and potential confounding factors[15].

Another meta-analysis with cohort studies evaluated the relationship of a usual diet, intestinal microbiota and intestinal inflammation, comparing patients with intestinal diseases with the general population. It was observed that a diet rich in plant foods, whole foods and sources of polyunsaturated fatty acids and polyphenols has the potential to prevent intestinal inflammatory processes, and these recommendations are plausible to increase the abundance of the intestinal microbiota[19].

Thus, despite studies showing apparently promising results, the quality of evidence of these studies is low, and these types of restrictive diets should not be maintained for long, as they are not nutritionally complete and are poor in important substrates for colonic bacteria, which can impact the goal of healthy colonization[1].

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CONCLUSION

Although diets for the treatment of SIBO seem promising, studies are still scarce and of low quality,limiting their clinical applicability. Therefore, it is important to be careful when prescribing restrictive diets, since the most severe cases of SIBO can cause malabsorption syndrome, which can lead to nutritional risk, and a healthy diet rich in vegetables and whole foods seems the best option to obtain a balanced microbiota. Thus, further studies with well-designed methodological designs are needed to support the clinical applicability of diets as treatments for SIBO.

FOOTNOTES

Other types of diets, such as a carbohydrate elimination diet and the “specific SIBO” diet, which are commonly disseminated on websites, do not have scientific evidence to support such a prescription.

The authors have no conflicts of interest to declare.

It is important to highlight that the type and amount of bacteria found in the gastrointestinal tract depend on an individual's diet[12]. Thus, changes in the intestine lead to a significant impairment of nutrient absorption, including that of macronutrients and some vitamins[10]. In SIBO, some patients may show some signs of lactose intolerance, but it is believed to be bacterial lactose intolerance and not a deficiency of the lactase enzyme[13,14].

The recommended treatment for SIBO remains empirical, and consideration should be given to identifying and correcting underlying causes, correcting nutritional deficiencies and administering antibiotics[20].

Obese individuals seem to have an increased risk for SIBO[15], with an estimated prevalence of 41%[16] and with a predominance of bacteria from the phylum Firmicutes to the detriment of Bacteroidetes[17].

Claudineia Souza 0000-0002-1172-2944; Raquel Rocha 0000-0002-2687-2080; Helma Pinchemel Cotrim 0000-0001-7698-6919.

He made it out of the concentration camp, and immigrated2 to America. In 1957, his friends had fixed3 him up on a blind date . He had no idea who the woman was. He picked her up, and during dinner began talking of Poland and the concentration camp. She said she was in Poland at that time. She said she used to talk to a boy and gave him apples daily. He asked if this boy was tall, skinny and if he had told her that she shouldn t come back because he was leaving. She said yes.

Fan JR

With that a,ll the bonds that the troll had bound were broken; all the wild beasts and birds which he had caught and hid under the ground were free now, and dispersed24 themselves in the woods and in the air

Webster JR

I had decided4 to spend my two days giving a monologue5 workshop. I wanted the men to have a chance to write and then perform before a camera. I wanted them to see themselves on video before I left the prison at the end of the second day. I felt that life in this prison had probably stripped them of most of their identity and that writing and performance art might restore some sense of who they were or who they could be.

They could all speak very well while they were outside in the streets, but when they entered the palace gates, and saw the guards in silver uniforms, and the footmen in their golden livery on the staircase, and the great halls lighted up, they became quite confused

Then she grew frightened, and thought, What can a young lassie do with an iron stove? But as she wanted very much to go home to her father, she promised to do what he wished

Fan JR

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