Many people who are diagnosed with small intestinal bacterial overgrowth (SIBO) get treatment, feel good for a while…but then, all that bloating , flatulence, cramping, reflux, constipation, and diarrhea starts to make a seriously unwelcome comeback. Unfortunately, it’s common to have a SIBO recurrence (or relapse) in which—once again—too much bacteria starts to colonize the wrong part of the GI tract. Here’s why it might happen, what you can do, and how to help prevent it in the first place.
Unfortunately, SIBO recurrence is not uncommon. “Sixty-five percent of all SIBO cases require retreatment,” says Sarah Steinberg, MDPhD , a double-board certified internal medicine and gastroenterology physician at Parsley Health. This number can be lower if you’ve undergone some type of post-treatment maintenance program with the help of a health professional. But still, it’s hard to completely eliminate the chance of recurrence.
As for why SIBO recurs, there are several possibilities. A big one: “I see a lot of people who get SIBO and then just want to go back to their old life—eating late, eating whatever they want, not exercising,” says Dr. Steinberg. Here, we dive into why these habits—and several other factors—can prime you for a SIBO repeat.
There are actually three different types of SIBO—hydrogen-dominant, methane-dominant, and sulfide-dominant—which refer to the main type of gas produced by the unwelcome bacteria in your small bowel. Specific antibiotics and herbal antimicrobials are used depending on the type of SIBO someone has. “A lot of time I see patients with hydrogen and methane SIBO, but their treatment was just focused on hydrogen, so they probably got inadequate treatment and we need to try again,” says Dr. Steinberg.
There’s also a possibility you didn’t have SIBO at all. When someone receives SIBO treatment several times but makes only minor improvements, Dr. Steinberg explores whether they may actually have small intestinal fungal overgrowth.
If you received antibiotics as your sole form of SIBO treatment, it may not have been sufficient. “If we just kill the bacteria and don’t address anything else that got you here, you’re definitely going to increase your risk of recurrence,” says Dr. Steinberg. She, and other clinicians at Parsley Health, like to do a “maintenance phase” after a combined antibiotic and herbal antimicrobial treatment, which involves appropriate probiotics , supplements for gut-healing, and supplements to enhance motility (movement of food through the GI tract).
Fun fact: Anything that slows GI motility causes too much bacteria to remain (and multiply) in the small intestine, which can trigger SIBO recurrence.
Speaking of gut motility, “some people have impaired small bowel motility due to chronic constipation, or an underlying condition like type I diabetes, celiac disease, Crohn’s disease, or hypothyroidism, which can predispose you to SIBO,” says Dr. Steinberg. So, appropriate management of these conditions, and taking specific steps to improve GI motility, may be necessary to treat SIBO and avoid recurrence.
Remember how Dr. Steinberg said patients who go back to (or never stopped) their old, unhealthy habits after SIBO treatment, often experience a relapse? Well, sitting for long stretches and all-day snacking (which often go hand-in-hand) are two of the big ones. Here’s why:
Interestingly, SIBO (and a SIBO recurrence) can be triggered by certain pathogenic bacteria. That’s because “an infectious insult, like a bad traveler’s diarrhea or food poisoning, can cause impairment in small bowel motility,” says Dr. Steinberg. Specifically, the bacteria that cause food poisoning such as E. coli, Campylobacter jejuni, Shigella, and Salmonella produce a substance called cytolethal distending toxin (CDT) , which can damage cells in the intestines and impair the MMC in certain people.
There’s actually a lot you can do to stay healthy and after SIBO treatment and prevent recurrence (as long as you weren’t treated for the wrong type of SIBO to begin with)—and most of that involves making diet and lifestyle changes that support long-term healthy gut function and motility.
According to Dr. Steinberg, the number one way we can support healthy motility is through movement—but going for one jog or taking one HIIT class and then sitting at your desk the rest of the day is not going to cut it. You need to be moving periodically throughout the day, too. “We all need to be getting up every 20 minutes, and if that’s not possible every 40 minutes to walk around, do a few balance exercises, do a few Sun Salutations, something to get moving,” she says. Some people may also benefit from post-meal walks.
When it comes to eating, the cardinal rule for improving motility is to stop eating at least three hours before bed. This allows that migrating motor complex (MMC) to clear out the small bowel while you sleep . “If you eat right before bed, you’re inhibiting the MMC and putting your small bowel at a tremendous disadvantage,” says Dr. Steinberg.
Another way you can help your MMC do its thing: Avoid snacking between meals. “Basically you want to put three to five hours between meals to give your small bowel time to push things through,” says Dr. Steinberg. Certain intermittent fasting protocols may be helpful, as long as you’re not pushing your eating window too close to bedtime.
Specific foods aren’t thought to trigger SIBO directly, but a low-quality, highly processed diet may lead to constipation, which slows motility and increases risk of SIBO relapse. So what should you eat? While many experts recommend a low-FODMAP diet during SIBO treatment and for a short time after, Dr. Steinberg says it’s not a long-haul strategy since it can be restrictive. Over time, you want to gradually re-introduce so you’re eating a varied, plant-heavy, nutrient-rich diet with plenty of fiber and probiotic-rich foods to support gut health and regularity.
When you’re experiencing stress, various hormones are released that down-regulate digestion and trigger contraction of GI sphincter muscles, which can inhibit motility and slow food transit in the stomach and small intestines. Any steps you can take to manage stress—exercise, meditation , deep breathing—can help alleviate stress-induced motility issues, and thus, help reduce risk of SIBO recurrence. “I also really like self-hypnosis for SIBO or IBS in general,” says Dr. Steinberg, adding that some of her members at Parsley Health like the self-hypnosis app Nerva , which is designed to help you retrain the gut-brain connection .
Oh, and if you can do your stress-busting activity outside, that’s even better. Exposure to sunlight helps reset circadian rhythms, which is great, since circadian rhythm disruptions have been tied to digestive issues . And avoid late-night screen time while you’re at it!
Sometimes the impaired GI motility that leads to SIBO recurrence is a structural issue that needs manual manipulation. For example, adhesions and scar tissue that remain after certain surgeries can impede the movement of the intestines and their contents. In these cases, a visceral manipulation therapist can be helpful, says Dr. Steinberg. These therapists are trained to help break up this scar tissue and massage the lower abdominal area in such a way that improves motility and does great things for overall digestion.
Since getting food poisoning can trigger a SIBO relapse, you’ll want to make sure you’re taking some basic food safety precautions when you cook and entertain. That means, heating meat and fish to the appropriate internal temperature, avoiding cross-contamination of utensils and cutting boards, following proper storage guidelines, and more outlined here by the USDA .
Treating SIBO and avoiding a recurrence takes real commitment, and going it alone can be incredibly overwhelming (and often unsuccessful). That’s why enlisting the help of a care team, like the clinicians at Parsley Health, can be smart—“everyone wants to do it alone, but because proper treatment for SIBO can be so individualized, it’s great to have not only an expert opinion, but a sounding board for what makes sense and what doesn’t,” says Dr. Steinberg.
Parsley Health clinicians can test (and retest, if necessary) for the different types of SIBO and treat accordingly with the appropriate antibiotics, herbal antimicrobials, or a combination of both. They’ll also walk you through a maintenance phase with appropriate supplements to support gut health and motility, and look for underlying conditions that may prime you for recurrent SIBO. All Parsley Health members also work with a health coach, who can help to personalize dietary recommendations and hold you accountable for lifestyle changes that can help prevent recurrence.
Stephanie Eckelkamp is a writer and certified health coach based in Allentown, PA. She received her B.S. in journalism from Syracuse University with a minor in nutrition. Her work has appeared in Martha Stewart Living, mindbodygreen, Greatist, Women's Health, Men's Health, Prevention, and Good Housekeeping. When she's not writing or nerding out on the latest health news, she's most likely on a walk with her pup Lucy Goose or trying to convince her boyfriend to eat more broccoli.