Why a Prokinetic?

by Valerie Polley | Aug 27, 2019 | 6 comments

 

Each year that I have been in practice, the more clients I see with small intestinal bacteria overgrowth (SIBO). When I opened my business over 3 years ago, SIBO was not a term in my vocabulary. I honestly don’t remember where and when I first heard about it. Now I have individuals reach out to me not only to help with diet, but if multiple rounds of Rifaximin didn’t help, what can they do? I have learned much about SIBO and how to help those struggling with it. This is a growing issue, where it is estimated that 60% of those with IBS actually have SIBO.

If this is the first time you are hearing this SIBO term, here is a short explanation. Our small intestines have some bacteria, but most of the bacteria resides in the large intestine/colon. With SIBO, there is more bacteria than normal in the small intestine. This makes it difficult to maintain a healthy gut environment. What happens? This bacteria in the small intestine begins fermenting the food being consumed causing multiple gut issues, including bloating, distention, gas, diarrhea, constipation, etc. Unlike irritable bowel syndrome (IBS), SIBO often needs further intervention above and beyond diet changes, either in the form of a prescription ordered by your physician or herbal supplements.

One aspect of SIBO that most clinicians agree on is the importance of maintaining that migrating motor complex (MMC). This cleansing wave is natural for everyone to have and occurs during a fasting state. Those with GI issues tend to have a more sluggish digestive tract, so it is important to help that MMC do its job more easily.

Two main ways to keep the MMC moving is to space meals 4-5 hours apart (no small frequent meals) and taking a prokinetic. The definition of a prokinetic is stimulating movement or motility, such as a drug that promotes gastrointestinal motility. The bottom line is that a prokinetic helps keep things moving throughout the GI tract. For those with SIBO this is important. Intestinal dysmotility plays a crucial role in the severity of symptoms and motility issues itself can be a cause of SIBO. Keeping that MMC going allows the bacteria to migrate towards the large intestine, effectively stopping accumulation of bacteria in the small intestine.

If you have SIBO and you are not on a prokinetic agent there are options. Your physician can prescribe a prokinetic drug, such as low-dose Erythromycin or Resolor® (Prucalopride). There are other options for prescription prokinetic drugs, but these are the two I see often. If you would rather not take a prescription, there are herbal prokinetic agents that many find to be helpful. Iberogast® and Motility Activator® are two of the herbal choices along with a handful of others.

If you have SIBO and have been through treatment, now is a good time to start a prokinetic agent. If you want a prescription, reach out and discuss it with your physician. If you lean towards herbals and you need help figuring out which type and dose, reach out to a dietitian or functional practitioner that specializes in treating SIBO.

The information in this blog is not a substitute for professional medical advice, examination, diagnosis and treatment. Always seek the advice of your physician or other qualified healthcare provider before altering your diet, starting a new treatment or making changes to an existing treatment.

 

Spend any amount of time on social media these days, and you'd think protein is the answer to all your health concerns. Protein coffee, protein cereal, protein deserts…even foods that never needed protein are getting a boost.

Protein absolutely plays an important role in overall health. But when it comes specifically to gut health, fiber is the real MVP.

Why Gut Health Depends on What Your Microbes Eat

Your gut is home to trillions of microorganisms collectively known as the gut microbiome. These microbes, which include bacteria, viruses, fungi, and more, influence everything from digestion and metabolism to inflammation and immune function

But microbes need fuel to survive.

Unlike human cells, your gut microbes thrive on dietary fiber—not protein—as their main source of energy. When you eat fiber, your gut microbes ferment it and produce compounds that actively support health.

However, when fiber intake is low, your gut microbes are forced to rely on other sources of fuel, including protein. And that shift can change which metabolic byproducts are produced in your gut. And spoiler alert—that's not always for the better.

What Happens When You Eat Fiber

Fiber is a type of carbohydrate that resists digestion in the small intestine. Instead of being absorbed, it travels to the colon intact. 

This is where the magic happens. Your gut microbes ferment fiber, producing a variety of different compounds. Some of the most important byproducts of fiber breakdown by your microbiome are short-chain fatty acids (SCFAs).

SCFAs are incredibly beneficial for overall health. Here are just some of their benefits:

  • Nourish colon cells
  • Strengthen the gut barrier
  • Reduce inflammation
  • Support regular bowel movements
  • Maintain a healthy gut pH
  • Protect against several diseases

In other words, fiber doesn't just help you poop—it actively supports the structure and function of your gut.

The Different Types of Fiber (And Why They All Matter)

You might be surprised to learn that not all fiber works the same way. Soluble fiber, which dissolves in water to form a gel-like substance, slows digestion, helps regulate blood sugar, lowers cholesterol, and, in some cases, acts as fuel for your good gut microbes. The fiber that can act as fuel for your gut microbes is called prebiotic fiber, and you can think of it as fertilizer for your gut microbiome. 

In contrast, insoluble fiber does not dissolve in water, but adds bulk to stool, helping promote gut regularity and speeding up the transit of waste through your digestive tract.

Both types of fiber are needed for a healthy gut, but soluble fiber is typically "gentler" on digestion and can be especially helpful for people with IBS.

What Happens When Protein Reaches the Colon

Protein is essential for muscle repair, immune function, and hormone regulation, and most of it is digested and absorbed in the small intestine. However, when large amounts of protein (especially protein from animal products) reach the colon, your gut microbes break it down through fermentation. Unlike fiber fermentation, protein fermentation produces compounds that can negatively affect gut health.

Byproducts of protein fermentation can include ammonia, hydrogen sulfide, phenols, and indoles. In large amounts, these compounds have been linked to gut barrier irritation, increased inflammation, unfavorable changes in gut microbiome composition, and a potential increase in colorectal disease risk.

This doesn't mean protein is harmful, but it highlights that a high-animal-protein, low-fiber diet shifts microbial activity toward less beneficial metabolic pathways. In other words? The extremely popular carnivore diet is not a good choice for gut health. Overall, it's best to focus on plant-based sources of protein, which studies show can improve gut microbiome composition. 

Why Fiber Matters More Than Protein for Gut Health

From a gut health perspective, fiber has several advantages over protein:

  • Feeds beneficial microbes
  • Produces anti-inflammatory compounds
  • Supports stool consistency and transit
  • Improves microbial diversity

Most people meet or exceed the recommended protein intake, but fall dramatically short on fiber intake (some studies suggest that as many of 95% of people in the United States don't reach the recommended fiber intake).

The National Academy of Medicine recommends that women aim for around 25 grams of fiber per day, while men should target about 38 grams per day.

Simple Ways to Increase Fiber Intake

Increasing your fiber intake doesn't require a complete diet overhaul. Small, consistent changes tend to work best, especially if you have a sensitive digestive system.

Instead of removing foods from your diet, focus on adding fiber where you can or switching to higher fiber options:

  • Toss canned beans or chickpeas into salads
  • Add chia or ground flax seeds to your yogurt
  • Include at least one plant food at every meal
  • Switch to whole wheat or fiber-enriched pasta
  • Choose rolled oats instead of sugary breakfast cereals
  • Cook and cool starchy foods like potatoes, rice, and pasta before eating to naturally increase resistant starch (a type of prebiotic) content

To avoid digestive problems, increase your fiber intake slowly by 2-3 grams per day, and ensure you're drinking plenty of fluids to keep things moving smoothly. To increase the diversity of fiber you're providing to your microbes, aim to eat 30 different plant foods (which include fruits, vegetables, legumes, nuts, seeds, herbs, and spices) per week.

The Bottom Line

Protein is essential for overall health, but when it comes to gut health, fiber plays the starring role. It feeds your beneficial gut microbes, strengthens the gut linking, and produces anti-inflammatory compounds that help keep your digestive system running smoothly. Meanwhile, diets high in protein but low in fiber may encourage metabolic byproducts linked with less favorable gut outcomes.

If your priority is improving gut health, the evidence consistently points in one direction. Eat more fiber, and your gut microbes will thank you. If you're struggling with increasing your fiber intake, a dietitian can help. Click here to get in touch with us at Blue Tree Nutrition and learn about how we can support your journey to better gut health.

6 Comments

  1. sylvia Miller

    Going to P/U xifaxan antibiotic for SIBO and would like to know if a prokinetic should be taken with it or after?
    17 YO son diagnosed with EoE earlier last year. He was prescribed PPI – I’m certain that caused his SIBO.

    Reply
    • Valerie Polley

      I have seen it both ways while taking Xifaxin. I would ask his physician what he normally likes to do. If he is scheduled for a follow-up breath after his Xifaxin course, I would just wait. You need to be off a prokinetic for a week prior to a breath test.

      Reply
  2. Kelly Allhands

    I’m just wondering how long a natural prokinetic takes to make changes in motility.

    Reply
    • Valerie Polley

      It depends on the person. It starts working right away, but the degree it helps will depend on the individual.

      Reply
  3. Judy Bradshaw

    How to treat sibo naturally and is Berberine used to help with sibo?

    Reply
    • Valerie Polley

      Judy,
      Thank you for asking. If you decide to go the herbal route, the supplement that is chosen depends on the gas that is elevated on a breath test and/or your symptoms. Berberine can be a good option for hydrogen gas, but there are also other options for hydrogen gas elevation. Please let me know if you have any other questions. You can also reach out to me directly at valerie@bluetreenutrition.com.

      Reply

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Hello, I am

Valerie

My name is Valerie Polley. I am a Indianapolis-based registered dietitian and owner of Blue Tree Nutrition. I consult with clients both local and far away.
I have a bachelor’s degree in nutrition from Purdue University and I have been practicing for 20 years.
I thoroughly enjoy helping clients through their gut health journey. I see a range of GI issues including, but not limited to celiac disease, IBS and SIBO. I also specialize in the FODMAP elimination diet.