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.

 

Our gut microbiome (the community of trillions of microbes that live in our gut) plays a key role in maintaining metabolic and immune health. Gut dysbiosis occurs when the composition and diversity of our gut microbiome shift. This could include overgrowth of harmful bacteria or a decrease in beneficial bacteria. Gut dysbiosis has been linked to a wide range of negative health outcomes, including increased levels of inflammation and changes in metabolism.

Many people switch to non-nutritive sweeteners like sucralose, aspartame, and stevia for health reasons, and for decades, we've believed that they pass through our bodies without affecting us. But emerging research shows that these compounds interact directly with our gut microbiome and may have potential negative effects on our health. 

This article will review what we currently know about the relationship between non-nutritive sweeteners (including artificial sweeteners and calorie-free natural sweeteners) and the gut microbiome, plus practical advice for navigating sweeteners.

Sucralose

Sucralose (Splenda) is an artificial sweetener commonly used in baked goods, gums, and sugar-free beverages and is approximately 600 times sweeter than sucrose (table sugar). However, recent research has linked it to adverse health effects such as systemic inflammation, metabolic disease, and gut dysbiosis. For example, a 2022 study found that sucralose consumption increased harmful bacteria and reduced beneficial bacteria, which was associated with changes in insulin and glucose levels.

Additionally, a 2025 randomized controlled trial examining the effects of replacing added sugars with sucralose found that people with type 2 diabetes who consumed sucralose experienced reductions in both alpha diversity (the number and types of species present in a single person) and beta diversity (differences in microbial composition between people). Interestingly, the people with overweight and obesity without type 2 diabetes did not experience the same changes.

Overall, animal studies and limited human studies suggest that sucralose may trigger intestinal inflammation, likely through its effects on the gut microbiome. However, since most of the evidence we have comes from test tube or animal studies, these results should be interpreted cautiously.

Aspartame

Aspartame is another commonly used artificial sweetener that is about 200 times as sweet as sucrose. While it does contain some calories, because you don't need much of it to reach the same sweetness levels as sucrose, these calories are negligible.

Like sucralose, most of the research into the gut effects of aspartame has been done in animals. However, we do have some very small human studies. A 2022 randomized controlled trial (RCT) involving 20 healthy adults found that participants taking aspartame showed changes in both probiotic (beneficial) and pathogenic (harmful) bacteria, but the changes were specific to each individual. 

Why the differences? It's likely due to the "responder vs. non-responder" phenomenon. We all have differences in our "baseline" microbiome. While certain bacterial species are common in healthy populations, our microbiome is as unique as a fingerprint. Whether an artificial sweetener has positive or negative effects on our microbiome may depend on which species are already present in our gut, as well as on our habitual diet. This difference in responses makes it very challenging to draw firm conclusions about whether artificial sweeteners are harmful.

Stevia

Many people choose stevia because it's a "natural" zero-calorie sweetener. Studies have shown mixed results regarding the effects of stevia on the gut microbiome. For example, while some in vitro (test tube) and in vivo (animal) studies have reported potentially harmful effects of stevia on the gut microbiome, others have found no impact, and some even reported beneficial effects through inhibition of inflammatory pathways.

Additionally, a 2024 human study found that stevia had no significant effect on the gut microbiome. This highlights the importance of not forming conclusions based solely on test tube and animal studies. Overall, it appears that stevia is a potentially less-harmful alternative to artificial sweeteners like sucralose and aspartame.

Practical Advice for Navigating Sweeteners

Since the research on artificial sweeteners is still evolving, the decision to include or avoid them comes down to personal preference. Here are some tips for including them in your diet in moderation:

  • Try gradually reducing the amount you use: If you typically use two packets of sweetener in your coffee or tea, try gradually reducing to one packet. Our taste buds are highly adaptable, and you may find that one packet is sweet enough once you get used to it.
  • Check your labels: Low- or no-calorie sweeteners (such as sucralose, aspartame, and sugar alcohols like erythritol) are often hidden in low-sugar foods like protein bars, yogurt, and diet sodas. Awareness is the first step to reducing your intake.
  • Rotate your sources: If you do use artificial sweeteners, try switching up the types you use. Since different sweeteners may affect your gut microbiome in different ways, this may reduce the concentrated impact on your gut.
  • Switch to stevia: While animal and test-tube studies show mixed findings, human research indicates that stevia has a limited effect on the gut microbiome, making it a better choice for people seeking to support their gut health.

Another way to support your gut if you regularly use artificial sweeteners is to rebuild gut diversity with fiber and fermented foods, while focusing on whole-food sweeteners.

  • High fiber prebiotic foods (like legumes, whole grains, garlic, onions, asparagus, and under-ripe bananas) act as "fuel" for your healthy gut microbes. Aim to include a variety of these foods in your diet to support the microbes already in your gut.
  • Add fermented foods, like unpasteurized sauerkraut and kimchi, kefir, or kombucha, to your diet. Some fermented foods contain live, beneficial bacterial cultures, while others are rich in "postbiotics" (beneficial compounds like short-chain fatty acids, which are produced when bacteria break down prebiotics).
  • Try using whole-food sweeteners instead of artificial ones. For example, sweeten plain yogurt with vanilla extract and berries or add dates to smoothies or homemade energy bites.

Final Thoughts

Emerging research suggests that certain low- or no-calorie sweeteners, including sucralose and aspartame, may affect the gut microbiome, whereas stevia appears to have a less negative effect. While individual responses can vary with a person's unique baseline microbiome, certain artificial sweeteners may increase inflammation or reduce gut microbiome diversity.

If you need personalized support navigating sweeteners or supporting your gut health, Blue Tree Nutrition can help. Click here to get in touch!

 

 

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.