A Zero Carbohydrate, Carnivore Diet can Normalize Hydrogen Positive Small Intestinal Bacterial Overgrowth Lactulose Breath Tests: A Case Report

Abstract

Background: Small intestinal bacterial overgrowth (SIBO) is a clinical condition characterized by an excessive bacterial growth in the small intestine. Clinical symptoms might be non-specific (dyspepsia, bloating or abdominal discomfort). Nevertheless, SIBO can cause severe malabsorption, serious malnutrition, immune reactions, and deficiency syndromes. This retrospective case report introduces six patients with positive lactulose hydrogen SIBO breath tests. The patients chose between different therapeutic options and willingly consented to a nutritional intervention, based on a zero carbohydrate, zero fibre, carnivore diet, extended over two to six weeks of time. The rationale for this dietary approach was based on the idea that opportunistic, carbohydrate favouring bacteria and methanogens proliferate in the small intestines if the natural barriers in the digestive tract have been weakened due to stress, illness, medication, etc. A zero carbohydrate, carnivore diet, consisting of animal fats and protein, could essentially eliminate these carbohydrate favouring bacteria through starvation while still providing plenty of both calories and nutrients.
Methods: six patients from our functional medicine clinic followed a strict zero carb, zero fiber, carnivore diet for 2-6 weeks. A lactulose breath test was performed immediately before and after the dietary change as well as extensive medical testing.
Results: five patients that followed the carnivore diet for four weeks or longer tested negative for SIBO, and the one patient that only endured the diet for two weeks had a near complete eradication of her hydrogen elevation. Methane values were generally low both before and after the dietary treatment, but there was a significant decrease in patients 3 and 5.
Conclusions: The carbohydrate, zero fibre, carnivore diet shows great potential for being a readily available, cost-effective, and equally effective alternative treatment for SIBO. According to our observations it also results in better satisfaction after meals, decreases cravings for sweets and generate weight-loss in patients where it is needed.

Full text

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A Zero Carbohydrate, Carnivore Diet can Normalize
Hydrogen Positive Small Intestinal Bacterial
Overgrowth Lactulose Breath Tests: A Case Report
Peter Martin
FunMed Gothenburg Sweden
Martina Johansson (  martina.akj@gmail.com )
Institution for Medicine and health https://orcid.org/0000-0001-7031-2892
Annelie Ek
FunMed Gothenburg
Research article
Keywords: Zero carbohydrate, carnivore diet, small intestinal bacterial overgrowth, SIBO, lactulose hy-drogen
breath testing, nutritional intervention.
DOI: https://doi.org/10.21203/rs.3.rs-148500/v1
License:   This work is licensed under a Creative Commons Attribution 4.0 International License.  Read
Full License

Page 2/12
Abstract
Background: Small intestinal bacterial overgrowth (SIBO) is a clinical condition characterized by an
excessive bacterial growth in the small intestine. Clinical symptoms might be non-specic (dyspepsia,
bloating or abdominal discomfort). Nevertheless, SIBO can cause severe malabsorption, serious
malnutrition, immune reactions, and deciency syndromes. This retrospective case report introduces six
patients with positive lactulose hydrogen SIBO breath tests. The patients chose between different
therapeutic options and willingly consented to a nutritional intervention, based on a zero carbohydrate, zero
bre, carnivore diet, extended over two to six weeks of time. The rationale for this dietary approach was
based on the idea that opportunistic, carbohydrate favouring bacteria and methanogens proliferate in the
small intestines if the natural barriers in the digestive tract have been weakened due to stress, illness,
medication, etc. A zero carbohydrate, carnivore diet, consisting of animal fats and protein, could essentially
eliminate these carbohydrate favouring bacteria through starvation while still providing plenty of both
calories and nutrients.
Methods: six patients from our functional medicine clinic followed a strict zero carb, zero ber, carnivore
diet for 2-6 weeks. A lactulose breath test was performed immediately before and after the dietary change
as well as extensive medical testing.
Results: ve patients that followed the carnivore diet for four weeks or longer tested negative for SIBO, and
the one patient that only endured the diet for two weeks had a near complete eradication of her hydrogen
elevation. Methane values were generally low both before and after the dietary treatment, but there was a
signicant decrease in patients 3 and 5.
Conclusions: The carbohydrate, zero bre, carnivore diet shows great potential for being a readily available,
cost-effective, and equally effective alternative treatment for SIBO. According to our observations it also
results in better satisfaction after meals, decreases cravings for sweets and generate weight-loss in patients
where it is needed.
Background
Small intestinal overgrowth (SIBO) is denoted as an increase in overall bacterial population in the small
intestine, particularly in types of bacteria not commonly found in that part of the digestive tract. There are
three different types of SIBO where some bacteria produce hydrogen, others methane and the third group
hydrogen sulphide.[1] Hydrogen- and methane producing bacteria are easily detected with a lactulose
breath test. The symptoms typically include gastrointestinal issues like diarrhoea, steatorrhea, chronic
abdominal pain, bloating, and atulence.[2] It is increasingly popular to treat these symptoms with dietary
changes; elemental diet as well as low FODMAP is continuously being used with a high success rate in
remission. Elemental diet is a mixture of pre-digested amino-acids, fats, sugars, and vitamins in liquid form,
while low FODMAP is a diet low in Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and
Polyols, as these nutrients are poorly absorbed and commonly cause gut issues.[3] Low FODMAP is not
relevant as a SIBO treatment, but rather to give some relief from IBS (irritable bowel syndrome). SIBO and

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IBS are oftentimes mentioned in conjunction, but they are not always dependent on each other. According to
studies SIBO is the most common cause of IBS, but not the one and only cause. Other explanations for IBS
could be, for example, celiac disease or dysbiosis in the colon.[4]
The main mechanisms restricting bacterial colonization in the upper gut are the gastric acid barrier and
mucosal and systemic immunity. When these mechanisms fail, bacterial overgrowth can develop.[5]
Another cause for bacterial overgrowth in the small intestine could be due to inecient migrating motor
complex (MMC). Bacteria, which normally should have been transported to the colon, remain in the small
intestine, and reproduce there.[6]
The functional medicine model of care provides an operating system that works to reverse illness, promote
health, and optimize function by addressing underlying causes, symptoms, and functional imbalances in
interconnected biological networks. [7] The functional medicine approach to SIBO includes treatment of
underlying disease, nutritional support, and broad-spectrum antibiotics. However, antibiotics increase the
risk of antibiotic resistance and undermine a healthy gut ora, thus compromising the entire immune
system.[8]
As an alternative approach the patients were recommended to follow a zero carbohydrate, zero bre,
carnivore diet for two to six weeks. The theory is that SIBO thrive on carbohydrates and bre and starve
when these macronutrients are eliminated. According to a study viewing Escherichia coli metabolism in the
gut, the bacteria grows best on sugars. [25]
The carnivore diet has gained popularity in recent years, as the extreme end of the spectrum of low
carbohydrate diets. The diet is commonly utilized by people with overly sensitive immune systems and
treatment resistant obesity. Even though there is evolutionary evidence for animal-based nutrition in our
species [9, 10], there are no published original research articles or clinical reports on the therapeutic effect of
a carnivore diet, and one reason for this might be the controversial status of an exclusively animal based
diet. However, this case report from our functional medicine clinic, is not about the long-term effect of this
diet, and our purpose is not to promote a zero carbohydrate, carnivore diet for any reason, but to present
evidence of its effectiveness as a cost effective, readily available, short-term nutritional therapy to
normalize a hydrogen positive result in the SIBO lactulose breath test.
Methods
This case report is a retrospective review of ongoing clinical work, with the SIBO breath tests recorded
between October 2018 to August 2020. All six subjects were regular patients at a functional medicine [7]
clinic (FunMed) in Gothenburg, Sweden, and followed the structured process used by this clinic. The
subjects consented to scientic publication of the collected data in writing. After a rst visit to an M.D. (Dr
Peter Martin) they all performed an extensive blood panel (Unilabs, Sweden), GI Effects comprehensive
stool test (Genova Diagnostics, UK), Nutrient and Toxic Element Prole (NutrEval, Genova Diagnostics, UK),
ImuPro IgG antibody screening for food intolerances (CTL & Ortholabor GmbH, Germany), and a SIBO
lactulose hydrogen/methane breath test (Biolab, UK). The SIBO breath test was performed before and

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directly after (on the last day of) the dietary change. No antibiotic drugs or antimicrobial agents were used
during the treatment period. There was no commercially available diagnostic tool for hydrogen sulphide
SIBO when these patients were treated.
The therapeutic diet
All patients were instructed to follow a strict zero carbohydrate, zero bre, carnivore diet for two to six
weeks. The diet was exclusively composed of animal fats and proteins: all types of meat, organ meats, sh,
poultry, tallow, lard, and eggs. No vegetables, vegetable oils or dairy products except for butter was included.
Extra intake of table salt was recommended to compensate for sodium loss. The patients could drink
coffee, tea, and water, but no sweetened beverages or diet sodas. No caloric limit or other restrictions were
implied, the patients were encouraged to eat as much and as often as they wanted.
Lactulose Hydrogen and Methane Breath Test
Breath samples (n=10) were collected using glass vacuum vials with rubber tops that was pushed on a
rubber-clad needle. Patients were instructed to, in the morning after a >12 hour overnight fast, breath into a
standardized plastic bag connected to the needle and sample their breath at t=0 min, and then ingest a
lactulose solution. Subsequent breath samples were collected at t= 20, 40, 60, 80, 100, 120, 140, 160 and
180 minutes. Preparation before the test is normally eating a zero carbohydrate, zero bre diet the day
before the test. The purpose for this is to starve the bacteria prior to the test to minimize ongoing gut
fermentation.[11] In our case, the strict diet was instead followed for two to six weeks.
The sample was sent to Biolab medical unit in England for analysis and measurement of hydrogen and
methane levels. Since lactulose unlike glucose is poorly absorbed in the intestines, but readily digested by
gas producing bacteria, this test makes it possible to detect bacterial overgrowth in the entire
gastrointestinal tract. A positive lactulose breath test was
dened as an increase of hydrogen at least 20 ppm (parts per million) above baseline within the rst 90
minutes, or if a hydrogen double peak was present, which is in line with our clinical experience reinforcing
the SIBO diagnosis.
NutrEval
Urine samples were sent to Genova diagnostics laboratories to measure organic acids, which indicates cell
functionality, nutrient balance, mitochondrial function, bacterial or fungus overgrowth and more. Blood
samples were analysed for content of minerals, toxic elements, glutathione, CoQ10, vitamin D and fatty
acids.
GI Effects Comprehensive stool test
Stool samples were sent to Genova diagnostics laboratories to analyse bacterial content in colon, digestion
of macronutrients, parasites, inammation, and more.
ImuPro IgG antibody test
Food intolerance test measuring IgG antibodies in blood for several foods. High levels of IgG antibodies

Page 5/12
indicate delayed allergic reaction to that specic kind of food. Blood samples were sent to CTL & Ortholabor
GmbH in Germany.
Blood tests
A comprehensive blood panel including kidney, thyroid and liver status, nutrients, lipid panel, CRP, insulin,
glucose and more. Unilabs test labs were used for these analyses.
Questionnaires
The patients also lled out the FunMed clinic standard questionnaires about their lifestyle and current
health status and went through the standard medical check-up. They all had individual health concerns that
were taken into consideration as well as monitored and investigated.
Results
Background data on all six patients are shown in Table1, while Table2 is displaying the individual
experiences of the carnivore diet intervention.
Figure 1 displays the results for the lactulose hydrogen/methane SIBO breath test for each patient before
and after dietary treatment. Note the variation in scale on the Y axis for patient 2 and patient 3. The ve
patients that followed the carnivore diet for four weeks or longer tested negative for SIBO, and the patient
that only endured the diet for two weeks had a near complete eradication of her hydrogen elevation.
Methane values were generally low both before and after the dietary treatment, but there was a signicant
decrease in patients 3 and 5.
Patient 2 and patient 4 followed the diet for four weeks whereas patient 3 followed it for two weeks, patient
5 for ve weeks and patient 1 and 6 for six weeks. Patient 3 was treated with antibiotics (Xifaxan 550mg
three times a day) for ve weeks prior to the carnivore experiment, without noticeable effect on the
hydrogen curve.
Table1.
This table presents an overview of the patient’s main concerns, nutrient deciencies, select lab results and
gastrointestinal status as well as their post-treatment SIBO test results.

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Subjects Main concerns Nutrient
deciencies
& select
other labs
Presence
of
hippuric
acid in
urine
Gastro-
intestinal
issues
E. coli
bacteria in
stool test
SIBO test
result after
diet
treatment
(weeks)
Pat.1
Female
22 y/o
Stubborn
fungal
infections and
rashes.
Magnesium,
potassium,
folate, B12.
Yes Gluten
sensitivity and
stomach
discomfort
High Negative
test (6
weeks)
Pat.2
Female
65 y/o
pre-diabetic,
over-weight,
hypertension,
Cushing’s
syndrome and
slight rosacea
tendencies.
Magnesium,
zinc, folate,
B12, glycine.
Elevated
pyroglutamic
acid and 5-
HIAA.
Yes Bloating,
stomach
aches.
Normal Negative
test
(4 weeks)
Pat.3
Female
46 y/o
Chronic
constipation,
high stress,
poor sleep, dry
skin, slight
rosacea
tendencies.
Magnesium,
potassium,
B2, B12,
glycine.
Elevated 5-
HIAA,
pyroglutamic
acid and 1-
methyl-
histidine.
Yes Chronic
constipation due
to slow bowel
movements
High Hydrogen
reduced
from
150ppm to
20ppm (2
weeks).
Methane
reduced
from 16 to
3ppm.
Pat.4
Female
48 y/o
Cravings,
fatigue, chronic
diarrhoea.
Primary
diagnosis is
Graves’
disease.
Magnesium,
zinc,
potassium,
vitamin D,
B1, B2, B6,
folate, B12.
Elevated 5-
HIAA,
pyroglutamic
acid and
carnosine.
No Chronic
diarrhoea Normal Negative
test (4
weeks)
Pat.5
Female
23 y/o
Fatigue, joint
pains, low
ferritin,
constipation,
OCD
Magnesium,
potassium,
ferritin, B6,
folate, B12.
Yes Constipation.
Possibly due to
poor thyroid
function.
Normal Negative
test
(5
weeks)
Methane
reduced
from 5 −
0ppm.


Page 7/12
Subjects Main concerns Nutrient
deciencies
& select
other labs
Presence
of
hippuric
acid in
urine
Gastro-
intestinal
issues
E. coli
bacteria in
stool test
SIBO test
result after
diet
treatment
(weeks)
Pat.6
Female
49 y/o
Hypothyroidism
(Hashimotos),
rosacea,
endometriosis.
Magnesium,
B1, B2, B3,
B6, biotin,
folate, B12,
glycine.
Elevated
arabinose, 5-
HIAA,
pyroglutamic
acid and 1-
methyl-
histidine.
Yes Slow bowel
movements.
Due to
hypothyroidism?
Normal Negative
test (6
weeks)


Table2.
This table provides a brief overview of the individual experience for each patient.
Subjects Experiences Physical side effects Weight loss &
labs
Pat.1
Female
22 y/o
Enjoyed the diet and continued with a
low carbohydrate, low bre diet. Rapid weight loss Approx. 2kg,
folate 8nM
(did not eat
liver)
Pat.2
Female
65 y/o
Found it boring without vegetables and
had cravings for sweets. Less bloating.
Better sleep.
None 2kg
CRP down from
5 to 0,77,
HbA1c 60 to 51
Pat.3
Female
46 y/o
Experienced better energy and found
the diet tolerable. Body aches during the rst
week. 2kg during
carnivore diet,
11kg in total.
Pat.4
Female
48 y/o
Had a dicult adaption period,
otherwise tolerable. Tongue coating
disappeared.
diarrhoea, low energy during
the rst 2 weeks. Weight after
carnivore diet
not recorded.
Pat.5
Female
23 y/o
Enjoyed the diet. Less headache, joint
pain and stomach pain. None Same weight
as before
Pat.6
Female
49 y/o
Enjoyed the diet and continued with a
low carbohydrate, low bre diet. Hair
and nail quality increased.
Adjustment problems with
diarrhoea, rapid weight loss
during the rst week.
Approx. 10kg

Page 8/12
Exploratory Analyses
With an extensive amount of laboratory analyses available for each patient we checked for other interesting
ndings besides SIBO test results. According to the measurements there were no distinct evidence from
stool tests that SIBO caused unsatisfactory digestion of fat or proteins, even though most patients had self-
reported digestive issues. All patients had nutritional deciencies according to the extensive blood and urine
organic acids panels. Hippuric acid was present in the urine of all patients, except for one, and may be a
marker of gut bacteria overgrowth [12], even though no clear reference interval seems to be acknowledged.
The comprehensive stool test revealed elevated E.coli content in the colon in two of the patients, but no
other SIBO-related bacteria or bacterial or parasite infections were found. E. coli is one of the major players
associated with hydrogen dominant SIBO.[13]
Limitations
The lactulose breath test has been shown to have a higher sensitivity but a lower specicity, as compared to
the glucose breath test.[14, 15] We argue that the test with the higher sensitivity (lactulose breath test) is a
better choice for SIBO detection in a functional medicine clinic, especially when the short term dietary
treatment can be considered having few side effects.[16, 17] However, because of a lot of contradicting
reports about the effectiveness of the various types of SIBO testing techniques[18], this may be a weakness
in this report.
This was an unsupervised dietary intervention. Even though the patients were highly motivated it is
impossible to verify to what degree they were following the diet. Further, even though SIBO tests were
adequately timed before and after the diet intervention, all additional tests were spread out rather than
perfectly timed before and after the carnivore weeks.
All subjects were females, reecting that 70% of our patients are female. Commercially available diagnostic
tools for hydrogen sulphide SIBO was not present before October 2020.
Discussion
This retrospective case report from a functional medicine [7] clinic, is to the best of our knowledge the rst
published evidence that a short term exclusively animal based, zero carbohydrate carnivore diet can
normalize hydrogen positive lactulose SIBO breath tests. The patients chose to eat this therapeutic diet
from two to six weeks of time. The rationale for this dietary approach was the fact that the most clinically
successful diet for the treatment of SIBO published so far, the elemental diet, can result in 80–84%
remission of SIBO in only 2–3 weeks of treatment. [19] As shown in this paper, our clinical experience with a
zero-carb carnivore diet reveals an equally high success rate, but with the added benet of being more
palatable and more suitable for hypoglycaemic patients and patients with insulin resistance. A carnivore
diet is cost effective, readily available, and according to our observations results in better satisfaction after
meals and decreases cravings for sweets.

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Conventionally, a double peak in lactulose hydrogen breath test (one due to SIBO and the other from colonic
fermentation) is considered diagnostic of SIBO. Pimentel et al suggested that a rise in breath hydrogen
20ppm above basal levels within 90 minutes after ingestion of lactulose should be considered a positive
test.[20] Following this rationale in conjunction with the fact that all patients had gastrointestinal issues
and nutritional deciencies [21] it is likely that the patients indeed suffered from SIBO. However, patient 3
and 5 lacked a distinct double peak while simultaneously suffering from chronic constipation. We
acknowledge this as an interesting observation as some data also suggest that patients with constipation
have different breath test results than patients with IBS or diarrhoea.[22] Patients 3 and 5 also had the most
prominent reductions in methane gas from the diet intervention which may lead to less constipation.
According to our observations as well as the patients’ own experiences, the diet intervention resulted in
resolution of gut issues. Several patients experienced additional benets such as weight loss and increased
well-being, even though the rst week of a zero-carbohydrate diet can be tough for anyone not used to
limiting their carbohydrate intake. In comparison with the elemental diet, the carnivore diet provides more
satiety, biocompatible nutrients, and general enjoyment as there is no caloric restriction and the patients’
have freedom to choose their daily food intake as long as they follow the guidelines. This makes the diet
more endurable than the elemental diet while seemingly being just as effective. Unfortunately, meat, organ
meats and animal fat has gotten a bad rap due to weak epidemiological studies linking these food products
to heart disease and cancer. [23] However, it is probably safe to say that very few of the heavy meat eaters
in these studies, ate a zero carbohydrate, zero bre, carnivore diet. Much more factors come into play in the
development of lifestyle diseases such as smoking habits, alcohol intake, training frequency and overall
quality of life. Although small case reports [24] has been published, no large, controlled studies have been
made on the safety of following a carnivore diet for longer periods of time. In the present material, no
serious side-effects were detected in following the diet for a few weeks of time as an elimination diet or for
SIBO eradication.
Conclusion
The present case report of six patients from our functional medicine clinic shows for the rst time (Fig.1)
that a zero carbohydrate, zero bre, carnivore diet, have the potential to normalize hydrogen positive SIBO
breath tests in a comparable manner to the elemental diet, but with the added benet of being more
palatable and easier to endure. The presented data points to a short-term carnivore diet as an evolutionarily
sound, cost effective and readily available addition to our clinical therapeutic options for SIBO, which merits
further evaluation in larger studies.
Abbreviations
SIBO Small Intestinal Bacterial Overgrowth
FODMAP Fermentable Oligosaccharides, Disaccharides, Monosaccharides And Polyols
IBS Irritable Bowel Syndrome

Page 10/12
MMC Migrating Motor Complex
IgG Immunoglobulins G
5-HIAA 5-Hydroxyindoleacetic acid
OCD Obsessive Compulsive Disorder
CRP C-reactive protein
Declarations
Ethics approval and consent to participate
Not applicable
Consent for publication
This case report is a retrospective review of ongoing clinical work. All patients were regular patients at the
functional medicine clinic FunMed in Gothenburg, Sweden, and consented to scientic publication of the
collected data in writing.
Availability of data and material
Not applicable
Competing interests
The authors declare no conict of interest.
Funding
This research received no external funding.
Author Contributions
PM was the clinician in charge of this study. He managed the patients, the test interpretation, and their
experimental dietary intervention, as well as contributed as an author. MJ and AE performed article research
and article writing. All authors reviewed and approved of the manuscript.
Acknowledgements
We thank the patients for allowing us to share their details and for their bravery in trying a highly
unconventional diet.
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