Why is SIBO so hard to treat? The healthiest diet seems little to no effective. Is it something very new that we aren't biologically adapted to deal with, so it requires antibiotics?

SIBO proves difficult to treat due to high recurrence rates (30-60% within 9-12 months), even after antibiotics, because diets alone fail to eradicate bacterial overgrowth and don't address root causes like impaired gut motility.

Main Challenges

Antibiotics like rifaximin clear overgrowth initially (60-70% success) but bacteria recolonize without fixing underlying issues: migrating motor complex (MMC) dysfunction from food poisoning or stress, structural problems (e.g., adhesions from surgery), low stomach acid from PPIs, or immune deficits. Healthiest diets (low-FODMAP, SCD) starve bacteria temporarily but can't fully eliminate them or restore motility, leading to relapse.

Not a New Phenomenon

SIBO isn't modern—it's ancient, linked to gut dysbiosis from infections or surgeries, with humans biologically adapted via MMC sweeps; today's antibiotics target it effectively short-term, but long-term success demands prokinetics, root cause therapy, and sometimes ongoing low-dose antimicrobials. Diet optimizes but rarely suffices solo.