Why Does SIBO Keep Coming Back After Treatment? — Why the timeline is longer than people expect

A patient who has spent two years cycling through SIBO treatments is typically looking for an intervention that works faster than the cycle they have been in. Substrate restoration is not that intervention. It is slower, not faster. The epigenetic processes that need to reverse, particularly SLC5A8 demethylation, operate on a timescale of months. The Fe-S cluster biogenesis machinery that needs to recover operates on a similar timescale. The mitochondrial proteome remodeling that follows SIRT3 reactivation takes weeks once NAD+ is restored. The shifts in luminal oxygen that allow the obligate anaerobic core community to re-expand take additional months once the host substrate is supplying the conditions. The realistic timeline for substrate-restoring work is three to six months for the first measurable shifts and six to twelve months for the full clinical response. Faster response to substrate work is generally a sign that something else was dominant in the case, and the substrate work is not the principal mechanism. Slower response is the rule for cases where multiple mechanisms compound. This timeline is a feature of the biology, not a feature of the consultation. It cannot be shortened by working harder. It can only be respected. Patients who are not ready for this timeline are often better served by continuing the antimicrobial cycle they are in, with full understanding tha