Are You Bloated, Fatigued and Gaining Weight? You May Be Experiencing Symptoms of SIBO.
The microbiome plays a role in how so much in our body works; from our brain to our immune system, even hormones. When trying to “fix” the health of your gut, you may be trying to go after things such as parasites, heavy metals, candida, and a host of many other conditions we know to wreak havoc on digestion. But what if you have tried all these protocols, and still feel like there’s something off? These may be symptoms of SIBO.
What if we’re still bloated, fatigued, experiencing brain fog, and gaining weight even after we follow other “gut healing” protocols?
Symptoms of SIBO can easily be mistaken for other conditions such as hypothyroid, heavy metal toxicity, and adrenal fatigue, and that makes it difficult for traditional medicine to recognize, acknowledge, and even treat. What doctors like Dr. Ruscio and I are hoping to do is provide you with a balance of well thought out, conservative, but progressive information.
What exactly is SIBO?
SIBO occurs when you have too much bacteria, both good and bad, in the small intestine. There are different theories and observations showing that sometimes it’s bacteria that comes from further down the intestinal tract and grows up. Sometimes it’s the bacteria that makes its way down through your mouth. It doesn’t make a huge difference in terms of how to treat this. Essentially you have too much bacteria in your small intestine, creating symptoms of SIBO.
The small intestine is responsible for 90% of caloric absorption, it represents over 56% of your digestive tract, and it is where you have the largest density of immune cells in your entire body. There’s a profound inflammation/immune system connection hinged into the small intestines.
Some of the “healthy gut” advice is centered around feeding gut bacteria with fiber in the form of prebiotics, vegetables, and fruit, and also with fermented foods such as kombucha and sauerkraut. Though typically health-promoting, in the context of those with SIBO and also with IBS, these may actually be the foods that are the worst for one’s gut health, making the symptoms of SIBO worse. This definitely causes confusion for an individual with SIBO, because all conventional wisdom about health gets turned upside town.
Oftentimes, people think they’ve done everything, but they really have not.
They’ve done everything that they know about for symptoms of SIBO, which is great, but it’s not everything that’s available out there.
Dr. Ruscio stated that the gut is really an ecosystem. It’s not about focusing on any one thing, the SIBO, the Candida, the yeast, the H pylori, or the inflammation. Your gut is like a garden, and you want to find the combination of factors that will create the healthiest soil. When you have healthy soil, or in this case a healthy host, you encourage the growth of healthy bacteria.
Sometimes we get caught in a ‘mono-therapeutic’ focus. Even when you suspect SIBO, you must always remember to look at the gut broadly in the context of your entire body, just so you make sure that we’re addressing it as holistically as we really should.
What are the most common symptoms of SIBO?
Bloating is one of the number one symptoms of SIBO that people notice immediately, or even hours after a meal when SIBO is present. Along with bloating, constipation and gas are the other classically defined symptoms of SIBO. We are now seeing non-digestive symptoms that form as a byproduct of a digestive problem.
Dr. Ruscio has told us how we’re now seeing an association with SIBO to hypothyroidism and even thyroid autoimmunity. A study by Polish researchers1 indicated that those with SIBO had a higher level of thyroid antibodies than those healthy controls.
We’re even seeing SIBO correlated with skin conditions such as rosacea. We see evidence that after treatment of the SIBO, the skin conditions improved. Also, we see our metabolism affected by SIBO, and we can improve by measure of of cholesterol and blood sugar after treatment of SIBO.
I struggle with the classic symptoms of SIBO.
A common mistake practitioners make is they want to test you to better gut health.
Yes, testing does have a time and a place, according to Dr. Ruscio, but we both agree that we’d like to recommend a protocol that can be done without any testing.
The goal is to create homeostasis in the gut. You can perform some pushes and pulls to facilitate a healthier environment, read your response, and begin to figure out what’s working well for you. Instead of having to worry about the metrics of a diagnosis, we can start by giving a gentle push to the microbiota and thus, hopefully, the microbiota will rebalance to a healthier equilibrium.
Here are the simple, inexpensive steps to take when addressing symptoms of SIBO:
Nutrition and Lifestyle
It’s important to start out with the foundational pieces of nutrition and lifestyle. Different diets can actually work well for some people while failing for others. You may hear disparate things about which diet is best for symptoms of SIBO. We hear about Paleo, Low-histamine, Low-FODMAP, and some others. So which is the best dietary approach for addressing symptoms of SIBO?
My Principle of Diet Variation:
One of the greatest mistakes we make as a modern-day population is staying on the same diet.
The human DNA is set up to change diets and force adaptation. Therein lies the actual key, and that’s why every diet is technically correct. With SIBO, I do find that sometimes diet is enough to eradicate it, and sometimes you need some help with supplementation. Yet another reason why SIBO is so tricky to treat.
With symptoms of SIBO there are a couple of places that are logical to start, as they work for at least a majority of people.
The Paleo Diet
A Paleo diet is a great place to start when experiencing symptoms of SIBO. It does not have to be high protein, high fat, high meat. It can be a lower protein and fat diet with higher carbs, too. Essentially the main tenet is a non-processed, whole-foods diet where you focus on meat, fish, eggs, vegetables, fruits, nuts, and seeds. It’s a very unprocessed diet and you can skew the balance of carbs, proteins, and fats to your individual desires.
There is data indicating that the paleo diet can help with IBS, and we know that anywhere from 4-84% of IBS may have the underlying cause of SIBO. IBS essentially has the same symptoms that manifest as SIBO, which is why they are kind of a proxy for one another.
The Paleo diet is a whole foods, unprocessed diet that eliminates packaged/fast foods, vegetable oils, all grains and gluten, dairy, legumes, and added sugar. You can eat fish, meat, eggs, nuts/seeds, and fruits and vegetables. Following these guidelines, my own Cellular Healing Diet is a good place to start.
Two to three weeks is ample time to at least be able to acknowledge that you’re starting to feel better. Will you be 100% healed? No. But you’ll know if things are improving. If you feel worse after 2-3 weeks, then try something new for another trial.
Sometimes, when on a gut-healing diet, as you gravitate toward healthier foods, you may be incidentally be eating more histamine-rich foods. Over time, a histamine intolerance can develop as a byproduct of a damaged intestinal lining.
It can be game-changing when you simply reduce dietary histamine, even though these are all the foods that so commonly promote health; fermented foods such as kombucha, sauerkraut, and kimchi, and even spinach and avocado can be problematic if consumed too frequently by people with histamine sensitivity.
It’s virtually impossible to eliminate them completely, so you don’t need to go to dichotomous extremes with your level of histamine avoidance, but realize you shouldn’t have a high histamine food with every meal for days and weeks on end.
You don’t eliminate histamines as the solution to your symptoms of SIBO. You have a histamine reaction because you have an inflamed gut. It’s this balance to remember.
The next one would be a low FODMAP diet. This is a diet low in carbohydrates, fruits, and vegetables, specifically the ones rich in the prebiotics they are powerful at feeding bacteria. Essentially, one of the main principles of a low FODMAP diet is it restricts these foods.
Since people with symptoms of SIBO have too much bacteria, feeding that bacteria would logically not be a good idea. Many high FODMAP foods are classic healthy foods, but what’s important is to focus on eating foods that you will benefit from dietarily. As an example, broccoli, cauliflower, and avocado are all high-FODMAP. Oftentimes, when someone goes Paleo, they cut out grains and start eating more vegetables, and they feel worse. This may be when a simple adjustment of eating low-FODMAP is a good idea. And again, try for 2-3 weeks and see how you feel.
We know that a low FODMAP diet can reduce leaky gut, inflammation, immune activation in the gut by decreasing histamine and may actually enable the increased growth of serotonin and PYY cells in the intestines to look more like that of healthy controls. Again, the magic is in the variation. Periods of dietary change are actually good regardless of the temporary changes it makes in the microbiome. As people become healthier they are able to thrive on a broader array of foods.
Probiotics, enzymes, and other non-dietary interventions.
We know that sleep, exercise, and stress management are important. Where people can become stuck, is focusing so much on diet that they forget to dive into some non-diet related changes. This is important because you can’t force a dietary solution to a non-dietary problem.
One of the next things you can do that can be very helpful is a course of probiotics. And it’s confusing, as there are hundreds, if not thousands of products out there.
There are 3-4 categories that almost any probiotic product can be organized into.
- Lactobacillus acidophilus and bifidobacterium infantis.
- Saccharomyces boulardii containing probiotic.
- Spore-forming, or soil-based probiotic.
It’s important to keep in mind, however, that the majority of people with either be neutral or benefit from the use of probiotics. There is a smaller subset that may notice a negative reaction. Why the category system is helpful, is if you try product after product and you keep having a bloating reaction, you can eliminate categories that are not working.
You can, in a very short time, personalize a probiotic protocol for your individual gut. One of the most powerful steps can be a high-quality probiotic, taking into consideration the different categories to help personalize the mixture to an individual.
I’d like to point out this potential pitfall as well. When you find one that works, and then stay on it for many months, you’ll end up monoculturing.
You must rotate bacteria, even go on and off of your probiotics.
Along with probiotics is the consideration of adrenal support and enzymes, particularly hydrochloric acid (HCL). I always want to qualify that for the individual, however.
The goal is to create a healthier milieu in the gut soil globally.
You can perform some pushes and pulls to the gut milieu and read your response to figure out what’s working well for you. Instead of having to worry about the metrics of a diagnosis, you can start by giving a gentle push to the microbiota and thus, hopefully, the microbiota will rebalance to a healthier equilibrium. Enzymes and HCL can help support this approach.
Sometimes it’s a simple adjustment to the dose and the duration. Sometimes we have to add in anti-biofilm agents to help with the stubborn colonies and/or along with that, anti-inflammatory and specific antiprotozoal agents. The nice thing here is you have one agent that can act as both of those.
If, after tweaking your diet and trying probiotics you’re not able to resolve your symptoms of dysbiosis, then herbal microbial agents can be one of the next things to consider. Herbs like oregano, allicillin, and berberine are great choices. The nice thing about these herbs is they will act against bacteria, fungi, and parasites all at the same time. You’ll also want to take these away from your probiotics.
After someone performs antimicrobial therapy, I do recommend you try a prokinetic. Prokinetic is an agent that helps to keep food moving through the intestines at an appropriate pace.
To take a broad-spectrum of natural prokinetic—many of the ingredients in these are very novel and, arguably, maybe even health-promoting like ginger.
You will want to wait until this point until you try experimenting with increasing the prebiotic and fiber content of your diet. People who are the most symptomatic have the highest chance of negatively reacting to prebiotic and/or fiber supplements.
It seems that the more symptoms of SIBO, the higher the probability that you’ll have a negative reaction to fiber or prebiotic supplementation or high levels in the diet. You’ll want to wait until you’ve gotten a little bit down the road of the gut-healing protocol to then cautiously introduce these to see if you will have a negative reaction. Then if you do, you’ll want to stop.
Prokinetics help to ensure adequate movement of food through the intestines. When there’s inadequate or slowed movement of food through the intestines, that’s one of the underlying causes of SIBO. However, there are no studies of natural treatments.
I would only recommend that you use prokinetics after you’ve gone through all the other steps in the protocol because you want to make sure you use this at the appropriate point in the sequence.
Then the furthest or the highest escalation of antimicrobial therapy can be a liquid-only meal replacement known as an Elemental Diet.
An Elemental Diet is essentially a meal replacement shake that is devoid of any artificial sweeteners, colorings, fillers, excipients, prebiotics, and it’s super hypoallergenic and gut-friendly. An Elemental Diet is known to help reduce both symptoms of SIBO and gut inflammation.
There’s a newer generation coming out that are palatable. If you are not responding to anything else, sometimes knowing that you can use a good elemental diet formula can be a real game-changer.
What if I want to get testing?
The reason I say testing isn’t entirely necessary, is because long term success can be garnered when we discover what combination of factors best support your individual gut ecosystem. Factors like diet, lifestyle, probiotics, prebiotics and fiber intake, fasting and use of herbal antimicrobials. This often means NOT treating test results but rather treating you as an entire person, your gut as a unique ecosystem and listening to your body’s response. By combining validated treatments, via a conservative and pragmatic approach, you can obtain excellent results.
There’s a breath test that can be performed for SIBO, though a SIBO breath test is not the final data point dictating treatment decisions. If you use the SIBO breath testing the right way, conservatively and in conjunction with someone’s history and symptoms, it can be helpful. Therefore, I recommend never making treatment decisions based on lab testing alone. This is why a SIBO breath test is not the final data point dictating treatment decisions.
Now, that can be helpful, but you will see disparate recommendations. Some people will vehemently recommend testing every time they go in to treat SIBO and perform serial retests. I think that that contingent is slowly becoming a bit less testing prone as we’re learning more about this. You will see others who recommend no testing at all. I think the truth lies somewhere in the middle, probably a little bit closer to the no testing at all.
The North American Expert Consensus2 concluded fairly liberal use of SIBO breath testing. The Rome Consensus3, which is probably the most highly regarded body in gastroenterology in the entire world recommended reserving it for select cases where you had evidence of malabsorption. One systematic review suggested treat to get a baseline to see if that’s one of the chess pieces on the board, and then from there, treat empirically, which is what we do in the book. Treat empirically, meaning treat someone, observe the response, and then use their response to adjust the treatment.
There are also other tests that can be done. There are other breath tests that can be done for H. pylori. Another option, which is testing with an endoscopy tube, taking a sample out of the small intestine, and culturing that sample. There are stool tests, of course, that can be done for other types of dysbiosis. There are even blood tests that can be performed and other urine tests. It’s tempting. I understand. In theory, it’s tempting to say “If we’re not assessing, we’re guessing.”
There’s another aspect of this, which is very important, is that we need to continue to listen to your body for changes, because it’s tempting to only look at what the labs show. This is one of the ultimate travesties of a testing-heavy method of practice is we don’t get those absolutely valuable pearls from your body’s response to steer how you’re moving things forward.
My goal is to bring this back to the simplest core set of recommendations, treatments, and tests. Simple is always best.
Dr. Ruscio recited a perfect Einstein quote to summarize this:
“If you cannot explain something simply, then you don’t understand the problem well enough.”
In other words, we should not conflate being remedial with being simple.
There is a lot that we know works. Sometimes we’re so busy chasing down the exotic, the new, and the complicated, that we haven’t even mastered the therapies that we know work. I would be doing you a disservice if we’re getting distracted from what we know works.
I do see validity in testing to identify what type of organisms (hydrogen or methane) if you’re using pharmaceuticals, because then you would want the one certain pharmaceutical that matches, depending on what it is.
Again, do we need to make it more complicated like that? I really don’t think so. I would rather have someone undergo antimicrobial therapy, look at their response, and then adjust accordingly. If you get so caught up in all the details of these tests, you may miss some of those simple directing cues at the expense of trying to analyze all of this complicated lab data that you’re pouring over.
I think there are two things that are the most important for people to keep in mind.
One is to be careful with where you get your information. I say that because I’ve seen enough my clients read on the internet why they should avoid low FODMAP, or carbs, or lectins, or oxalates, or fiber, or gluten, and they’re not given the context and the carefulness with the crafting of the message. They end up making themselves sick or making their lives more difficult because they have this fearful relationship with food.
If that’s happening to you, it’s really detracting from your health rather than contributing to your health.
Dr. Ruscio referenced mindset quite a bit during our conversation, and applied this Nietzsche quote:
“He who has a why to live can bear almost any how.”
The formula is simple. Diet. Lifestyle. Proper supplementation.
Keep in mind this minutiae: When people go on a low FODMAP diet, sometimes they’ll become less bloated but more constipated because the low FODMAP diet is reducing some of these fibers and prebiotics. For the majority of cases, by optimizing your diet, finding the right probiotics, using a little bit of natural laxation support (which for some people, it’s totally normal if you need that). A little bit of fiber, or magnesium, or Vitamin C, or a mixture of those can be great.
It’s important that you maintain afoot in what you want to do with your life. What happens sometimes is these come together, and people start withdrawing from their work, or from their purpose, or from even their social interactions because they’re trying to diet harder, and harder, and harder.
It’s very important to have a healthy outlook on your diet and good educators to help you achieve that healthy outlook. Then you can keep that purpose in your life because that purpose will help pull you through some of the challenging times we all go through.
- Konrad P, Chojnacki J & Kaczka A et al. “Thyroid Dysfunction in Patients with Small Intestinal Bacterial Overgrowth”, Europe PMC, 44(259): 2018, pp 15-18.
- Harper A, Naghibi MM & Garcha D. “The Role of Bacteria, Probiotics and Diet in Irritable Bowel Syndrome”, Foods. 2018 Feb; 7(2): 13
- Gasbarrini A, Corazza GR, Gasbarrini G, M. “Methodology and indications of H2-breath testing in gastrointestinal diseases: the Rome Consensus Conference”, Aliment Pharmacol Ther. 2009 Mar 30;29 Suppl 1:1-49. doi: 10.1111/j.1365-2036.2009.03951.x.