September 21, 2017 by Amy Hollenkamp
During my SIBO journey, managing my weight was a monumental task. I had a very rapid and scary weight loss of about 25 pounds in a 4-month period. And I was at a healthy weight before the loss so I looked and felt quite emaciated when I reached my lowest weight.
What was even scarier than my severe weight loss was how others perceived my weight loss. There were 3 main reactions that were all detrimental to my healing journey.
First, my immediate family was legitimately worried I had an eating disorder. Their intervention strategy was not helpful, because I didn’t have an eating disorder! I just wasn’t absorbing food and felt sick when I ate.
Instead of helping me figure out why I was in so much pain and not absorbing food, they were incessantly nagging me to eat cookies and high calorie foods that I knew would make me sick! I felt misunderstood and isolated from my family in the early stages. But eventually, they realized that my weight loss was not desired and started to support my gut health recovery.
Second, some of my friends and acquaintances had an even scarier reaction then my family. Many of them praised my weight loss!! I constantly heard compliments like “you look so good” or “I wish my arms were as skinny as yours”. I felt like death, but at least I looked good was the disturbing vibe I would get from some of my friends and co-workers.
Third and the scariest reaction of all, my conventional doctors seemed unconcerned by my severe weight loss. I think it is common for doctors to ignore weight loss if the patient still falls in the normal BMI range, which I did (just barely).
In fact, malnutrition is commonly under-diagnosed in hospitals. The inability to flag malnutrition demonstrates the failure of the conventional medical system to fully recognize the critical role nutrition plays in health and disease. How is nutrition supposed to be viewed as a valuable tool in disease prevention and management when doctors only average about 20 hours of nutrition education in their whole medical training?
Far too often doctors’ lack of nutritional awareness allows malnutrition to slip through the cracks. But a good dietitian or functional practitioner understands the consequences of unintentional weight loss and will act with a sense of urgency when they see rapid weight loss in their patients. But, many SIBO sufferers are left to their own devices to halt any weight loss, because they can’t afford or they don’t have access to a dietitian or functional practitioner.
But, our inability to recognize rapid weight loss as a serious problem is even more rooted in our societies idolization of thinness than the failure of our docs to diagnose malnutrition. As a culture, we equate thinness with health. Our hungry runway models strut down the cat-walk with BMIs under 18 and show clinical signs of malnutrition.
When we live in a country that strives to look malnourished, it is no surprise that we can fail to see weight loss as a serious problem. I have seen some in the SIBO community even celebrating their steep weight loss. That always terrifies me!
Losing large amounts of weight before and during treatment should be seen as a warning sign (not to be ignored or celebrated)! If you are experiencing uncontrollable weight loss, you are probably either not absorbing the food you are eating and/or not eating enough calories.
SIBO patients are at high risk for losing weight due to three reasons:
- The overgrowth is disturbing optimal digestion and absorption. In the case of SIBO, you aren’t what you eat….you are what you absorb.
- SIBO symptoms (nausea, fullness, reflux etc) may make it more difficult to eat the right amount of calories.
- Overly restrictive diets can make it easy to under eat. Nothing sounds appetizing when you are eating the same 10 foods.
How to determine if you are losing too much weight??
Weight loss criteria for the diagnosis of malnutrition for chronic illnesses by the American Dietetics Association are:
- equal to or greater than a 5% loss of body weight in 1 month
- equal to or greater than 7.5% loss of body weight in 3 months
- equal to or greater than 10% loss of weight loss in 6 months
- equal to or greater than 20% loss of weight loss in 1 year
Malnutrition refers to the deficiencies, excesses or imbalances in a person’s intake of energy and/or nutrients. If you are not eating and/or absorbing enough of food, you can easily become malnourished.
I lost 11 % of my body weight in the first month and about 18% of my body weight in total unintentional weight loss, which should have raised some alarms with my physicians. But, my doctors didn’t really take my weight loss that seriously, because I still had a normal BMI. Any dietitian would have clearly classified me as malnourished. Based on my interactions with others in the SIBO forums, many SIBO sufferers would meet the criteria for a malnutrition diagnosis.
If you meet this criteria, make sure to bring it up to your doctor or health care practitioner. If they wave off your concerns, than you should find a new doctor!
The consequences of being Malnourished with SIBO!
Whether the malnutrition stems from chronic under eating or from malabsorption, it is going to be impossible to heal from SIBO if you are starved of nutrients! I want to highlight the two biggest repercussions of chronic undernourishment and how that hinders SIBO recovery:
1. Malnutrition is disastrous on your hormones.
When we are underfed, our chronic stress response (the HPA axis) becomes activated and cortisol levels will start to rise. High cortisol levels will down regulate thyroid hormone activation and synthesis, which will slow down your metabolism. This down regulation of the metabolism may have developed as an adaptive response to food scarcity. Your body is essentially trying to slow the burning of your fuel while supplies are low.
Lower thyroid hormone activity is very problematic when trying to clear SIBO. Hypothyroidism caused by chronic stress activation and a general lack of nutrients from malnutrition will slow the motility of food through the GI tract. With motility impaired, the small intestine is a ripe environment for an overgrowth.
In addition, HPA activation will further promote a SIBO friendly environment by reducing blood flow, enzymatic release and nutrients to the gut impairing digestion and weakening gut barrier function. Therefore, chronic stress activation from malnutrition can wreak havoc on the gut.
Sex hormones will also plummet if your percentage of body fat becomes too low. Leptin is a hormone produced by our fat cells that tell our brains that we have enough fuel (energy reserves aka fat) stored in our bodies. It sends satiety signals to the brain to tell us to put the fork down.
But as we lose body fat, leptin levels fall and signal to your brain that energy stores are low. Since reproduction is the most energy expensive process a human can invest in, the brain will suppress sex hormone synthesis when leptin is low to prevent wasting scarce resources.
You can’t have babies if your body is starving! Low sex hormones from malnutrition and low leptin levels is a huge reason why woman with SIBO lose their periods when they lose too much weight.
If you lost your cycle and have lost some weight when you started a restrictive SIBO diet, you may not be getting enough calories or nutrients to support hormone synthesis.
2. Nutrient deficiencies are eminent and will prevent healing
The fewer calories and nutrients you are consuming/absorbing the greater the chances are that you aren’t meeting your bodies needs. SIBO impairs absorption on its own and when this is paired with undereating caused by an overly restrictive diet nutrient status is hit doubly hard.
From a macronutrient level, you need enough calories to provide you with fuel for energy metabolism, immune function, repairing the GI tract, hormone function and to spare your muscles from wasting.
In particular, eating enough protein is crucial for maintaining and repairing the intestinal barrier and to maintain muscle mass.
Carbs are important to feed brain cells and RBCS, to support hormone function and to spare protein from being broken down from the muscles to be used to make glucose.
Micronutrient deficiencies will also develop when you are undereating. The fewer the calories you eat/absorb the harder it is to maintain proper vitamin and mineral levels. And you need micronutrients to heal from SIBO!!
Adequate levels of macro and micronutrients are essential for proper gut function. In particular, the immune system of the gut will start to atrophy if proper nutrients aren’t available to support it’s function.
Secretory IgA is an antibody found in the mucous layer above the gut lining that serves as the first line of defense in protecting us from toxins and pathogenic microorganisms that we consume. In terms of SIBO, IgA is essential for fighting off and preventing overgrowths of bacteria in the small intestine. When IgA becomes low, bacteria, toxins and food will bypass the mucosa causing an immune response which creates an inflammatory cascade in the body.
Kiran Krishnan, a crazy smart microbiologist and gut health expert, says that when individuals with gut issues and food sensitivities limit the diversity of their diet, their secretory IgA usually declines. He attributes this mostly to nutrient deficiencies that ensue from a restricted diet. Zinc, vitamin C, selenium, choline, glutamine, glycine and omega 3 fatty acids are key nutrients for IgA formation.
If your immune system in the gut is on the fritz from lack of nutrients, you can guarantee that your SIBO is not going to clear any time soon. Running some tests to check nutrient levels is a good idea if you can afford it. You may require some supplemental nutrient support during your treatment until you can adequately meet your needs with a diverse diet.
Why are you losing weight? Are you under-eating? Not absorbing?
If you are struggling to maintain your weight, you should determine if the weight loss is due to problems with absorption or from too few calories. These are also not mutually exclusive. I think many SIBO sufferers are both experiencing impaired absorption and eating too few calories. Naturally their could be some level of malabsorption if SIBO is active.
I think a good first step is to rule out any deficiencies in absorption. The easiest and cheapest way to assess this is to check out your poop! Undigested food stuff in your stool can be a good indication that you aren’t absorbing properly. Oily, pale and malodorous poop can also indicate malabsorption. Stools that float and are harder to flush can indicate malabsorption too.
A comprehensive stool analysis can also give you an idea about your absorption capacity. Levels of fecal fat and protein breakdown products found in the your stool can indicate if you are absorbing properly. Pancreatic elastase can aalso indicate any digestive enzyme inefficiencies that would hinder optimal digestion and absorption.
Nutrient deficiencies can indicate malabsorption, especially iron and B12. If you are eating plenty of meat and are struggling with anemia, I would suspect malabsorption.
If absorption is deemed suboptimal, you should work with a functional practitioner to determine the cause of the malabsorption. It could be due to an unsuccessful clearance of SIBO. Some digestive support and nutritional supplementation may be necessary to address digestive and nutritional deficiencies while you are digging to the bottom of your absorption issue.
Once you have a picture of your absorption ability, you then should determine if you are eating enough calories. I definitely was unintentionally under-eating when I switched to the SCD/Low Fodmap combo when I first started my treatment. Since my diet was much lower carb than my typical diet, I underestimated the amount of fat I needed to add into my diet to compensate for the missing calories from carbs.
Plus, the diet was so restrictive that I started to dread eating. I was so bored with the limited variety. When nothing sounded good, I would only eat a small snack or I wouldn’t eat at all.
Based on what I’ve observed in the SIBO community, I think that it is under-eating is quite common when switching to a lower carb or SIBO style diet. If you started unintentionally losing weight when you began a restrictive diet, I would suspect that you are not eating enough calories.
To confirm that you are under-eating, track your calories for 3-7 days to get an idea of the average calories you are actually eating. I find the USDA SuperTracker to be a useful tool when trying to track calories.
You can compare your average calorie intake to your estimated calorie needs using an online calorie calculator. If you are chronically eating less than your estimated needs, then you would benefit from increasing your calorie intake.
There are also some common symptoms of under-eating such as hair loss, feeling cold, sleep problems, blood sugar swings, mood swings and constipation. Check out this article written by Laura Schoenfeld, an registered dietitian, to learn more about the signs of undereating.
Malnutrition during SIBO treatment from malabsorption and/or under-eating can derail SIBO recovery. You can not heal from SIBO if your body is starving. Losing a couple pounds is probably not a big deal. But if you experience moderate to severe unintentional weight loss, I would work closely with a medical professional to stabilize or regain weight.
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Until next time!!