It has been awhile since I last updated the blog—And boy have I missed it. Between running a business and starting my podcast, my time has been limited. But, I am rededicating to write at least 1 blog each month. Please hold me accountable if content lags. I am not apposed to a kick in the butt from you to get writing!
Having worked with 100s of SIBO/IBS clients at this point, it has become increasingly clear how many problems there are in the conventional and functional medicine approaches to SIBO. My clients have usually seen multiple GI docs and functional medicine docs with little results. Many even describe the popular protocols made their symptoms worse.
My clients come to me frustrated, confused and sometimes believe that they will just have to learn to live with SIBO forever. I have been in the SIBO pit of despair myself and it is not a fun place to be. But, many of my clients and I have also come out the other side. So, don’t lose hope yet!
And its not just the SIBO sufferers that are frustrated—the practitioners are frustrated too. Even many functional docs don’t know how to help their chronic SIBO sufferers beyond basic SIBO protocols. Many are not specialized in SIBO and they are just trying use the knowledge they do have to help.
The simple truth I have seen working with many SIBO sufferers is that popular SIBO protocols don’t work long term. You are not doomed to have SIBO forever. You are not broken—the solutions are.
Both the functional and conventional medicine space needs to take a hard look at how they are addressing SIBO. I am frustrated as a practitioner seeing the setbacks that many of my clients face because of the failed protocols they have done under the guidance of another practitioner! I usually have to work my clients out of a bigger hole than when they stared their gut journey.
And I am not trying to throw anyone under the bus, but when my new clients have tried all the popular protocols with little to no success—it is time to rethink the paradigm and how we are addressing SIBO as a collective.
Please allow me the remainder of this post to lay out what the main problems are in the current SIBO model.
#1. One-Sized Fits All Approaches
Probably the number one problem I see is that conventional, functional and integrative health practitioners are using the same protocols for everybody. Usually that is a restrictive diet and some sort of antimicrobials. Usually they are focusing primarily on clearing the SIBO.
One of the most important things I have learned is that every client I work with has different genetics, needs, goals and root causes. Functional medicine preaches to be individualized but it rarely is when it comes to SIBO from what I have seen. It almost feels allopathic but with more natural options and supplements.
The biggest problem that I see happening with these protocol approaches is that root causes get missed and never addressed. The mechanisms at play driving the gut dysfunction should be top priority. Therefore, the SIBO may get cleared temporarily but it comes back because the breakdowns in digestion and motility are not addressed.
If you are working with a provider, make to discuss the mechanisms behind your SIBO. Try to dig deeper with your provider and make sure you have a plan to address your specific root causal factors. If your provider is just giving a protocol without discussing the how to address the root causes, I would find a provider than can.
#2. Restrictive Diets
Restrictive diets get misused and abused in both the conventional and functional medicine approaches to SIBO. The biggest fall out from restrictive approaches is that nutrition takes a hit.
Through my anecdotal experience working with SIBO clients—restrictive diets lead to food fears, weight instability, nutrient deficiencies, stress and more gut imbalances. You can’t beat SIBO while you starve yourself and your microbiome on these diets.
Doing a low FODMAP diet short term may be helpful for symptom reduction for some, but is usually not necessary for all. And if you are going to do a low FODMAP diet, seek out the help from a dietitian to get the support that you need to reintro foods. Most individuals I have worked with stay on restrictive diets way too long.
My clients come to me having been told by practitioners that they have to starve the SIBO and should eat a strict diet. Not only is this usually not necessary (and I would argue it could be harmful for the reasons listed above), but they provide little to no support on implementation of the diet. This failure of oversight and guidance from their practitioner usually results in undereating.
Your gut will be dysfunctional if you are not getting enough calories. With these strict diets, my new clients are almost always low in calories. And, I am almost always left wondering—why didn’t their practitioner help them ensure they were well nourished (versus just advising restrictions)?
To be fair, most conventional and functional medicine practitioners are not super well trained in nutrition. I strongly believe that if diet restrictions are advised—that you work closely with an RD or practitioner that is qualified to support you during the process not just give you a list of yes/no foods.
Not only do restrictions starve you, but they starve your good microbes. Low FODMAP has been shown to lower Bifidobacteria and Faecalobacterium which are key species that keep your gut happy and healthy. Restricting too long leaves your gut susceptible to more imbalances, inflammation and permeability.
In general, I am working on adding as much variety into my clients diet as possible. We isolate their specific triggers and do not remove arbitrarily based off any list. I encourage my clients to experiment so that we can figure out what works and what doesn’t. I also coach my clients on how to add more foods back into their diet following being restrictive.
I also want to add that their hasn’t been any research to support that you can starve SIBO with restrictive diets. I theorize that you can not starve the SIBO as the dysfunction that leads to SIBO is way more complex than food. Food is not the problem–its the breakdowns in digestion and motility that are the real problem. The answer involves fixing the environment not restricting foods.
#3. Kill at all costs mentality
The SIBO world is overly aggressive with clearing tactics. I am horrified at times hearing my clients having been on round after round of antibiotic or herbal treatment for SIBO.
And I want to make it clear that antimicrobials are not bad and they can be very helpful, but they are not needed in every situation and they are not the only tool in the SIBO tool box. For a good portion of my clients, they lead to no change or even make things worse.
I believe the overzealous use of antimicrobials is rooted in the idea that SIBO is an “overgrowth” or over abundance of bacteria. There is newer research that supports that SIBO and IBS symptoms may be more a result of small intestinal dysbiosis versus an overabundance of bacteria. Meaning that the composition mattered more than how much bacteria was present or not.
More bacteria in the small intestines was associated with higher fiber diets, but was not associated with gut symptoms in a recent study. But, dysbiosis or imbalanced small intestines was associated with gut symptoms found in IBS and SIBO.
Pimentel recently mapped the small intestinal microbiome as well—he found that diversity was lower in the small intestines of those that had SIBO. This wasn’t the major finding highlighted in the article, but to me it is HUGE. If diversity is already low in those that have SIBO—should antimicrobials and restrictive diets be the go to strategy for SIBO since both will further lower diversity in the small intestines?
From what I have seen, aggressive kill/starve approaches shouldn’t be the go to strategy for SIBO because it doesn’t work. I hope that more studies are done soon that confirm this, but we will wait and see.
You can not just kill and starve the gut forever—you have to repair and rebuild at some point, which requires diversification of your diet and fostering microbes not killing them. You should consider the pros and cons of antimicrobials with your particular case. I would also hesitate to jump on consecutive rounds of antimicrobials especially if they have not proven to be helpful in the past.
The SIBO space is also pretty freaked out about probiotics and prebiotics but I have seen them to be valuable tools for gut rebuilding. Some people have no response to herbals at all but only improve when we start actually feeding good microbes gradually with prebiotics.
Stay open to new experiments. Sometimes feeding the microbiome with a diverse diet is just what your microbiome needs.
#4 Leaning too heavily on the Breath Test
The breath test has a lot of flaws that could alter results. Mainly, it assumes that everyone’s transit time from mouth to the large intestine is 90 minutes—which is not true as there is a great degree of variability between individuals on how fast the solution moves through the system. The reason this is important is that it can lead to false positives and negatives for the test.
I would highly recommend checking out Lucy Mailings article here to read through the all the scientific evidence on breath testing. It is so through and well done!
Some practitioners live and die by this test! My personal opinion of this test is that is should be looked at through the lens of the clients entire case and symptom presentation.
I have had a few clients who had symptom resolution and did a breath test and it still came back positive even though they didn’t have bloating, pain or discomfort any more. Does that mean that we need to jump on herbals to clear the SIBO?
Heck no! I trust how my clients are feeling instead of relying on the results of an imperfect test.
#5 Focusing too much on supplements and not enough on lifestyle
Again, I want to say that this is not an attack on supplements. They can be incredibly useful. But, more is not better. Not every symptom needs a supplement. Functional medicine providers are very guilty of oversupplementing.
I have worked with clients on 20-30-40 supplements and their practitioners never removed any—they just kept adding to their regimen. Over supplementing reminds me of just the functional medicines version of overmedicating. But, there can also be even more ethical issues as most practitioners are taking commission on their supplement sales. So the more you take, the more they make.
Some of my clients are on way too many supplements and I work with them to wean down to the most important ones. Weaning down off supplements can be a little scary but I always remind my clients that they can go back on them if they need to.
With so much focus in the functional medicine space on supplements and protocols, lifestyle approaches are treated as an after thought and not a priority. Sleep, stress management, connection, movement and play are all areas that are all neglected.
You have limited time, energy and resources when you get bogged down with a very strict diet changes and tons of supplements it can be hard to have any capacity to focus on the other key areas. I usually find that loosening the diet and reducing supplements allows for more time and energy to be focused on lifestyle.
I will also give practitioners the benefit of the doubt because many clients would much rather take a pill than work on lifestyle factors especially if there are big lifestyle issues like hating their job or a toxic relationship. Those require more drastic energy investment, so it may feel easier to take a pill versus finding a new job or going to therapy to help with your relationship.
But, no pill is going to repair being locked in fight or flight from chronic stress. If your lifestyle is causing chronic stress, you will remain stuck until you invest in lifestyle strategies.
And I believe it honestly takes a lot of coaching on the part of the practitioner to help you set goals and build progress with lifestyle goals. Our culture doesn’t value rest so it can take some mindset shifts to help my clients reach their lifestyle goals. The goal isn’t to be perfect but to continue to progress over time.
I really do believe we need to adjust how both the functional and conventional medical systems are approaching SIBO. The answer is not diet restrictions and cyclical antibiotics—this has proven not to work long term. Approaching SIBO from a root causal and individual standpoint is where the long term success lies.
I also want to emphasize that there is no one way to beat SIBO. Some of my clients liked using a little herbals, some noticed improvement with prebiotics and probiotics, others really needed to repair breakdowns in digestive capacity and motility to feel their best. Don’t be afraid to experiment even if it is outside of the typical approaches, because like I said efficacy is not high with the popular protocols.
Ok, that ends this long Ted talk like rant! Until next time 😊