The Long Game: Living with SIBO Beyond Restrictive Diets

Colorful: Salad with Chickpeas & Tofu (aka low-FODMAP, plant-based proteins)

Recently, a reader asked how I was doing on my long-term keto diet. And I was like, what long-term keto diet?

So I'd like to make something clear.

I am not on a long-term keto diet! Yes, sometimes I eliminate carbs for a few days to get my digestion back on track, or to recover from a carbohydrate-induced IBS/SIBO flare. In cases such as these, three days of keto is a godsend.

I discuss doing a keto reset on one of the most popular Sexy Sibo blog posts to date: The Main Idea: Ketogenic Healing and a No-Bloat Food List for Meaningful SIBO Reduction, which you can read here.

That post, written in 2015 during a moment when I had been eating keto-style for 10 days, is a classic. However, please don't think for a moment that I have been following a strict ketogenic diet ever since then, nor that I think you should.

Au contraire.

Here's a fun fact. When I started Sexy Sibo back in 2015, it was one of the first blogs about SIBO in the world! Almost nobody knew what SIBO was in those days.

But things have changed. There are many SIBO blogs now, and many SIBO specialists. There is a SIBO summit here, and another SIBO summit there. There are SIBO conferences, SIBO books and SIBO protocols. And there are promises. Lots of promises. "Take this (or take that) and get cured." "Eat this (or eat that) and get cured."

I've even seen a recipe book that indicates you can clear your SIBO in 30 days.

Listen. I've been actively dealing with my SIBO for a solid 5 years now. And in that time, I've come to terms with another fun fact that, at first, was tough to accept.

It is quite possible, if not likely, that I may never 100% "clear" my SIBO. 

Once upon a time, it was very exciting to think I could figure this thing out and get permanent relief, once and for all. I no longer think this way.

I don't think the digestive tract of a middle-aged person can ever become the digestive tract of a 12-year old, or even a 25-year old person. Microbes build up over a lifetime. They move in, and they stick around—literally, inside a safe, sticky biofilm. A Biofilm of Doom, if you like.

But that's just how it is. THERE'S NO ESCAPE, MY FRIENDS!

And, as the saying goes, A man's gotta eat—(Note: by "man" here, I mean human). So, no. I am not following a lifetime diet of meat, fat and green vegetables.

Ketochrome: Short Ribs in the Slow Cooker

I've widened my scope quite a bit and regularly include many more plant-based, starchy/carby foods in my diet than I did at first. These foods include organic brown rice cakes and whole grain basmati rice, as well as Jasmine rice. They include extra-firm tofu now and then, roasted beets on a salad, winter squash several times a week, low-FODMAP fruits here and there and even, in season, a high-FODMAP fruit or two. For instance, Honeycrisp apples. Or a ripe, juicy peach on a hot summer day. (Did that peach make me bloat? Yes. Was it worth it? I think so.) I may even have some delicious medjool dates or Turkish figs with yogurt for dessert.

If you are just discovering you have SIBO, do please (with the blessing of your primary care provider or other healthcare professional) try the low-carb and SIBO-safe diets I recommend elsewhere on this blog. Consider doing a round or two of antimicrobials, herbal or allopathic. See how far you progress and pay attention to what works for you.

This last bit is the key. For a long-term approach, you'll need to find out what works best for you, and is sustainable for your body, mind and spirit.

It's important to have access to something like my 3-4 day keto reset to fall back on, because there will be times that you REALLY need relief. But it's also important to have pie once in a while. Finding the balance and learning to adapt is the journey.

One more thing.

Personal experience has taught me that if I restrict my diet too much, or for too long, I tend to binge. That is a miserable cycle. So, after 5 years of dealing quite intensively with my SIBO, I have consciously, lovingly, given myself permission to be bloated.

Today, 5 years in, my focus is on finding balance with my diet, digestion and lifestyle using an informed, intuitive eating approach. Because low-FODMAP diets are incredibly well researched for IBS, I tend to rely on low-FODMAP foods most of the time. If I flare, I drop back to keto. Day by day, I try to be aware of and honor my needs—physical, emotional, spiritual. Food has a place in all three.

Please check out my official website www.eat2evolve.com to learn more about my work, outside of the Sexy Sibo arena. I am currently becoming certified as an Eating Disorder Recovery Coach while keeping my Certified Nutrition Specialist credential up to date and offering Nutrition Therapy sessions—both in person at my office in Hadley, MA and via phone consultation for those who live at a distance. I would love to work with you!

May you be comfortable, joyful and deeply nourished.

xo Diana

Support for Constipation & Motility

Supporting gastrointestinal motility and bowel regularity are core features of a comprehensive treatment protocol for SIBO and IBS-C.

I've been hard at work behind the scenes at my day job (Product Development Manager at Moss Nutrition) developing two new products to address these needs and I am thrilled to announce that both are now officially launched!

MMC Select™ is a prokinetic formula designed to help promote gut motility by supporting healthy function of the migrating motor complex (MMC)—the "cleansing wave" that sweeps food, bacteria and debris out of the stomach and small intestine towards the colon. As we've discussed before on Sexy Sibo, the MMC is active between meals when the digestive system is at rest, which is why practicing "meal spacing" is so important for SIBO! MMC Select™ contains a careful selection of evidence-based ingredients for motility support: organic prokinetic ginger root, a premium concentrated DGL deglycyrrhizinated licorice extract researched for motility support, 5-HTP + P-5-P to help increase gut serotonin levels, absorption-optimized anti-inflammatory curcumin phytosome and alkalinizing potassium, a traditional prokinetic nutrient.

Colon Select™ is designed to help provide safe, gentle relief from occasional constipation with meaningful levels of researched and traditional ingredients. This formula features:

• Magnesium in two forms: ascorbate (vitamin C) and hydroxide
• Triphala, the revered Ayurvedic triple herb combination for enhancing bowel tone & function
• Aloe ferox extract (Cape Aloe) in the clinically relevant potency for helping to promote elimination: minimum 18% aloin content
• A blend of 5 time-honored botanicals to help stimulate complete and comfortable bowel movements: Marshmallow, Ginger, Sweet Fennel, Barberry Bark & Turkey Rhubarb Root.

Click on the product names above to visit the Moss Nutrition website and read more about these fabulous SIBO-specific products. I am so happy to be able to offer them to the world, and to my patients and clients in particular! (If you are a new patient or client, contact me for details about ordering.)

Yours in joyful service,
Diana🌀

"The pain's just a program."

I’ve been watching Season 2 of Westworld, which is currently being released in single episodes on Sunday nights. The sci-fi plot is fascinating in a semi-incomprehensible, deeply philosophical kind of way, which I love. But overall, the show is so horribly violent that every week I ask myself if I even want to keep watching.

Then I do.

In this week’s episode, one of the main characters needs to strap himself into a torturous device that will saw through his cranium, remove a circle of his bony skull cap and extract a small mechanism buried inside his brain, all while he is wide awake with no anesthesia.

Naturally the character is afraid of how painful this surgery will be, but it’s the only option, the world is at stake. As his head is being locked into position, he steels his resolve with these gritty words: “The pain's just a program.”

Granted this character is a Host, rather than a human. In Westworld, Hosts are extremely lifelike robots or cyborgs, who actually can think and feel. However, everything about them, including their mind, is manmade. Their flesh and blood only look, taste and smell exactly like “real” flesh and blood. Ultimately, every thought and sensation they experience is computer-generated. Even though they can feel it. The pain is just a program.

I’m thinking about this as I wake up and deal with my own pain. My gastrointestinal discomfort, which I live with every day, which goes hand in hand with my IBS and SIBO. This pain is just a program of my condition. How I respond to it, on the other hand—the story I tell myself about it, the program I assign to it—is up to me.

Pain is a hallmark of irritable bowel syndrome (aka IBS, aka the mother of SIBO). Irritable bowel syndrome is, of course, the most common gastrointestinal disorder in the developed world, “affecting 5%–27% of Western society. GI symptoms, including abdominal pain, bloating, distension, excessive wind, and altered bowel habit, characterize this condition when anatomical abnormalities and inflammation have been excluded.” [Extending Our Knowledge of Fermentable, Short-Chain Carbohydrates for Managing Gastrointestinal Symptoms. Jacqueline S. Barrett, PhD, BSc (Biomed)(Hons), MND Nutrition in Clinical Practice Volume 28 Number 3 June 2013 300–306.]

Abdominal pain. Bloating and distension. Excessive wind. Sound familiar?

In addition to pain itself, many people with IBS are known to suffer from something called chronic visceral hypersensitivity (also referred to as bowel hypersensitivity). Viscera in this case means our intestines, and hypersensitivity means we feel more sensation there, in our visceral, abdominal gut region, than normal people without IBS might tend to feel. A tiny bit of pressure feels like a great deal of pressure. A great deal of pressure feels unbearable.

I know this symptom well. It’s rare that I DON’T feel some pressure in my viscera, even after a good night of sleep and 12 or more hours of overnight fasting. To my disappointment, most days I wake up feeling not-empty. When I check my profile in the mirror, indeed my stomach is usually bloated. But often, it is not as bloated as it feels. And even if it were: Feeling bloated is just a program.

Bloating is not my first choice for a program. I’d rather have a different program. But I don’t. This is it, baby. It’s a FEELING. Feelings come and go. Some stay for longer, some for shorter. Long or short, it’s important to remember this:

I have feelings, but I am not my feelings.

And also:

This, too, shall pass.

One problem with visceral hypersensitivity is that it impairs your ability to ascertain whether the stomach is empty or full. This makes it tough to practice something like intuitive eating, a wonderful, non-dieting approach to food intake. Intuitive eating encourages tuning into and respecting the body’s natural hunger and satiety signals. But how can we respect our body’s signals when they are indistinct, if not indiscernible, due to a functional flaw in our hunger/fullness-perceiving mechanism. Can you say Catch-22?!

This problem is compounded by the fact that when a person with IBS feels bloated or in pain (which is, essentially, most of the time), the pain goes away while they are eating. Eating when in pain is never a good idea, everyone knows that. But ironically, the act of chewing and swallowing food causes the brain to release sedating serotonin and pain-killing endorphins. Therefore, eating makes a sore gut feel better, but only during the act of eating. Afterwards, it often feels way worse.

This final irony is really a challenge for anyone like me who’s ever suffered from a binge-type eating disorder and now has IBS. Your whole, viscerally hypersensitive, digestively disordered life can start to feel like one gigantic, non-stop trigger. Every. Single. Day.

So, let’s talk about IBS and eating disorders.

For a long time, researchers have recognized a strong association and even a causal relationship between IBS and disordered eating, particularly disorders of the binge eating (BE) type. Both bulimia nervosa (binge/purge cycling) and stand-alone binge eating disorder (formerly known as compulsive overeating, now simply BED) can lead to the development of irritable bowel symptomology.

In other words, eating massive quantities of food—not just once in a while, as on Thanksgiving, but day after day, again and again—screws up your gut.

This is not a shocking conclusion. It makes sense that chronically overloading your stomach, with or without puking afterwards, would screw up your gut, but why exactly this happens is not known for sure. An excellent research paper entitled “Binge eating, body mass index, and gastrointestinal symptoms,” posits three possible mechanisms for the observed association between bingeing and IBS. Because this is so important and so well-referenced, I’m going to quote the article verbatim, then summarize the passages underneath. Feel free to scroll down if technical jargon makes your brain hurt, otherwise, enjoy:

“The significant, positive association between BE and IBS symptoms, which persisted even after introducing potential medical and psychiatric morbidities (e.g., hypertension, Crohn’s disease, depression) and BMI, suggests that the influence of BE is particularly robust. Given the exploratory nature of the current analyses we present three potential interpretations of the underlying association between BE and IBS. First, both BE and IBS have demonstrated important relationships with psychosocial stress [29–31]. Stress is known to be a common precipitant of BE [29] and many individuals who struggle with this behavior may be prone to using BE in an effort to reduce anxiety or dysphoria [31]. In addition, stress is thought to play an important etiological role in functional GI disorders (the most common of which is IBS) [30, 32–35]. The observed association could potentially reflect a pattern that would be expected to occur if stress were a critical third variable that influenced both BE and IBS. While the current analyses do not lend themselves to mediation to assess the influence of stress, such analyses would be important to undertake in future studies.

“A second hypothesis is that the acute symptoms of IBS (e.g., nausea, diarrhea) may cause patients to either severely restrict their diets so as to avoid specific foods or to undergo prolonged periods of restriction to avoid IBS flares. Given the known association between dietary restriction and urges to binge [36], the observed association might suggest an inadvertent side effect of attempts to avoid IBS episodes via food restriction or limitation.

A third hypothesis is that individuals with concurrent BE and IBS may experience acute symptoms of IBS as a result of bingeing on foods that are not well tolerated. Symptoms of IBS are often triggered by food intolerance, particularly with foods that are high in fat content [37–39]. Macronutrient studies of those who engage in BE reveal that typical binge episodes are dense with high-fat foods and carbohydrates [40]. Thus, patients who struggle with BE may be more prone to IBS flare ups given that their binges are likely to be rich with foods that are poorly tolerated due to IBS.” [Peat CM, et al. Binge eating, body mass index, and gastrointestinal symptoms. J Psychosom Res. 2013 Nov;75(5):456-61.]

Okay, allow me to break those long paragraphs down to their essence:

Three Possible Reasons for the Association Between Binge Eating and IBS

1) Psychological Stress (causes both compensatory overeating, and cortisol-induced GI issues)

2) Restricted Diets that Eliminate IBS Foods/Triggers (dieting behaviors, rigid food plans, and restricting food intake in general causes compensatory bingeing)

3) Typical Binge Foods are IBS Triggers (the 2013 article mentions ‘foods high in fat and carbs’ as a primary culprit; if it were written today, I expect they would specify FODMAPs.)

Did someone mention Catch-22?

Now, just for fun, let’s throw visceral hypersensitivity into the mix. Feeling bloated all the time not only causes and increases stress levels, it makes it almost impossible to know, based on natural signals from your gut, if you are hungry, how full you are becoming during a meal, and when to stop eating. However, if you try to follow a portion-controlling food plan, you’re restricting. If you try to follow a SIBO-friendly or Low-FODMAP Diet, you’re restricting. And restricting leads to bingeing, and bingeing leads to IBS, and will you ever get off this merry-go-round, and if that isn’t stressful, I don’t know what is!

Talk about crazy making.

Okay. Deep breath.

It’s no surprise that stress is number one on the above list. Stress is at the root of IBS, no question. Therefore, finding ways to reduce and manage stress is of PRIME IMPORTANCE for people with IBS and SIBO. I can’t stress this enough, and it’s a big piece of what I work on with clients.

As for items 2 and 3, here’s where things get even trickier. It’s a fact that fermentable sugars and carbohydrates feed SIBO bugs, and that most fats and proteins don’t. Following a SIBO-smart diet is the most direct way to reduce the famous SIBO symptoms of gas and bloating. But if we force the diet or we restrict to tightly for too long, we risk going off the rails in a big way and really setting ourselves back.

This is the dance, finding the sweet spot between SIBO-smart eating and ease. Learning how to make intelligent boundaries around our food, eating inside those boundaries, allowing ourselves to eat outside those boundaries, and noticing the consequences of both. Living with it, and circling around, consciously.

As a clinical nutritionist specializing in SIBO, people expect me to practice what I preach, so I want to be clear: I don’t just preach “Eat this, don’t eat that.” I also preach tolerance. I also preach self-love. And what is very important for me, and for all of you to understand, is that everyone is ALLOWED TO GO OUTSIDE THE BOUNDARIES. Eating outside the SIBO-safe box doesn’t make you bad, wrong or undeserving in any way. It may make your tummy sore, it may make you gain weight, it may make you bloated, or constipated, or give you the runs. But at the end of the day, it’s just food. Food, and your body. How your body responds to food. And whatever you are feeling today, this too shall pass.

The important question is: How do you want to feel? How do you want to feel today? And not only today, but tomorrow? Because what you eat today is going to affect tomorrow. In fact, it may affect the entire next two weeks if you really go outside the boundary of what your gut handles best. We’ve all been there, and it’s not fun.

It’s not fun, but it’s okay. The pain is just a program. The program is in your mind.

Which brings me to a fresh idea: How about moving beyond the program? How about creating more ease around all this pressure to “be good” and “stay on plan” by dropping out of the program, out of your mind, and into the moment. Ask your body what it wants and needs right now? Slow down and check in. Cultivate an attitude of loving presence by practicing mindfulness and compassionate self-love.

The longer I am on this path, the longer I cycle through struggle and resistance and surrender and letting go, the more I am convinced that BEING SWEETLY PRESENT WITH MYSELF is the answer.

Being sweetly present with myself means non-judgmental checking in. Pausing and connecting. Looking at everything I know as tools, not rules. Asking my body how it’s feeling in this moment. Engaging playfully in an ongoing conversation with my body.

“Hello, my body! How are we feeling right now? What would you like to do today?”

My body is not the enemy. My body is my friend. It responds to whatever I provide as input—movement, stillness, food, no food, water, no water—it just responds. And by responding, it speaks. My body always does the best it can, and it is very forgiving, very resilient. Most importantly, it’s always there. Talk about a loyal companion!

Here’s a sweet exercise you can try right now.  Wrap your arms around yourself. Give your own shoulders a little squeeze or a rub. Now, rock yourself gently side to side, and say, “I love you, my body. Thank you for being there for me. Thank you for always supporting me. Let’s keep talking!” After you’re done hugging yourself, try putting one hand on your belly, and one hand on your heart, and saying kind words to yourself again. “Thank you, my body, for always being there for me. I appreciate you, and I love you.”

Make friends with your body. Continue the conversation. Be curious. Keep listening. Enjoy a full, deep breath together. Ask it what it wants. Maybe it wants to eat something delicious. Maybe it wants to go outside and play. Maybe it wants to rest. Whatever it is, and wherever you are, however you are feeling, just try to be with it. Be here.

And be kind to yourself, even when you hurt. The pain is just a program. Ditto for cravings, and compulsions. You can manage them, with knowledge and with kindness, returning to yourself again and again as you journey along your own, unique path of healing.

SIBO SOS Summit

Just a quick post to make sure you've heard about an awesome webinar event called the SIBO SOS Summit taking place this week! This is the second time the Summit has aired, with all-new videos added for Summit 2. (I've been invited to be a speaker in Summit #3, so stay tuned for more on that!) Click here to watch more than 40 experts from across the SIBOsphere share a wealth of expertise and different perspectives on how to diagnose, treat and manage SIBO.

My Cheating Fart

 

Food is Love - Exhibit A

As anyone who’s ever followed a restricted diet knows, maintaining your resolve can be very, very challenging. Even if you are restricting for health reasons, even if you know what the consequences of diverging from your program will be, temptation is always out there. It doesn’t matter if you are a newbie or an experienced practitioner of SIBO-safe eating. Nobody’s perfect. We all fall down. Which is why the ability to pick oneself up is such a gift.

I haven’t posted much in the past few months. Without going into full-on confession mode, the truth is I’ve been struggling with the holding of firm dietary boundaries, and it set my progress back. I flared. I started feeling sorry for myself. My stomach hurt a lot (like every day). Constipation increased. I was gaining weight and feeling sluggish. Poor me!

It isn’t fair that fresh fruit in season is so delicious. Not to mention Kettle Potato Chips, New York Cheddar (see Exhibit A, above). It isn’t fair that others can eat those foods without consequence, but I can’t—not without paying the price in pain and bloating.

But that’s my situation. I have SIBO. And I don’t believe it is ever, forever going away. I’ve had IBS-C since I was in my teens. My gut was damaged long ago by emotional and behavioral trauma, and my motiity and microbiome is permanently altered. There is no cure. In fact, the main takeaway message (for me) from the 2017 Integrative SIBO Conference I attended in March, was this:

SIBO is a chronic, relapsing condition for the majority. Two thirds of all cases will never be cured. Ongoing management is expected.

If you are in the lucky one third of people with SIBO for whom the condition is not chronic, I am so happy for you! There’s a light at the end of your tunnel.

For most of us, though, 100% symptom resolution is not expected. Why? Because in the majority of cases, elimination of the underlying cause is not possible.

Yes, with proper treatment, 80-90% symptom resolution is expected, which is great, but relapse is expected, too. According to SIBO expert Allison Siebecker, the common timeframe for relapse is 2.5 months. But it can happen in 2 weeks, or even 2 days if there is an underlying structural cause, or if the condition was not completely eradicated by one round of antibiotics, in which case multiple rounds are called for. And even then.

SIBO is a chronic, relapsing condition for the majority.

Just as taking insulin doesn’t cure diabetes, antibiotics will not fix our problem forever. People will feel better, but not 100%. There is usually not a cure for SIBO that makes it so you never have to think about it again. Ongoing management is expected.

This is sobering, indeed. But it’s not a death sentence, no more than birth itself. Ongoing management required just means that we have to accept, grow up, keep learning and, if we chance to tumble, we get back on the horse.

Last weekend, I was fortunate enough to be in Maine and meet up with Amanda Crutcher, a nutritionist friend of mine from way back, who shined some light on my resolve. She told me how she’s eating these days, and it’s exactly how I need to be eating, too (not that I didn’t know how, but knowing and doing are two different things.)

Amanda inspired me to firm up my boundaries (no more nuts and fruit for dinner like I’d had the night before, “because I was travelling”—hel-lo!). She reminded me to focus my diet on a) vegetables that are both low-FODMAP and low starch, and b) clean animal foods.

Food is Love - Exhibit B

Clean animal food means: grass fed meats, wild-caught fish, pastured eggs and full fat/lactose-free dairy products, such as raw milk aged cheese and organic heavy cream. Amanda pointed out that chicken, upon which I’d been relying (so easy! so tasty!) often can cause problems due to being grain fed, and hence high in inflammatory omega-6 fatty acids. And she motivated me to resume the beneficial practice of Intermittent Fasting (aka Meal Spacing, a critical strategy for SIBO) with more diligence and attention.

Amanda also introduced me to a podcast called The Health Edge, which I began listening to immediately on the drive home, and am now recommending to you. Check it out!

On that note, I will leave you with a promise to always be honest here, never hold myself up on any kind of pedestal, and hopefully be back soon with more recipes, tips, resources and inspiration. May you be true to yourself and successful in your efforts. Management is not so bad. We just have to be strong, and never stop trying.

xo Diana

Hydrochloric Acid: SIBO Wants You.

Here's a trick question for you. We all know the acronym SIBO refers to an overgrowth of bacteria, in a place it does not belong (the small intestine). But how and why did that bacteria overgrow there in the first place? The answer is: it depends.

Many cases of SIBO are caused by infection. Some nice person traveling in South America catches a stomach bug, and the next thing you know, they’ve got post-infectious IBS and SIBO. For others (*blush*) it’s long-standing IBS with chronic constipation that gets the ball rolling. And then there’s that little-discussed culprit: eating disorders. The research may be scant, but in my personal experience, as a clinical nutritionist and through my involvement with various IBS discussion groups and boards, it appears that many SIBO sufferers have experienced anorexia, bulimia or binge eating. (You can count me in there, too. Full disclosure.)

Eating too much too fast isn’t good for anyone, but it’s especially problematic when what goes in doesn’t come out. Folks with eating disorders seem to develop IBS or other digestive problems across the board. Those who develop acid reflux are often prescribed drugs like Proton Pump Inhibitors (PPIs) to inhibit hydrochloric acid production (makes sense, right?). But, surprise! People taking PPIs are at high risk of developing SIBO.

The thing is, not only do we NEED hydrochloric acid to properly digest our food, we need it to digest (i.e. kill) germs. Stomach acids help to maintain proper gut pH levels in the gut and subsequently prevent the overgrowth of pathogens and bad bacteria. The less gastric acid we produce, the more alkaline our GI tracts become, and the more likely that Small Intestine Bacterial Overgrowth will follow.

Reduced acidity in the stomach may be caused by PPIs and antacid drugs like Tums, but that's not all. Low stomach acid also results naturally from the normal decrease in gastric HCl production that occurs with age. And low stomach acid essentially cripples the antimicrobial effects of healthy gastric phase digestion. Bacteria, parasites and yeasts that survive gastric phase digestion due to low levels of hydrochloric acid go forth, thrive and multiply in the warm, dark moist environment of the small intestine. 

Meanwhile, poorly broken down food particles (notably carbohydrates) that linger in the small intestine without sufficient acids and enzymes to digest them—but plenty of bacteria to frolic with—undergoes fermentation. Fermentation inside the closed tube of the intestine creates trapped gas, and from there you get symptoms such as pressure, stabbing pain, increased feelings of fullness, embarrassing flatulence and belching.

Hello, SIBO.

Now for the good news. You can boost your hydrochloric acid levels by taking a Betaine HCL SUPPLEMENT. Betaine HCL comes in tablets or capsules, and it’s not expensive. Look for a product like this one that delivers 750 mg or so per pill, and ALWAYS TAKE WITH FOOD. Betaine HCL will help boost protein digestion, increase vitamin and mineral absorption, lower gastric pH and kill off bad pathogens in your stomach and upper GI tract.

Dosing Betaine HCL is a bit of an art. To find out the actual dosage that’s right for you, start by taking one pill per meal. Then, increase your dose gradually, day by day (2 pills per meal, then 3 pills per meal, etc.) until the point where you start to feel a slight burning sensation in your gut. That is the sign you’ve reached your tolerance level. Once you’ve determined your tolerance level, drop back to the next level down and take that many going forward. (Or you can just do what I do: use your intuition and, depending on the size of your meal, take 1, 2 or 3.)

Geeky Note: Isn’t it weird to think that hydrochloric acid, one of only six strong acids on earth, is made INSIDE of our bodies? And that it can be contained in a pill, which you can safely put in your MOUTH?! Click here to see what HCL does to an apple...

Leaky Gut and SIBO: Are they BFFs or not?

A lot of people (like me) who end up with SIBO just started out with plain old IBS. Studies have found that anywhere from a meager 10% of IBS patients all the way up to a whopping 84% (hel-lo!) will test positive for intestinal bacterial overgrowth. Not all people with IBS get SIBO, therefore, but if you have SIBO, you pretty much are guaranteed to have IBS. SIBO and IBS go together like outlaws in love.

Lots of people with IBS also test positive for increased intestinal permeability—sometimes referred to as gut barrier dysfunction, and commonly known as "leaky gut syndrome."

A leaky gut situation results from chronic irritation, inflammation and immune activation in the GI tract. Alcohol abuse, aspirin and other drugs, toxins, trauma, synthetic food additives, food allergies and food intolerances (think gluten, casein, even potatoes) are some possible causes of leaky gut syndrome.

Anyway, the other day I was wondering if I have leaky gut. My thinking was that if both leaky gut and SIBO are common in people with IBS, leaky gut might be common in people with SIBO, too. Makes sense, right? But evidently, the association is not that straightforward.

A 2009 study titled The Relationship between Small-Intestinal Bacterial Overgrowth and Intestinal Permeability in Patients with Irritable Bowel Syndrome (Park JH, et al. Gut Liver. 2009 Sep;3(3):174-9) looked into this very question.

Researchers compared the digestive tracts of 38 people with IBS and 12 healthy controls without IBS. All subjects were tested for both SIBO and leaky gut, and the results were surprising.

Yes, incidence of leaky gut was higher in subjects with IBS, as expected. However, in those people with IBS, the presence of leaky gut was NOT correlated with the occurrence of SIBO.

The researchers stated, "no significant difference in intestinal permeability was observed among the patients with IBS-D, IBS-C and IBS-A". [Note: A=Alternating Diarrhea and Constipation, but sometimes called M for Mixed.] In other words, leaky gut was equally common in IBS of all types.

Not so with SIBO. The researchers had expected SIBO and leaky gut to go together like cheese and crackers, but contrary to expectations, no significant difference in leaky gut occurrence was observed between those IBS patients with SIBO, and those without.

Take home message: If you have SIBO, 
you may or may not have leaky gut syndrome, too.

Ha!

If you want to find out if you actually have leaky gut, you can take a test such as the famous Lactulose/Mannitol urine test—in use since the mid-1970s and available from places such as Genova Diagnostics. The test is pretty basic. You drink a pre-measured amount of two sugars, lactulose and mannitol, in solution, and then pee in a cup at 30-minute intervals over a 6 hour period. Typically, only mannitol, the molecularly smaller of the two sugars, is rapidly absorbed by villi in a healthy, intact small intestine, after which it is excreted in urine. The chunky disaccharide lactulose molecule is too large for normal villous absorption, and therefore should not show up in the urine, unless it managed to "leak" through the intestinal lining due to swelling, inflammation and weak gut barrier function. So depending on how much lactulose appears in the urine, leaky gut is there or not.

A nice cup of bone broth, with herbs.

If you DO have a leaky intestine, your next step is deciding how to address it.

It goes without saying that numero uno is maintaining your diet upgrade and continuing to avoid all the fermentable sugars and starches that feed SIBO bugs.

In addition, I suggest you consume bone broth made with marrow bones or meaty bones (not cartilaginous joint bones) and either drink a cup daily, or use the broth regularly in your cooking.

Leaky gut or not, bone broth is deeply nourishing for the intestinal lining.

Next, consider supplements. Interestingly, some of the so-called "top supplements" for treating leaky gut syndrome are verboten, or at least highly questionable on a SIBO-friendly diet. FIBER supplements? No, thanks! PROBIOTICS? A big question mark for SIBO peeps. (We already have too many bacteria in our guts—much of which may be the right bacteria, but in the wrong place—so adding in more doesn't necessarily make a whole lot of sense.)

But there are a few SIBO-friendly supplements that I really do like for treating leaky gut syndrome. Two favorites are L-Glutamine powder and Hydrolyzed Collagen powder—supplements that can be stirred into water and taken daily to help heal your inflamed intestinal lining. I also recommend taking digestive support with meals, both to help promote proper food digestion and breakdown, and to help minimize the chances of large undigested food particles traveling too far down the digestive tract where they can interact with and irritate your gut lining.

L-Glutamine is an amino acid that directly enhances gut barrier function and protects the endothelial cells lining your small and large intestines. Glutamine has been shown to help support the rapid turnover, healthy reproduction and maintenance of these cells. Glutamine also has an anti-inflammatory effect on the gut lining, to help further promote healing.

Collagen is a short chain protein, or peptide, that occurs naturally throughout the body as a building block of connective tissue. Collagen peptides are present in hair, skin, nails, bones, joints, cartilage and the endothelial cells lining both vascular and intestinal tissues. Collagen contains high levels of the amino acids proline and glycine which, along with L-glutamine, are critical players in repairing a damaged intestinal lining.

Digestive Enzymes supplement the function of your pancreas, an organ designed to secrete digestive enzymes every time we eat. Pancreatic enzymes are required to help us break down fats, proteins and carbohydrates. However, pancreatic function decreases with stress and age, and many of us just don't produce a sufficient quantity to do the job. Taking supplemental pancreatic enzymes or plant-based digestive enzymes can make a HUGE difference in how well you digest your meals.

Betaine HCl is a form of hydrochloric acid (HCl). Hydrochloric acid is naturally produced in the stomach to initiate protein digestion and to kill pathogenic microbes every time you eat, but again, production decreases as we age, or may be impaired by medications such as proton pump inhibitors prescribed for reflux. Many people with IBS and SIBO have hypochlorhydria, a fancy term for low stomach acid production. Taking extra helps.

I have not been tested for leaky gut syndrome and don't know if I have it, but I am currently taking a few supplements to help support digestion and promote intestinal comfort. Since readers often ask what I personally am eating or taking to treat my SIBO, I'm sharing this short list with you in friendliness, not as a prescription. (For a prescription, please email me to set up an appointment!)

Pancreatin Select is a broad-spectrum digestive enzyme that contains pancreatic digestive enzymes along with extra lipase, ox bile, digestive bitters and betaine HCl. It's fantastic. I take one or two per meal. And I'll take an additional capsule or two of straight up Betaine HCl if I'm eating a large protein meal. These two supplements are fantastic for increasing digestive power and vitality.

I also just started taking a Hydrolyzed Collagen supplement which, surprisingly, tastes awesome—kind of like whey protein. I'm hoping it will help fortify my gut lining, but other researched benefits include stronger bones, stronger joints and improved skin tone and texture, so we'll see how that goes!

Finally, I've been enjoying a drink of GI Select at least a few times a week. This product combines L-glutamine with other gut healing ingredients, comes in a powder you mix with water and tastes like lemonade. I find it to have a very soothing effect on my gut while being refreshing and hydrating. (Drinking enough water is always an issue for me, so anything that makes water taste better gets two thumbs up from Sexy Sibo.)

xo

SexySibo Safe Foods List - Updated

It's been 16 months since I posted my original "Safe Foods List" in one of my first posts on this blog. Well, today I have a new Safe Foods List to share with you. Because Things Change.

This is something you, too, will discover, as you modify your diet and advance, stall or heal on this journey. Don't consider it a setback if a food you used to be able to eat without any problem suddenly starts bothering you. Be prepared to adapt. Dealing with SIBO is an ongoing and transformational challenge. Your diet will always be a work in progress. Just keep paying attention! When you stay in sync with the body's changing needs, you can keep symptoms at bay, feel a million times better and beat the bloat, one day at a time, every day. Oh, Yeah.

2016 *NEW* SexySibo 
Safe Foods List

animal protein
-eggs
-seafood (salmon, tuna, shrimp, cod, etc.)
-meat (beef, lamb, Paleo bacon, etc.)
-fowl (chicken, turkey, duck)
-bone broth & meat stock

cooked vegetables
-spinach
-chard
-zucchini
-carrots
-green beans
-winter squash (butternut, kabocha, acorn, etc.)

lactose-free dairy
-aged hard cheeses (best are those made with raw milk, and goat/sheep milk)
-full fat Greek yogurt (no added gums/pectins) or 24-hour yogurt (GAPS style) -1/2 cup serving
-heavy cream (no added gums/pectins)

safe treats & sweets
-dry wine
-distilled spirits (gin, vodka, whiskey)
-chubby checkers (see recipe on this blog!)
-non-fermenting sweeteners: monkfruit (Lakanto); erythritol (Zero); stevia
-lemon & lime juice

----------------------------------------------------

Second Tier Safe Foods - I avoid these if symptomatic, otherwise I do okay with them.

raw veggies (stick with cooked veg when symptoms are present!)
-lettuces of all types
-spinach
-carrots & baby carrots
-green herbs (chives, dill, cilantro, etc.)
-ripe tomato
-red bell peppers
-olives

fruits (not for every day, but nice every now & then)
-avocado (up to 1/4 medium avo. per meal)
-blueberries, other berries - 1/4 cup

Takra--an Ancient Ayurvedic Digestive Remedy

 
While discussing SIBO with a colleague who specializes in Ayurvedic medicine, I learned about an ancient digestive remedy known as "Takra" - loosely translated as "buttermilk". You make it by blending yogurt with with water until a foam forms on top, then remove the foam in stages until only liquid remains; then add spices specific to your dosha (Ayurvedic type) and health concerns. For IBS, a basic blend of black pepper, cumin, turmeric and Himalayan pink salt might be appropriate. Other recipes suggest coriander and ginger.

According to the website trueayurveda, "Takra or buttermilk, not to be confused with the buttermilk we buy already prepared by other methods in the store, is a liquid preparation prepared by continuously churning yogurt in water. This preparation is used in many diseases and is overall quite healthy for the human being. It is a great treatment for IBD and Crohn’s disease as well as poor digestion, hemorrhoids, tumors, oedema, diarrhea, anemia, urinary diseases and many more."

I haven't tried Takra yet, but I'm intrigued. The first question is what yogurt would I use? "Fresh yogurt is best" means making my own, ideally. I did once make 24-hour yogurt with raw milk from the farm, but it was a lot of work. I think store-bought 24-hour yogurt, which is extremely low in lactose, could do, at least for starters. (I like the Bulgarian yogurt sold in glass jars from White Mountain Foods. According to their website, it contains just 5 g of lactose per cup.)

The big recommendation for this remedy is to make it fresh EVERY DAY, using a ratio of 1 cup of yogurt to 4 cups of water. The takra made with that is divided into thirds, to be consumed over the course of one day in three divided doses, each taken 20-30 minutes before a meal.

If you're interested in trying Takra, please let me know how it goes! I'll report back on my experience, too, but I didn't want to wait for that to share. Recipe instructions and further details may be found by following the link below:

Atmayaan Arogya Sangha: Takra: Butter milk -The healthy drink Butter milk is known as “Takra” in ayurveda. Its properties and medicinal qualities are described in as fo...

Fasting therapy - a solution for IBS?

People with SIBO put a lot of focus on food. Figuring out the Right Diet that will allay symptoms for good, once and for all, is basically our Holy Grail. I've talked about this a bunch, like in this earlier post about creating your own list of safe foods to eat. But what if not eating anything at all for a while was the answer?

In an article entitled "Effects of fasting on irritable bowel syndrome" (Kanazawa M, Fukudo S. Int J Behav Med. 2006;13(3):214-20), a study is described where fifty-eight patients with IBS were divided into two groups. One group was given prescription meds and psychotherapy to reduce their symptoms. The other group fasted for 10 days, drinking only water. To break the fast, food was reintroduced in a controlled manner over a 5 day period.

 

Results? The 10-day fasting group did better. Fasting was found to significantly improve 7 out of the 10 symptoms assessed: abdominal pain-discomfort, abdominal distension, diarrhea, anorexia, nausea, anxiety and "interference with life in general" (love that symptom). Drugs and psychotherapy improved only 3 symptoms (abdominal pain-discomfort, abdominal distension and interference with life.)

 

The researchers concluded that fasting may have beneficial effects on intractable IBS. "Intractable" would include those of us for whom IBS has advanced to SIBO, I fathom.

In my former life, I juice fasted on a regular basis (consuming only green juices and/or veggie juices with lemon and green apple added for flavor and sweetness, see photo above.) A 3-day fast was sufficient to give great results in the bloating department, although I remember feeling gassy was still a problem.

 

Maybe juice fasting low-FODMAPs style would be a success. 

 

I hesitate to water fast, despite the great results reported above. Fasting on water alone is often not recommended for anyone. There are different reasons for this, such as potential to damage the intestinal lining due to lack of substrate for fiber-fermenting bacteria. (Hmmm...isn't that who we want to starve? I'm in a quandary.)

 

One popular SIBO therapy is to follow a 10-day+ Elemental Diet, which is essentially a modified fast with fortified liquid protein drinks taken daily. Supposedly they taste pretty nasty, though.

 

I'm having good luck doing a very simple, unflavored isolated whey protein shake in the AM, which I spike with powdered supplements including L-glutamine, quercetin and a powdered multivitamin/mineral. Now I'm thinking about doing some kind of fast, maybe drinking more of these shakes per day in place of meals, or adding in small quantities of low-FODMAP vegetable juices. Not sure, just contemplating. Would love to hear your thoughts.

 

Bottom line: Diet alone isn't cutting it.

And: Sometimes, no food is the best medicine.