Just because there’s an answer now, doesn’t mean it’s going to be quick or easy

I’ve been wanting to come on for a while to discuss some thoughts related to SIBO that have been brewing for a while. It’s such an interesting and exciting time to be involved with treating SIBO in Germany. It’s like there’s this great awakening happening, a few years after it started in the US/Australia/ UK and so many people are becoming aware of the fact that their IBS diagnosis, for which nothing much could be done from a medical perspective, is actually caused by a very specific and treatable condition/set of issues for which much can be done. 

Let’s pause and acknowledge that this is a very exciting moment in time for those people and it represents a needed paradigm shift and new way of thiking aboit the body. I love it and I’m so here for it.

However, something I see a lot (which I can also totally empathise with) is that because there is now a concrete ANSWER to the question of what’s causing their IBS symptoms and a relatively clear treatment path forward- that doesn’t mean fixing the SIBO and symptom constellation it causes will be easy or fast or pleasant. 

Let me repeat- just because there is now a clear answer doean’t mean it’s an easy fix. That can be a hard pill to swallow, and I can really relate. 

I remember when, in my desperation to find out what was suddenly causing my extreme constipation and bloating during medical school to feel so releived to see that positive SIBO test and have an answer. After being prone to constipation for most of my life when stressed or travleing, things had gotten a lot worse when I started medical school AND transitioned off my vegan diet.  A good 2-3 years after my SIBO diagnosis, and after going down the long road of SIBO treatment, post treatment relapse prevention, and root cause investigation, I’m fully recovered and so grateful for the lessons learned. But it took a few years to be permanently free of my initial symptoms and a whole lot of work, reflection, and money spent on my part to get here. It also took a Hashimotos diagnosis and a seperate path (still ongoing) to support my thyroid healing. I have been doing great for the majority of those few years, and this is all to say being relaistic about the time you’ll spend working through your SIBO (and other potential contributing causes) is important.

SIBO as a long term undiagnosed issue and how this impacts recovery time

Another thing I’ve been thinking about a lot is SIBO as something many of us have probably had chronically for years. Many of my patients tell me they were diagnosed with IBS at an early age, in their teens or when they went out into the world as young adults. The story often goes that they developed symptoms slowly at first (lactose intolerance for example), bloating, occasional episodes of diarrhea, etc and then after a certain point, symptoms statred piling up more rapidly. That’s a common picture. The turning point at which symptoms starting piling up is often a major stressor. Pregnacy/birth, major chhanges in diet like going vegan, very stressful periods etc. It can also be a medical event like antibiotics or surgery. For most people, one or two rounds of antibiotics isn’t going to cause SIBO. It’s usually cumulative and at some point, we reach a course of antibiotics that may be the straw that breaks the camel’s back. 

I think many people have had SIBO simmering in the background for way longer than they have been experiencing major symptoms related to it. The door to SIBO may have been opened years before you take that breath test and decide to committ to turning your digestive health around. This is important, because from the perspective of how this impacts estimated recovery times- it lengthens them significantly. A general rule of thumb is, the longer you’ve dealt with a symptom or health condtition, the longer it takes to reverse it. This isn’t written in stone and there are many suggestions, but it can be especially true for SIBO. There is another reason for this as well, which brings me to my next point.

SIBO is *usually* a symptom and the tip of the proverbial iceberg.

I remember a wonderful debate put on by my medical university on the topic of SIBO. The debate was between two of the most respected professors at the schol. Both had a clinical and research focus on naturopathic gastroenterolgy, but they  came at the subject from very different perspectives and paradigms. Dr. Steven Sandberg-Lewis ND, affectionately called Dr SSL by his students is one  of the father’s of SIBO knowledge and has massively shaped the current thinking around treatment and root causes, as well as downstream conditions linked to SIBO. His book functional gastroneterology is a wonderful primer and his mentees include Dr. Allison Siebecker and myself, among many others lucky enough to have studied with him at NUNM. He is an old-school naturopathic doctor in many ways, and I always admired the complexity and elegance of his approach to treatment. I learned pretty much everything of importance not only in regards to SIBO from him, but the rest of naturopathic gastroenterolgy as well, having spent a few years beinged mentored by him.

The other doctor debating the subject was Dr. Paul Kalnins ND. A very well respected and much loved professor with a strong focus on Anthroposophical medicine, integrative herbalism, classical chinese medicine and the biochemistry of herbs. A really amazing and incredibly deep understanding of these complex topics and their intersection made him a veruy popular lecturer and his clinical shift was one of the most coveted in our clinical rotations. His herbal tincture perscriptions for patients often led to amazing results, and the connections he was able to treat wtithin the body using expertly composed herbal tincutres was inspiring. I remeber the patient with chronic constipation he helped immensely by focusing on gut nervines and calming herbs in her tincture formulation. No SIBO treatment protocol required, though a positive SIBO test was incuded in her medical file.

All this background to say, the debate was fascinating as the two doctors discussing the topic of SIBO had very different opinions on WHY it developed, HOW it should be treated, and WHAT it even was. I came away from that talk with a strong belief that SIBO was nothing if not incredibly complex and that there was no one answer, no one treatment algorithm, and no single approach that would help everyone with a SIBO diagnosis. I was onviously hooked and had found my specialty.  This debate, as wel as learning from both of these amaxing doctors, has heavily influenced how I treat SIBO in my own practice. By now, I’ve worked with close to a thousand SIBO patients and feel very stronfly that no two are exactly alike, and what they need for long term remission is completely different.

This last bit, the incredible diversity in SIBO treatment and remission needs is due, in my opinion, to the fact that SIBO is usually just the tip of the iceberg. More of a syndrome and collection of symptoms than a specific clear cut  disease process like ulcerative colitis.  This was the position Dr. Kalnins took, saying that because SIBO was mostly a symptom of other imbalances within the digestive system and the body, it needed to be treated as such. If one sticks to the tip of the icberg metaphor, most can agree that only dealing with the tip, or the visible part, is not a long term sustainable solution to the issue. It’s not that Dr. SSL completely disagreed with this particular position, but believed that SIBO could also frequently come about more ‘directly’ and as a result of short term imbalances in the body such as recent antibiotic use, surgery requiring opiate pain killers which slow motility, or post infectious autoimmune changes to the digestive system after gastroenteritis ( due to food poisoning or a gut infection). The list of deeper or ‘upstream’ issues that can lead to SIBO is longer, in my opinion, than the list of direct or linear causes. This is honestly true for most disease processes in the body though. Most chronic issues do not come about in a linear cause-effect way. This key point HAS to inform a successful SIBO treatment course, as it is really the point. If your SIBO isn’t a direct and linear result of a clear and obvious cause, then just getting rid of the bacteria with powerful herbs or antibiotics will likely lead to a merry go round of relapses. Improvement will likely follow initially as the bacteria are eradicated and fermentation in the small intestine is reduced. However, the issues that led to SIBO establishing itself in the first place are probably still there. Take the ileocecal valve for example. If this doorway between te large and small intestine doesn;t function as it should, it's a huge contributor to the development of and relapse risk of SIBO. The problem is, it’s not as simple as fixing the hinges on an actual door- voila! It’s trickier. The valves in our body are controlled in large part by the nervous system. Lots of things can go wrong with the nervous system to lead to downstream valve issues, and teasing this apart usually requires some  hands-on treatment (visceral osteopathy, mayan abdominal massage, chiropractic) as well as a close look at what factors are burdenig the nervous system (like chronic stress). 

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If I could have read an article like this one when I was first diagnosed, I think it would have been very helpful. All I could find at the time (almost 10 years ago now) as laundry lists of symptoms and associated conditions, as well as some interesting studies comparing the herbal and antibiotic treatment approaches. I’m hopeful that this blog post helps you realize SIBO can be a wonderful teacher and going through the treatment will teach you a lot about your body, other areas of your body that need attention, as well as habits and lifestyle factors that aren’t serving your digestive health.

I’ll leave you with this final thought. I see a lot of doctors, heilpraktiker, and coaches calling themselves SIBO experts, selling courses,  and using, sometimes exclusively, a treatment algorithm.  A cookie cutter recipe for SIBO, that takes you step by step through the same herbs as the next person with SIBO, and without much attention to the element of individuality or complexity within this diagnosis. I’m not saying using a SIBO treatment algorithm is bad or that it shouldn’t be done, but I think it shouldn’t END there. This ‘tip of the iceberg’ condition defies a cookie cutter approach. When we simplify it down to JUST an algorithm used by a doctor or practitioner that doesn’t understand that the long term success with SIBO lies in those individual details and differences, we see high relapse rates (sometimes up to 70%). Some doctors in the conventional medical system don’t have the time for this approach, which I can understand and empathise with. I’m writing this so that if you HAVE been treated with a simplified 1-2-3 approach and have either not had the results you hoped for OR experienced a relapse, that there is a different way to approach the issue. Not black and white different, but individual enough that it can make all the difference.