November 17, 2019 at 01:30PM by CWC

Robin Berzin, MD, is a practicing physician and the founder and CEO of Parsley Health, a functional medicine center that just opened a flagship location in Los Angeles. Here, the Well+Good Council member reveals one of the most misdiagnosed gut conditions—and her approach for treating it.

We’ve all had the feeling of being bloated, gassy and uncomfortable after a heavy meal or night of over-indulging. But as a physician at Parsley Health, I see many people for whom feeling gassy, bloated, and excessively full after eating is a nearly daily occurrence—and this isn’t healthy digestion.

While occasional digestive issues can be normal, chronic digestive issues are not. Regularly experiencing abdominal pain, bloating, constipation, diarrhea, or gas can indicate an underlying intestinal problem. Often, though, people are given a general, blanket diagnosis of Irritable Bowel Syndrome (IBS). While there are no precise medical tests to confirm an IBS diagnosis, it is the most commonly diagnosed gastrointestinal condition worldwide and it tells us very little about why patients are experiencing discomfort in the first place. Remember, the word “syndrome” just means a constellation of associated symptoms. In my book, giving something a name isn’t enough—we need to understand why you have these symptoms.

Giving something a name isn’t enough—we need to understand why you have these symptoms.

For example, up to 84 percent of IBS patients actually have an underlying condition called small intestinal bacterial overgrowth (SIBO), a phenomenon that can result from the overuse of common medications like antibiotics and acid blockers as well as eating a diet high in refined sugars and flours; SIBO can also come from chronic constipation and a lack of proper gut motility. SIBO is a serious condition affecting the small intestine and occurs when bacteria that normally grow in other parts of the gut start flourishing in the small intestine.

At Parsley Health, our approach is to work to uncover what is at the root of a patient’s symptoms. That’s why when a patient comes in with any gut-related symptoms, we work with them to try and find out why.

There are a few things I look for that may indicate “IBS” could actually be SIBO.

a couple eating
Photo: Stocksy/Sergio Marcos

Ongoing digestive issues

Lets consider the case of a 36-year-old patient of mine, Anna. She first came in complaining of intense gas and constant, painful bloating, which another outside doctor had called IBS. Her bowel movements were irregular and when she did go to the bathroom, she reported a mix of loose stools and intermittent constipation. Her acne had also gotten worse at the same time her digestive issues started.

Anna had already experimented with her diet by avoiding gluten, dairy, and soy. Recently, she’d even been trying daily celery juice to help promote a bowel movement in the morning. However, her symptoms were far from resolved.

Symptoms that don’t resolve by removing common triggers

Although Anna had eliminated gluten, dairy, and soy, which are common food sensitivities, they’re not the only ones. I recommended she try reducing high FODMAP foods in her diet as a next step. FODMAPs (which stands for fermentable oligo-, di-, mono-saccharides and polyols) are a group of fermentable carbohydrates that are known to exacerbate SIBO symptoms because they feed the microbes in the small intestine, often contributing to digestive discomfort. When a patient of mine notices an improvement in digestive symptoms with the introduction of low FODMAP diet, it often confirms that they’re likely suffering from an underlying intestinal imbalance like SIBO. To no surprise, reducing foods high in FODMAPs majorly helped Anna with her persistent bloating.

Imbalanced gut bacteria

When I suspect a patient may have SIBO, either based on the FODMAP challenge described above, or based on their clinical history (a lot of antibiotics; a history of chronic stress that led to chronic constipation), I order a clinical-grade breath test to establish if SIBO is present and if so, which type of SIBO is there, as treatments vary based on the type of bacteria present. A SIBO breath test works by testing for the presence of hydrogen or methane in the breath. If an overgrowth of bacteria ferments in the small intestine, the gases those bacteria give off can actually be detected through the breath. Anna’s test results confirmed my suspicion—she tested positive for SIBO, methane predominant.

In my practice, we’ve found that when we pair herbal antimicrobials with antibiotics, we see higher rates of success.

I treated her with an evidence-based protocol that included antibiotics followed by antimicrobial herbal supplements, which studies have shown decreases the likelihood of SIBO recurrence. In my practice, we’ve found that when we pair herbal antimicrobials with antibiotics, we see higher rates of success. Often, I see patients whose gastroenterologist previously prescribed them a short 10-14 day course of antibiotics for SIBO without recommending additional herbal antimicrobials, dietary interventions, or  stress management techniques like mindful meditation to support their healing. Failing to incorporate a holistic treatment plan led the SIBO to come right back. At Parsley Health, we help educate our patients on the importance of the gut-brain connection as an integral part of our SIBO protocol. Our approach is showing to be more effective and sustainable.

With the protocol and dietary modifications, Anna’s digestive symptoms resolved over three months, and she even saw improvements in her cystic acne. Her follow-up breath test results also came back normal.

So how can you support your gut microbiome?

healthy lunch
Photo: Stocksy/Suzanne Clements

1. Eat more plants

The composition of the gut microbiome is mostly defined by the foods and beverages we consume every day. Foods like sugar, refined flours, alcohol, and the chemicals from processed foods all shift which bacteria live in our gut over time.

Research shows that people who eat more plant-based diets have increased amounts of butyrate-producing bacteria, a short chain fatty acid which helps to support intestinal integrity and promote anti-inflammation. On the flip side, studies on individuals who consume a diet low in resistant plant starches and high in fat and gluten have greater amounts of the Bacteroides genus, a family of bacteria that contribute to gut permeability.

2. Uncover food sensitivities

Undiagnosed food sensitivities are also a common cause of IBS, so I recommend working with a health coach or nutritionist to do an elimination diet. This can help you uncover any specific triggers for digestive upset, remove them from your diet, and decrease intestinal inflammation and promote gut health.

3. Find a de-stressing activity that works for you.

Aside from diet, increased stress can also negatively impact the composition of our gut microbiome. Studies show that chronic stress can increase the growth of “bad” bacteria like bilophila and dehalobacterium, which have been linked to autoimmune disorders in humans. Not everyone will have the same unwind activity. Yours could be yoga, cooking, painting. There is no wrong answer.

4. Get cardio into your weekly routine.

Newer research suggests that cardiovascular exercise supports favorable changes in the presence, activity, and diversity of gut microbes. Because exercise improves the transport of oxygen within the body, it can also help support the transport of oxygen and movement through the gastrointestinal tract leading to better digestion. Even without taking your diet into account, research shows that exercise contributes to gut diversity, so if you’re having trouble making changes to your nutrition, starting with exercise can be a great first step in supporting a healthier community of bacteria in your intestine.

Robin Berzin, MD, is the founder and CEO of Parsley Health, an innovative primary care practice with offices in New York, Los Angeles, and San Francisco. Dr. Berzin attended medical school at Columbia University. She is a certified yoga instructor and a meditation teacher.

What should Robin write about next? Send your questions and suggestions to experts@wellandgood.com

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Author Robin Berzin, MD | Well and Good
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