how to get rid of sibo

8 Reasons Your SIBO Isn't Clearing

If you’re like most people, you probably felt a mixed sense of frustration and relief when you found out that you have Small Intestinal Bacterial Overgrowth (SIBO). Relief, because all of your symptoms finally made sense. Frustration, because you’d heard how difficult treating SIBO could be; diet changes, herbs, antibiotics, pro-kinetics.  It’s a lot to learn about, let alone put into action!

You ran a breath test. You changed to a low FODMAP diet. You found a practitioner and took a protocol of herbs or supplements. All of this felt empowering, and, at first, your symptoms started to get noticeably better. In fact they may have even resolved for the first time in years! But, then things changed and those old familiar symptoms started to return….

When things don’t go as planned…

What is even more frustrating than finding out that you have SIBO, is when you complete the protocol…..and the bloating, discomfort, diarrhea, or constipation,  come right back, despite your best efforts. It’s just not fair, right?

What is even more frustrating than finding out that you have SIBO, is when you complete the protocol…..and the bloating, discomfort, diarrhea, or constipation,  come right back, despite your best efforts. It’s just not fair, right?

I’m doing everything right….so why won’t my SIBO go away?

There are a few main reasons why people repeatedly fail to resolve their SIBO, despite using appropriate treatment strategies:

  1. Using the wrong cocktail of herbs and supplements

    A quick Google search will produce dozens of herbs that have been used to treat SIBO. But knowing which herbs or supplements to use for which type of SIBO (methane or hydrogen dominant, or mixed), or what dosage is necessary, is not always obvious.

  2. Not treating for long enough  

    Duration of treatment should be based on several factors. Most important is what levels of hydrogen and methane gasses were found on your lactulose breath test, prior to the 120-minute mark. Many practitioners will recommend a standard treatment length of 2-4 weeks. While this is adequate for some cases, more progressed cases may require 8-12 weeks of continuous treatment with antimicrobials.

  3. Not including probiotics during treatment 

    Many people hesitate to include probiotics during treatment, thinking that they might make SIBO worse. This is especially understandable if you took a certain probiotic formula and immediately felt symptomatic. Yes, some strains (especially d-lactate forming ones like acidophilus), can aggravate pre-existing SIBO. But some strains of antibiotics are shown to be more effective at treating SIBO than prescription antibiotics! Stick to soil based organisms, spore based probiotics, or Bifidus strains to be safe.

  4. Not considering prescription antibiotics  

    I get it.  I’m a trained herbalist first, always. And that means that I am just as reluctant for you to use prescription drugs as you are. However, we learn in pharmacology training in medical school that everything is a toxin, taken in the right dose. That’s right; even water can be toxic if you drink too much of it.  Every medical practitioner eventually thinks about something called the cost to benefit ratio– “does the benefit given by this treatment, in this situation, outweigh the risk of using (or not using) it?”.  In the case of antibiotics used for SIBO–specifically Rifaxamin– the benefit almost always outweighs the cost.

    Rifaxamin is an antibiotic with several unique properties. It is not absorbed into systemic circulation– meaning that it stays in the gut. You can’t, for example, use Rifaxamin, to treat an ear infection, because it would never get to the inner ear.   Rifaxamin is largely inactive by the time it makes it through the small intestine and into the colon. This means that it doesn’t upset the beneficial flora in the large intestine, leaving our good bacteria intact.

    In other words, Rifaxamin isn’t associated with many of the negative actions that are associated with antibiotics in general. It is only used for one thing, and it does that thing very well. Dr Mark Pimentel, associate professor of medicine at Cedars-Sinai Medical Center, and a leading researcher in the area of IBS and SIBO diagnosis and treatment, says that he sees Rifaxamin be effective in at least 70% of patients SIBO.

    While it’s certainly not a magic bullet, it’s worth a second look, if you’ve written it off as a potential treatment option!

  5. Underlying structural abnormalities

    While this isn’t the most common reason, it does exist, and won’t show up on breath testing. Changes in the intestine (like strictures, a blind-loop resulting from a GI tract surgery,  problems with the ileocecal valve, or other structural issues)  provide an ideal environment for bacterial colonization and overgrowth.  These cannot be detected by physical examination or on a breath test, and can only be seen on imaging studies like x-rays and MRIs.

  6. Co-infections  

    “Hey, who invited that guy to the party?”  Some people with SIBO either haven’t had their stool tested for parasites, or, have used panels that weren’t good enough to catch them. If you have one or more parasites living in your gut, you will generally not get a full response to your SIBO treatments until you have properly diagnosed and treated the parasitic infections.

    Another common scenario is having a mixed pattern of candida or other fungal overgrowth alongside of SIBO. Some SIBO may in fact really be “SIFO”– small intestine fungal overgrowth. Although there is some overlap, fungal/yeast overgrowth tends to respond to different herbs and supplements than are used to treat bacterial overgrowth. Sometimes, people need to adjust the treatment approach to target both bacteria and yeast, in order to get full results.

  7. The wrong diet at the wrong time

    Eating low FODMAP can be a helpful way to manage symptoms. But eating low FODMAP, or too low-carb whiletreating with anti-microbial agents can actually be counter-productive!

    Studies show that using Rifaxamin plus Partially Hydrolyzed Guar Gum (PHGG)  is more effective at clearing SIBO than Rifaxamin used alone. PHGG is a pre-biotic, which means that it feeds bacteria. So you would think that it would worsen SIBO by feeding the bacteria in the small intestine. In fact, it does exactly this, except that feeding the bacteria while using an agent that targets them while they are reproducing, yields exactly the opposite effect– it kills them off in higher numbers.

    In this way, prebiotics make the treatment work better. Feeding the bacteria (either with a prebiotic like PHGG, or with FODMAP foods, as tolerated) is generally a good idea while taking herbs or prescriptions to treat SIBO.

Cops & Robbers: Clearing SIBO isn’t all about “killing the bad guys”

Reason number 8 is its whole own section, because it is probably the most significant driving cause in your stubborn or recurrent SIBO.  Many people, in fact many practitioners, are treating SIBO as if it’s a parasite. If your SIBO treatment only consists of using things to “kill the bad guys”, you’re missing the boat.

To see why this is true, we have to recognize that SIBO isn’t an infection that we “pick up” from somewhere out in the world, but rather a situation that arises because the terrain of the gut has changed so that it is now hospitable to bacteria.  While we are supposed to house trillions of bacteria in the large intestine, the small intestine is supposed to be relatively sterile.  There are several aspects of the “terrain” that need to be considered.

  1. Digestive secretions

    Pancreatic enzyme insufficiency, or inadequate stomach acid or bile production all set the stage for less-digested proteins, carbohydrates, and fats. This means less nutrition for you, but also means more fermentable matter for the bacteria causing the problem!

  2. Motility and the MMC 

    People with SIBO have altered digestive motility. This can be either a cause or an effect of SIBO, depending on the individual case. Although most people with SIBO will have symptoms of diarrhea or constipation, the kind of motility that is most important when it comes to getting rid of SIBO, and keeping it gone, is the Migrating Motor Complex. The migrating motor complex is responsible for cleaning the small intestine, specifically between meals.  It functions like house keeping, in order to sweep bacteria, and undigested carbohydrates and fibers that might feed bacteria, out of the small intestine and into the colon.

    Re-establishing proper motility and MMC activity is critical to your recovery from SIBO, as well as for future prevention. There are many ways to encourage proper patterning of gut motility. Using prokinetic herbs or drugs is standard, but many therapies (like abdominal massage, acupuncture, and neurological chiropractic) can enhance the benefits.

    The vagus nerve is the main player here, and we know that vagal tone can be disrupted by trauma and ongoing stress. While physiologic approaches (like probiotics, prokinetics, abdominal massage, acupuncture, gargling, or chanting) are helpful, sometimes it is more important to find ways to gently face into the underlying mind-body issue. Therapy, hypnosis, and MBSR can prove to be indispensable in these situations. Often times the experience of having SIBO can facilitate an opportunity for deeper exploration of what is living in our hearts, minds, and spirit that is unresolved.

  3. Dysregulated cortisol levels and the Immune system

    One of the main reasons SIBO can arise is if your digestive immunity is compromised. Around 86% of your total body immunity is located in the GI tract.

    Anything that suppresses or alters this immune activity can leave you more vulnerable to fostering bacterial growth where it shouldn’t be–in your small intestine!

    Adrenal fatigue (HPA-axis dysregulation) leads to imbalanced stress-hormone levels (cortisol). And having cortisol levels that are chronically either too high or too low can lead to reduced levels of immune secretions in the gut. They can also slow down repair of the tissues that make up our stomach and intestinal lining, leading to leaky gut.

    You need to test, to know.

  4. Sympathetic Dominance

    If you are constantly in “fight-or-flight” (also known as sympathetic dominance), your gut is at a disadvantage. Chronic stress overstimulates the sympathetic branch of our nervous system (like the gas pedal), and suppresses the parasympathetic branch (like the breaks). We need both, in balance.

    Sympathetic dominance is known to slow motility; digesting the nutrients you’ll need tomorrow simply isn’t a priority if you’re running to save your butt, NOW!, if you’re running from a wild boar. It also shuts down digestive secretions, and suppresses immune activity, while up-regulating inflammatory compounds. Not a good look.

    Digestive-focused hypnosis, Heart-rate Variability training, and meditation techniques such as Mindfullness Based Stress Reduction are a great way to give input to the nervous system and retrain it to kick off it’s shoes and relax a little.

The factors leading to your SIBO were really the perfect storm.  Addressing these issues can make or break the success of your treatment.   To learn more about how to get rid of SIBO, please schedule an appointment, or, contact my office to set up a FREE 15-minute consultation.

by Bassem

Kimchi

I Had To Take Antibiotics...How Can I Protect My Gut?

Many of my patients are surprised to hear that I, too, grew up with the ubiquitous bottle of pink bubblegum flavored prescription syrup in the fridge each winter.  Amoxicillin—it’s the go-to antibiotic of choice for everything from ear infections to strep throat or pneumonia in children everywhere. Trust me; I had my fair share! Back when I was growing up, we just didn’t understand the ramifications of repeat antibiotic use, so it seemed that one could rarely leave the pediatrician’s office without a prescription for one.

Antibiotics are only effective for bacterial infections, and won’t have any impact on viral infections such as the common cold.   With the rise of antibiotic resistant infections, or so called “superbugs”, even the doctors prescribing these drugs have taken  a muchmore judicious approach to using them. We now know that the risks of repeat antibiotic use during childhood are long-lasting and have been linked to increased risk of allergies, autoimmune diseases, diabetes, obesity and even ADHD later in life.

There are many situations where antibiotic use can be avoided. For instance, most urinary tract infections, ear infections, sore throats, and the weepiest of oozing red eyes can be treated safely and effectively by aggressively using the right herbs or natural treatments. —In fact, I’ve treated hundreds of these types of ailments in my own clinic with only natural medicines and have seen great success.  . Even the dreaded diagnosis of “strep throat” can be treated with appropriate herbs by a trained professional. The overwhelming benefit of using a natural approach to these ailments is that the “good” bacteria in your gut stays protected. Additionally, you avoid the side effects that often come with antibiotic use, like bloating, diarrhea, constipation, fatigue, and loss of appetite.

Certainly, there are situations where antibiotics can be lifesaving–I personally owe my life to IV antibiotics used for a bad case of sepsis I experienced several years ago.    And while ear infections and urinary tract infections almost never need to be treated with antibiotics, if you’re in pain, or have been up every night for a week with a sick, crying kid, and are at your wit’s end, you may wind up gladly accepting that prescription.

In cases of bacterial infection, antibiotics will do the job, but not without massive casualties among the beneficial flora in the gut that form our defense system.

Our digestive tract houses around 500 species and up to five pounds of bacteria that help preserve our health every day. We have trillions of bacteria populating our large intestines—in fact, their cells out-number our human cells; one could say that we are “more bacterial” than human. These tiny organisms are so critical to our survival, it’s like having another essential organ that you couldn’t live without!  Beneficial (or probiotic) bacteria in our guts play a host of vital roles for our health:

 

Nutrition:

Intestinal bacteria actually synthesize essential nutrients like B12 and K2, or convert them from the food we eat into active forms.  In fact, while we get some of our vitamin K2 from eating dark leafy veggies, up to 75% of it is made in the gut.

Studies have recently shown that some gut bacteria are able to produce the active methylated form of Folate (5-MTHF), a key component in things like brain function and mental health, cell division and DNA replication, and normal fetal development during pregnancy. Having adequate amounts of the right type of good bacteria can be a game changer for individuals with MTHFR mutations, who are notoriously at a disadvantage in producing adequate quantities of this essential nutrient.

Hormone Balance:

A healthy microbiome is an indispensable part of the process by which we maintain hormone balance.  Specific bacteria produce enzymes that help us break down and metabolize our estrogen. Essentially, these bacteria work to flush hormones that have been used, and are ready for elimination, out of the body, making way for fresh new hormones to take their place.

If you have the wrong types of bacteria in your gut, then estrogens get reabsorbed and recirculated, setting the stage for estrogen dominance and associated symptoms such as infertility, PMS, low libido, cramps, heavy menstrual bleeding , and PCOS. This also makes us more susceptible to estrogen related cancers like breast and uterine cancer.

Without enough of the good guys, we are setting ourselves up for a toxic build-up of hormones that can lead to PMS, menopausal symptoms, or worse.

What is living in our gut strongly influences almost every conceivable aspect of our health. In fact, most people don’t know that symptoms like allergies, acne, depression, fatigue and autoimmune diseases often have digestive problems at their root.

Immunity and Respiratory Illness:

Our microbiome also supports our overall immunity. Approximately 70% of your immune system is located in your gut and the good bacteria are informing this at all times. Studies show that gut microbiota influences our immune system, both in the intestines, but also systemically.

The use of broad spectrum antibiotics, (and other factors like chemical exposure, diet, and environmental exposure) alter the makeup of our microbiome. Multiple studies report that this alteration can negatively influence the immune response in your airways leading to greater susceptibility to many allergic airway diseases, including seasonal rhinitis and asthma, as well as viral infections of the respiratory tract.

Acute respiratory tract infections are the leading cause of death in infants and young children worldwide, and while these can be bacterial in origin, the majority of them are caused by viral infections. Researchers believe that that the composition of the microbiome may affect the severity of viral infection in children.

Digestive Disorders:

Locally, in the gut, disruption of the balance in the microbiota (dysbiosis) has been associated with inflammation-linked disorders, like inflammatory bowel disease.

Metabolic Syndrome and Weight Gain:

A Danish study with 169 obese and 123 non-obese participants confirmed that people with lower amounts of good bacteria had higher body fat percentage, increased insulin resistance, higher markers of inflammation, and poor cholesterol balance. They also gained more weight over time.

Several days to a week of antibiotics will wipe out majority of the bacteria, both good and bad–decreased diversity and altered composition can be seen within 3-4 days.  Even a single dose of Clindamycin (commonly prescribed for things like bacterial vaginosis or sinus infections) causes an enduring loss of  90% of normal microbial diversity.

Our intestines are somewhat like an apartment building—there is only space for so many tenants.  You want to have primarily good tenants, who pay the rent on time, take care of the place, and like to keep tidy. But wiping out the majority of the tenants, both good and bad, leaves it as a toss-up in terms of who will take residency after you stop taking the antibiotic.

So, while bacterial counts in the gut start to recover within a week, studies show that the composition of the microbiome is significantly altered from what was present prior to treatment.  And because antibiotics only work against bacteria, this leaves room for pathogenic yeast or fungal strains to gain a running head-start while you are taking the prescription. While yeast like Candida are a normal part of our healthy microbiome, they should only comprise a small percentage of a diverse population. When they start to overgrow, and run the show, a myriad of problems and increased production of toxins can disrupt our digestive health and also impact other body systems outside of the gut.

The good news is that we have a lot of influence over who we promote when it comes to rebuilding the good guys! If you must take antibiotics, here are a few things you can do to help protect your gut and immunity while taking them:

Foods

Avoid sugar, alcohol, dairy (except fermented), and gluten: These foods either contain proteins that are harder to digest across the board, or tend to feed yeast.

Eat probiotic fermented foods:  sauerkraut, kim chi, any other fermented veggies such as beets or carrots, coconut kefir, kombucha, yogurt (preferably homemade and 24-hour).

Drink bone broth: collagen heals the gut and is also prebiotic (feeds the beneficial flora).

Eat Prebiotic foods:  Prebiotics are fibers found in specific foods that are food for the beneficial flora. Jerusalem artichokes (sunchokes), raw dandelion greens, garlic, leeks, onions, jicama, Chicory root (which you can find in Dandy Blend beverage), asparagus, green bananas and plantains, cacao, burdock root, or foods high in resistant starch (such as cooked and cooled rice, legumes, or potatoes) are all foods with high prebiotic content.  You can also take a prebiotic supplement, like Mega PreBiotic—start slow! Interestingly, these types of starches onlyfeed the beneficial flora, and not the “bad guys”.

 

Supplements

Butyrate: Part of the reason why prebiotics are so helpful is that they provide raw material for the good bacteria to ferment, producing short chain fatty acids.

Butyrate, one of the SCFA’s produced in this process, is the energy source of choice for the cells lining the colon and helps regenerate colonic mucosal membrane. It has several different actions that are cancer-preventative. Butyrate also fights inflammation in the gut. In fact, not having enough Butyrate can trigger or worsen ulcerative colitis, chron’s Crohn’s disease or colon cancer.

While most of our butyrate is produced by our healthy flora, grass-fed butter is also a great source of dietary butyrate, and, it is also available in supplement form. Generally, I recommend taking it for 2-4 weeks following antibiotic use.

Probiotics: The most important probiotic you can take during and after a round of antibiotics is actually a strain of yeast.  Saccharomyces boulardii is a beneficial, non-pathogenic yeast that was first identified on lychee and mangosteen fruits in the tropics. While it may sound strange to intentionally put yeast into your digestive tract, S. Boulardii is a completely different species from the pathogenic candida species that are associated with digestive and other health problems.  Besides increasing short-chain fatty acids (remember those from above? We want those!) that soothe the mucosal cells in the gut, these yeast are also stellar at treating and preventing diarrhea, and also boost secretion of IgA (immune agents) in the gut. They are helpful for treating C. Difficile infection, reducing inflammation in IBD, and help to prevent the formation of food-allergies.  I recommend Designs For Health Floramyces, or Saccromycin DF by Xymogen.  The dosage that I recommend in this case is 5-10 billion CFUs 3-4 times daily. It is important to start taking Saccharomyces Boulardii as soon as possible, as it can (and should) be taken during course of antibiotics to help prevent yeast overgrowth and calm inflammation. Since they only work on bacteria, antibiotics won’t kill the yeast. Keep taking it for 2-3 weeks after completing the antibiotic.

Generally, after the antibiotic is completed, I recommend adding in an additional Acidphilus/Bifidus containing probiotic blend for several weeks, such as Klaire Labs Therbiotic Complete.

 

Have you taken antibiotics and noticed health changes after taking them? Or, have you taken preventative measures like the ones above that you felt safeguarded your health? If so, what differences did you notice?

by Bassem

Woman stretching in front of sun

What’s Causing My IBS? (And 5 things You Can Do Now!)

Catherine was a 42-year-old small-business owner who came to me struggling with constipation, bloating, gas, intestinal cramping, and painful bowel movements—almost every symptom of IBS. She was exhausted after years of suffering with these symptoms, and felt lingering anxiety most of the time, not knowing when her gut was going to act up and prevent her from being able to run her business, and enjoy time with her daughter who was about to graduate and leave for college. 

She first noticed these symptoms around the same time that she’d gone through a very stressful period of building and then selling a house that she’d thought she would be calling home. During this time, she started having daily back pain from the stress. She was taking a lot of ibuprofen to manage the pain, when she started to experience a burning feeling in her stomach as though she had an ulcer.

Her doctor diagnosed her with gastritis caused by the ibuprofen, and recommended taking Prilosec, a drug that blocks acid production. While the Prilosec did help relieve the burning discomfort in her stomach, she found that the pain returned every time she tried to come off of the drug. Worse yet, After taking it for a year, she started to notice other digestive symptoms like bloating, gas, pain, and constipation, and stopping the Prilosec didn’t make these symptoms any better. That’s when she came to see me.

IBS is very common, affecting up to 15% of the population, although many people with symptoms have not been medically diagnosed, so these numbers may actually be an underrepresentation.  Sufferers commonly experience gas, bloating, abdominal pain or cramping, constipation, loose stool or diarrhea, and may notice symptoms come and go, or change over time.

What is IBS….?

IBS is not actually a disease. Rather, it is a syndrome, meaning that someone can be given a diagnosis of IBS if they have a cluster of symptoms that show up regularly within a specific period of time. While the exact cause is unknown, it is thought to occur because of problems with the way the gut, brain, and nervous system interact. Recent research shows that most cases of IBS have multiple factors involved, such as changes in gut motility, small-intestinal bacterial overgrowth, low-grade chronic inflammation, and hypersensitivity to pain in the nerves of the intestines. There are predictable triggers for IBS, and the root cause can be different in each person.

If you struggle with symptoms of IBS, there are a few simple things that you can do right away:

Diet

There are certain foods that can be a trigger for IBS symptoms, the most common ones being Gluten, grains, dairy, soy, sugar, and processed foods, although there can be many others. Many people find that by going on a whole-foods paleo diet, many or all of their symptoms resolve. If you haven’t already, going on a 30-day clean Paleo diet, eliminating the above mentioned foods, as well as legumes, can be a safe and easy place to start.

While this step alone can be the magic bullet in some people, other people may get relief by further refining the Paleo diet and following a low FODMAP diet. FODMAPS are naturally occurring compounds found in the carbohydrates in specific foods that can be fermented by gut bacteria. Since many cases of IBS are caused by having dysbiosis (the wrong kinds of bacteria) in the gut, or by SIBO (small intestinal bacterial overgrowth–too many bacteria in the wrong place), temporarily restricting foods that feed these bacteria can help.

The idea with the Low FODMAP diet, as with other diets that restrict fermentable foods (such as SCD, GAPS, and Low Fermentation Potential Diets) is to starve out the undesirable bacteria that are causing the symptoms to occur.

You should notice improvement within several weeks, if these approaches are going to benefit you. However, I don’t recommend following a Low FODMAP diet long term, because all of the beneficial bacteria that form a healthy microbiome need these fermentable compounds for food as well.

It is also common for people following a low FODMAP diet to not get enough fiber content in their diet, (which can cause additional gut symptoms) so it is important to include the low FODMAP foods that contain fibers (such as blueberries, oranges, carrots, potatoes, eggplant, nuts and seeds, zucchini, cucmbers, green beans, tomatoes, dark leafy greens, and grapes). Low  FODMAP fibers ferment more slowly and are less likely to cause digestive symptoms.

If you get symptomatic improvement by removing high FODMAP foods from your diet, it suggests that you may have SIBO or dysbiosis at the root of your symptoms, and you may need to use other approaches in combination with diet, in order to get full resolution of your IBS.   Again, FODMAPs are not the cause of your IBS, but rather a sign that something living in your gut, that likes to eat FODMAPS for food, is.

Strategic Supplements

Try taking Digestive enzymes and HCL

Digestive Enzymes are produced by the pancreas, and are used to break down the carbohydrates, fats and proteins that we eat. This not only makes them easier for us to digest and absorb for nutrition, but also prevents less-broken-down starches from making their way into the small intestine, where they are the perfect fuel for feeding bacteria there, causing or worsening SIBO.

Heavy alcohol consumption, gallbladder dysfunction, parasites and other digestive infections, and chronic stress or Adrenal Fatigue are a few of the things that can deplete enzyme production.   Enzymes are very safe to use and can turn symptoms around overnight in some people, especially gas, bloating, and diarrhea.  There are several brands that I’ll recommend to clients, including Dipan 9 by Thorne, Pure Pancreatic Enzymes by Pure Encapsulations, or PanZyme pH by Xymogen. Different people need different dosages to get results, typically ranging from 1-4 capsules per meal. Start low and increase over several meals to find your dosage.

Betaine HCL is a supplement that increases the amount of hydrochloric acid in the stomach. HCL is required for proper digestion of proteins and absorption of amino acids, as well as for availability of vitamin B12 and minerals such as magnesium and iron.  One of the things that stomach acid does is to activate pepsinogen into the enzyme pepsin, which helps to break down proteins, which is why I recommend making sure that your HCL supplement also contains pepsin.

Stomach acid is also essential for killing off potentially pathogenic organisms in the food we eat, preventing infections, and for regulating emptying of the stomach into the small intestine.

But is it safe for me to swallow acid in pills?

For most people, HCL supplementation is extremely safe.  The lining of your stomach is at least 1mm thick (which may not sound like much, but compared to many other linings in the body is quite sturdy!) and is designed to withstand exposure to extremely acidic secretions. But there are a few people who should not take Betaine HCL without supervision:

  • People taking corticosteroids
  • People taking NSAIDS such as aspirin, ibuprofen (advil, motrin), and others
  • People with active gastritis or ulcers

These drugs and conditions can damage the lining of the gut, and HCL can cause risk of bleeding or ulceration.

That said, in most people the risks of eating food while having low stomach acid levels outweigh the risks of taking supplemental stomach acid. If you are concerned about trying HCL, it is always a good idea to use the supervision of a trained practitioner.

How much should I take?

Just as with digestive enzymes, each person has a unique dose that will give them the support they need. The only way to figure it out is to experiment. A common pitfall I’ve seen is people not taking a high enough dose to get benefit. Here’s how to figure it out:

  • 10-15 minutes before a meal that will contain protein (at least 4-6 ounces), take 1 capsule of Betaine HCL (the highest dose per cap that I use is 520 mg/cap).
  • Eat your meal as usual, and take note of any sensations in the stomach area, either before you eat, during or after the meal. Most people report a feeling of warmth, pressure, or mild burning.
  • Use this dose for 1-2 more meals, and then increase to 2 caps before the next protein-containing meal. Again, note any sensations.
  • Increase number of capsules, in this manner, until some warmth or mild discomfort is noticed. When this occurs, reduce capsule dosage by 1 cap, and keep that dosage moving forward. If you noted warming at 5 caps, your dosage for most meals should be 4 caps. This amount may shift a little depending on the amount of protein or type consumed; if you eat a 6 ounce steak, you will need more than if you eat 2 scrambeled eggs.

If you experience discomfort at any point, you can quickly neutralize the HCL by mixing ½ teaspoon of baking soda in a cup of water and sipping it. This should stop any pain or discomfort.

If you notice burning even at one capsule, it is likely that you have thinning of the stomach lining, and should avoid HCL until you have taken steps to heal this to some extent. People with thinning of the stomach lining (atrophic gastritis) can usually tolerate digestive bitters tincture, apple cider vinegar in water, or lemon juice in water before meals, and these will all naturally help increase stomach acid in a more gentle way.

Add probiotics

There have been many clinical trials run on the effect of combination probiotics containing Lactobaccilus and Bifidus strains with IBS patients, all of which showed improvement of symptoms in a large percentage of the participants. Many patients showed noticeable reduction in gas and bloating, and a reduction in diarrhea or constipation depending on which they had predominantly. The products used in these studies generally contained a blend of the following strains:

  • L Acidophilus
  • L casei
  • L plantarum
  • L bulgaricus
  • L helveticus
  • B longum
  • B infantis
  • B breve

Some people with SIBO, or with histamine reactivity, don’t tolerate D-lactate forming probiotics (many of lactobaccilus strains fall into this category) well.  If eating fermented foods like sauerkraut or yogurt worsens our symptoms, you may fall into this category. In these cases, I suggest trying either soil-based or spore-forming organisms, which are generally well tolerated by people with both SIBO and histamine issues. The two products that I use most frequently are MegaSporeBiotic and Prescript Assist.

My other favorite probiotic,  Saccharomyces boulardii, is actually a beneficial yeast. While adding yeast to your gut may sound like a bad idea, since yeast overgrowth like candida can be a trigger for many digestive problems, S. Bouarldii is non-invasive and will complete with bacteria and other fungi in the small and large intestine. This means that in combination with other approaches, S boulardii can help crowd out SIBO and allow for restoration of a thriving microbiome.

Lifestyle and Stress Management

While not the most obvious solution, focusing on getting enough good quality sleep can profoundly improve IBS symptoms.

One of the causal factors in IBS is disruption of the migrating motor complexes, or MMC. These are electrical signals that trigger peristaltic waves that sweep through the intestine when we are fasting (when we are sleeping, or when we have gone more than 4 hours without eating). They help to sweep undigested food particles through the small intestine and into the large intestine, which prevents food from hanging around to long, allowing bacteria to ferment it and colonize the small intestine.

Restoring the MMC is very important in treating IBS, and in preventing SIBO regrowth after treatment, and it is largely regulated by our circadian rhythms and by the hormone melatonin.  In fact, studies have shown that motility is directly proportionate to depth of sleep.  The production of melatonin by our pineal gland is dependant on light and dark cycles. So, getting enough hours of sleep per day, and sleeping during hours where it is dark out help to maintain our circadian rhythms.   Conversely, lack of sleep, sleep disturbance, and shift work can provoke IBS. Aim to get a minimum of 7, but more optimally 8 full hours of sleep—this may be something you have to schedule and prioritize as much as you would a business meeting! Avoid exposure to bright lights and blue light (from digital screens) after dark, as these shut down our melatonin production.

Stress also provokes IBS symtpoms, so minimizing stress wherever possible is also important. While some things in life that cause stress are outside of our control, there are many choices we can make in our day to day lives that can lower stress or adapt the way we respond to stressors. While this is a topic too large to explore here, a few quick ways to lower stress are:

  • Avoid multitasking and concept shifting. Focusing on one task at a time fosters a sense of calm.
  • When possible, consider saying “No” more often, when asked to take on new projects or roles.
  • Practice yoga, in a class setting, or even for 10-15 minutes daily at home. There are hundreds of great apps and videos available online that offer short sessions of all levels.
  • Even 10 minutes a day has been shown to lower stress, raise quality of life, and lower inflammation. Some of my favorite apps for helping people get started are www.headspace.com, www.buddhify.com, and www.calm.com.
  • Practice Gratitude—shifting your focus to anything in your life that you appreciate, or finding something about the present moment (or person you are interacting with) that you appreciate, never fails to shift our internal and external environment for the better.

Fine-tuning your diet, adding a few targeted supplements, and taking stpes to actively manage stress can solve or greatly reduce frustrating symptoms of IBS for many people.  If you try these approaches, and are still struggling with gas, bloating, diarrhea, or constipation, I suggest working with a trained practitioner to run some testing to find the root cause of your issues.

The most important testing to run for IBS:

If you need help with IBS, click here to set up a free 15-minute consult with me!

Catherine noticed improvement right away when she started taking a strong digestive enzyme and HCL w/pepsin with meals.  At her second appointment, we reviewed her lab tests, which showed that she had a parasite called Enodolimax Nana, as well as methane-dominant SIBO.

After doing treatments for both of these digestive infections, Catherine took pro-kinetic supplements to restore her motility, gut repair supplements to heal leaky gut,  and probiotics, while waiting for her follow-up retesting.

Although she felt much better, and her constipation had almost completely resolved, her retest showed that she had 2 types of fungal overgrowth that her initial testing hadn’t picked up. We treated her using an anti-yeast/fungal protocol, and within 2 months, Catherine’s bloating had resolved, she had regular daily bowel movements, and no more digestive pain, as long as she avoided gluten exposure.

by Bassem