Approaching SIBO treatment with naturopathic medicine

Photo Cred: Mikhail Nilov/Pexels

By Kim Furtado, ND

When I began my practice twenty years ago, small intestine bacterial overgrowth (SIBO) was not commonly tested for or diagnosed. Over time, I learned that the diagnosis is important, however, SIBO can be difficult both to diagnose and to treat. It is common for me to have a new patient who has been diagnosed with SIBO by another doctor, has undergone treatments, but has not improved clinically. In these cases, I fall back on the principles of naturopathic medicine to navigate clients back to health.

The clinical picture related to bacterial overgrowth can range from bloating, indigestion, diarrhea, abdominal pain or discomfort, flatulence, and a myriad of leaky gut symptoms. From a naturopathic perspective, inflammation and poor absorption of nutrients in the gastrointestinal (GI) tract can have effects on the body, resulting in varied symptoms, such as skin disorders, joint pain, autoimmune conditions, and cardiovascular issues. Therefore, it makes sense to treat the gut for many clients, not just the ones who have overt digestive disruption.

For clients with SIBO, the root problem is that the bowel flora has essentially refluxed from the large intestine into the small intestine. In that new location, the microflora wreak havoc on the small intestine function of absorption through inflammatory damage to cellular structure. Overall, diminished gastric secretions and reduced intestinal motility are considered key features of why SIBO develops.

A logical treatment plan typically engaged for SIBO focuses on treating the gut. This includes antimicrobial treatment to eradicate the overgrown bacteria followed by probiotics, or beneficial bacteria in supplemental dosages. Additionally, a cornerstone of treatment is a highly restrictive diet, such as fermentable oligo-, di-, mono-saccharides and polyols (FODMAP), ketogenic, or other versions of low carbohydrate diets. The key concept is to form an embargo, in which preferred food sources are restricted to starve or kill off the overgrown bacteria. Most protocols also include a motility agent to help with restoring peristalsis, or the forward motion of the digestive tract.

What begins to not make as much sense is the dilemma that gut focused SIBO treatment plans are either only partially effective, or symptoms relapse for clients as soon as a component of the treatment plan is discontinued. For example, a compliant client who has successfully implemented the FODMAP restrictions feels better while on the diet, but all symptoms return when restricted foods are reintroduced. There is also the challenge that many clients cannot achieve compliance because the diets are difficult to implement correctly. In addition, many clients react poorly to some of the elements of antimicrobial drugs or herbals that are meant to be providing relief.

What I have found interesting over the course of practice, is that if SIBO is considered the disease process and the clinical focus is only on GI treatments, then clients can enter the loop of recurrence of symptoms after treatment. However, if SIBO is understood to simply be a symptom of an underlying imbalance, and that root cause is addressed, then the SIBO resolves.

For example, the innate healing power of nature is a key naturopathic principle, called the Vis Medicatrix Naturae. As fascinating as the microbiome can be, with more to discover each day, we can start with a simple premise: the innate wisdom of the microbiome knows how to establish its own territory or maintain homeostasis. Microbiologists can describe in detail the normal flora of all various parts of the body, and the flora of the large intestine is widely different than the small intestine. Each organ has its own structure and function, and each microbiome has its own biodiversity, structure, and function.

The key to re-establish balance within the GI tract is to optimize innate wisdom. Practitioners should consider what is the reason for this client’s breakdown or disruption of that inherently competent, wise structure and function within the microbiome and GI tract. The overgrowth of the bowel flora is not the reason, but rather it is the symptom occurring due to underlying dysfunction. With each client there is not always one simple reason. However, with individualized care the clinician can apply another key naturopathic principle, Tolle Causem, or treat the cause.

In my experience, there are three key underlying factors that disrupt function in the GI tract and microbiome. Namely, toxicity from the environment, chronic prolonged stress, and underlying hormone imbalances, including diminished thyroid function and adrenal hormone imbalances. Each of these are inter-related but can be successfully assessed and treated in order to restore health GI function.

First, environmental toxins have been shown to adversely affect the microbiome. While the full impact of environmental toxins on the microbiome are still poorly understood, preliminary study, as described in the World Journal of Gastroenterology, documents oxidative damage to colon cells from fine particulate matter in air pollution, and suggest that environmental pollutants may alter significantly the microbiome composition. Clinically, it makes little sense to try to balance and restore the microbiome while ignoring the chronic burden of low dose exposure of toxic chemicals such as lead, mercury, organophosphates, solvents, and plastics. No amount of balancing can occur in the face of acute, direct assaults on the microbiome.

Secondly, under-lying thyroid hormone imbalances can also wreak havoc on digestion. For example, peristalsis or the forward motion of the GI tract depends on adequate triiodothyronine (T3) hormone levels in the tissue. The muscle tone of sphincters is also reduced if thyroid function is low. Clinicians must be aware that digestive function can be disrupted by thyroid function. As integrative practitioners understand, patients may go undiagnosed if only thyroid stimulating hormone (TSH) is tested. A full thyroid panel that includes TSH, as well as thyroxine (T4) and T3 tests is key. Moreover, even with normal laboratory results, some patients’ only sign that they have low peripheral conversion of T3 is a basal body temperature (BBT) below 97.5 F. In this case, sometimes the presence of environmental toxins can create a reduced capacity within the liver for peripheral conversion. Clinical support the client with SIBO who has a low BBT is then directed toward detoxification and liver support instead of only boosting thyroid function.

Lastly, stress hormones also disrupt digestion. For example, if a person is driving and hears a siren, they might remember also feeling that in their gut. This is a poignant example of how peristalsis is disrupted when under acute distress. Layer in the complexity of how chronic stress affects the gut-brain axis, communication and function can easily break down.

The cues and signals that the microbiome use to maintain homeostasis will also break down the ability to maintain correct structure and function. Clinically, it is critical to assess adrenal status, and correct for imbalances in cortisol, dehydroepiandrosterone and in post-menopausal women, don’t overlook low progesterone. I explain to a client that the body is not a democracy, and cells don’t decide what to do, but rather they follow orders. If the gut is bathed is fight or flight, or sympathetic dominant catecholamines, neurotransmitters and hormones, it responds by down-regulation and suppressed function.

No number of gut-focused supplements and nutritional changes can successfully override the sympathetic nervous system dominance. As researchers in the journal Gut Microbes describe, patients with GI imbalances have disrupted nervous system, neuroendocrine and immune function. These imbalances are influenced by the emotional motor system (EMS) reactions to interoceptive and exteroceptive stress.

To restore GI tract imbalances, which are result of a chronic stress response, a restorative plan must include adaptogens for stress and comprehensive support for each client. It is critical to include new stress coping tools such as meditation and breathing exercises to restore vagus nerve function and reduce chronic stress impact. This complexity of chronic stress and the autonomic nervous system directly affects the neuroendocrine system in ways that create direct changes in hormone levels.

Overall, it helps to understand that the effects of prolonged stress, toxic burden, and hormonal imbalances are sometimes manifested as SIBO. Ultimately, if treatment remains focused on the GI effects of SIBO, there can be high recurrence rate of symptoms or ongoing digestive disruption. When practitioners treat the cause and not the effects, the restorative power of the body’s function and microbiome homeostasis can be reinstated.

References

Daher, R., Yazbeck, T., Jaoude, J.B., and Abboud, B. (2009) Consequences of dysthyroidism on the digestive tract and viscera World Journal of Gastroenterology. Retrieved from: https://www.wjgnet.com/1007-9327/full/v15/i23/2834.htm

De Palma, G., Collins, S.M., and Bercik, P. (2014) The microbiota-gut-brain axis in functional gastrointestinal disorders. Gut Microbes. Retrieved from: https://www.tandfonline.com/doi/full/10.4161/gmic.29417

Marynowski, M., Likońska, A., Zatorski, H., and Fichna, J. (2015) Role of environmental pollution in irritable bowel syndrome. World Journal of Gastroenterology. Retrieved from: https://www.wjgnet.com/1007-9327/full/v21/i40/11371.htm

About the Author

Kim Furtado, ND

Kim Furtado, ND, received her Doctor of Naturopathic Medicine degree from Bastyr University in Kenmore, Washington. She also holds a Bachelor of Science Cum Laude in Biology from George Washington University in Washington, D.C.  Inspired by the healing power of earth-based natural medicine, Furtado is dedicated to continued education and research. Furtado’s special interests include herbal medicine, nutrition, environmental medicine, chronic illness, and women’s and children’s health.

Furtado enjoys serving as a community resource and effective educator of lifestyle changes. Furtado is a member of the American Association of Naturopathic Physicians (AANP). She is also executive director for the Delmarva Community Wellnet Foundation, where she founded the SNAC Garden Program. Furtado views healing as an active journey on which she is honored to travel with each person. She is dedicated to the principles of naturopathic medicine and the knowledge that all medicine begins with prevention.