It is incredibly common for new patients to report to me that they put off scheduling a new patient visit because they just weren’t ready to make any kind dietary changes. They walk in fully prepared at that point to make detailed diet diaries, adhere to strict dietary advice, and give up their favorite foods in order to feel better. Unfortunately, diet and health culture has over-sold the idea that “you are what you eat” and that nutrition is the main underlying factor for both health and disease.
Now I’m not at all suggesting that diet is not related to health. As a naturopathic physician who specializes in treating digestive disorders as well as a variety of mental and hormonal health concerns, I am acutely aware of how much our food choices can affect us. I also do commonly see patients whose intestinal symptoms are 100% caused by food intolerances and food allergies. But we need to avoid the common and easy mistake of putting all diseases into one diagnostic “box”. This is not only poor medicine, but it can actually be very harmful to patients and limit their ability to heal.
So, if it is not the foods, what is causing so many people to suffer from uncomfortable intestinal symptoms? Here are the top three reasons I see in my clinic:
SIBO/Microbial Imbalances:
SIBO (small intestinal bacterial overgrowth) is a disorder caused by an over-abundance of bacteria in upper intestinal tract. It is also possible to develop SIFO (small intestinal fungal overgrowth). The lower intestinal tract can experience bacterial and fungal overgrowth as well as host a wide variety of intestinal parasites. These microbial infections are much more common than physicians previously thought. Research is now confirming that many IBS patients actually have underlying intestinal infections that are contributing to their symptoms (1). Common symptoms of SIBO/microbial imbalances are excessive gas and bloating, early satiety, abdominal pain, and either constipation or diarrhea depending on what microbe or microbes are present.
Testing for SIBO and microbial imbalances can be done by breath and stool testing. Once we identify and eradicate the underlying infection, most patients see significant improvement in their intestinal symptoms.
Digestive Enzyme Insufficiency:
Many patients confuse digestive enzymes and probiotics, thinking that they are the same thing. But enzymes are entirely different substances with a very different function than probiotics. When you eat food, your pancreas secretes a specific blend of enzymes that help break down food into tiny particles that can then be absorbed through the intestinal lining. A similar but slightly different type of enzyme is hydrochloric acid, which is secreted by the stomach to assist in this same process. Lastly, the gallbladder releases bile which helps break down fats. If food is not completely broken down by this specific combination of enzymes, then we will not be able to absorb all the nutrients contained inside. Additionally, undigested food traveling through the intestines can lead to fermentation, which then causes belching, excessive bloating, gas, and potentially constipation or diarrhea. Down the line, long-term enzyme deficiencies can be a direct cause of SIBO, GERD, and malnutrition, among other conditions.
Testing for digestive enzyme insufficiency can be a little complicated. Ordering a fecal pancreatic elastase level will give us some idea of how efficient the pancreas is at making digestive enzymes. It is also possible to test hydrochloric acid levels by sending the patient for a Heidelberg study. During this exam a small pill attached to a string is swallowed and then measurements are taken at periodic intervals to measure acid levels in the stomach (2). Due to the cost and invasiveness of this test, it is often easier to do a trial of enzyme supplementation rather than test. But there is one important caution when experimenting with enzymes: taking hydrochoric acid if you have gastritis or an active stomach ulcer can cause significant irritation and damage to the stomach lining. It is reccomended to only do this trial if you are sure that you don’t have these conditions or under the care of an experienced physician.
Gastritis:
Gastritis occurs when there is inflammation of the stomach lining. This disease often causes uncomfortable pain and fullness in the upper abdomen, and it can be commonly confused symptomatically with gastric reflux disease. There are several potential causes of gastritis, which can be broadly categorized into two main types: non-infectious and infectious. Infectious gastritis is usually caused by the bacteria H. pylori, while non-infectious gastritis can be caused by chronic use of anti-inflammatory medications, bile reflux, alcohol and tobacco use, autoimmune disorders, or stress. For some people, food intolerances can also be an underlying cause.
The only way to definitively diagnose gastritis is to have the patient undergo an upper endoscopy with a gastroenterologist. Although an upper endoscopy is invasive, the testing is safe and the information gathered from such a test can be incredibly valuable. If H. pylori is suspected, we can test for an active infection in the stool or breath.
The bottom line is this: while underlying food intolerances or poor dietary choices can definitely be a cause for chronic intestinal distress, there are many other conditions that can cause similar symptoms. Often, we need testing to differentiate one disease or disorder from the next. Working with a physician who is trained in the diagnosis and treatment of intestinal disorders can help patients get to the bottom of why they are suffering and receive the appropriate treatment for their condition.
Dr. Katie Nuckolls is a naturopathic physician and owner of Thrive GI: Natural Digestive Medicine in Vancouver, Washington. For more information, visit our contact page or schedule a free 15-minute consultation online.