Manipulating the gut microbiome—usually by increasing various strains of bacteria and fungi—can be a powerful tool for healing painful, life-altering symptoms in the gastrointestinal tract.
Evidence that this can work is growing. But it’s as if medical doctors are examining the issue through a fogged mirror. In part, that’s because they rely on guidelines developed by professional associations to direct their care. Without those guidelines, they'd be stuck.
The American Gastroenterological Association (AGA) explained that their guidelines can take up to two years to develop for any specific condition. That is, one disease is matched with specific sets of symptoms treated with proven interventions under certain circumstances. When the highly technical guidelines are released, they spell out the sequence of diagnostic and treatment approaches for each phase of the disease the patient is in, which takes previous treatments into account. Clinicians follow the guidelines like a flow chart.
A part of the challenge for creating such a flow chart is how diverse and individualized some gut issues—and patients—can be.
Meanwhile, other practitioners are more comfortable going forward with microbiome-based approaches using research-based protocols. They will use diagnostics like stool analyses and treatment approaches such as diet, prebiotics, probiotics, antibiotics, and fecal microbiota transplants (FMT).
This emerging research is accessible to the public and many people struggling with gut issues are following developments far more closely than their doctors. For this reason, it’s not uncommon for patients to tackle their gut health outside of doctors’ offices.
In some cases, patients doing their own research are educating doctors about what’s working to improve their symptoms. This can help oil the wheels in a system that’s been stifled by bureaucracy.
Lack of Sufficient Research
Physicians’ broad consensus on the gut microbiome’s role in IBD pathology “underscores the importance of microbiome-focused therapeutic strategies,” according to the authors. However, doctors said they hesitate to use such approaches because of scarce research data.Even the mechanism for how the gut microbiome might be involved in gut inflammation is a contentious subject. American doctors seem to be divided about whether imbalances in the gut microbiome—often called dysbiosis—are a result or cause of IBD, according to Dr. Colleen Kelly, AGA spokesperson. That is further complicated by research that’s not always conclusive.
“There have been a number of studies looking at manipulation of the microbiome through diet, prebiotics/probiotics, antibiotics and FMT, but findings in clinical trials have not yet shown an effective intervention that can be reliably utilized to treat these diseases,” she told The Epoch Times via email.
Stumbling Blocks for Doctors
Specific challenges reported by the doctors surveyed are the high costs of these treatments, modest evidence, and scarce treatment guidance. Insurance is unlikely to pick up the tab on any treatment that isn’t “evidence-based.” Evidence-based can be a complicated requirement given it can take decades for findings from research to make their way to clinical practice, which typically involves guidelines from a professional association or health authority.Doctors are reluctant to recommend probiotics due to variability in strains and high cost. The doctors also gave antibiotic use conflicting reviews, given the risks that include killing commensal bacteria that are vital for the immune system to fight future flares.
FMTs are not an approved treatment for IBD, and though some of the doctors believed it could be the most effective option, the authors said it was underutilized. Physicians expressed concerns about side effects, how often patients may need to have the treatment, and uncertainties due to lack of research and guidelines.
A Different Approach
Functional doctors, however, may be more likely to explore diet, prebiotics, probiotics, and sometimes even FMTs with their patients. The reason is because functional doctors operate on criteria called “biological plausibility,” explained Dr. Joel Evans, chief of medical affairs with the Institute for Functional Medicine, as well as the founder of the Center for Functional Medicine.Biological plausibility prompts functional doctors to consider any approach that makes scientific sense, he said. These health care providers must understand the mechanism by which the treatment operates, the risks of patient harm must be minimal, and the patient must understand both the mechanism and risks.
Problems patients face with most gastroenterologists are largely the result of a system that’s based on an “evidence-based” practice. Doctors have come to automate their practices around guidelines from organizations like the AGA, Dr. Evans told The Epoch Times. Insurance companies rarely provide coverage for anything that isn’t “evidence-based,” which means doctors aren’t likely to look outside that model.
“We have to start off with the assumption that doctors are well-intentioned,” he said. “As time has gone on, medicine has become more complicated, meaning the science and discoveries have become more complicated.
“At the same time, doctors are working harder because they’re forced to see more patients, less time per patient, spend more time with charting of patients, so doctors are having less time to learn new things.”
Diet is a Logical Place for Many
For patients without a functional doctor versed in new treatments, an easy place to start on their own is diet. Various foods have been shown to influence the gut microbiota, but while some foods are healing for some, they can worsen symptoms for others.For instance, sufferers of small intestinal bacterial overgrowth (SIBO)—often found in patients with IBD—rarely tolerate fiber and fermented food, especially in large quantities, as well as prebiotic and probiotic supplements.
In SIBO, bacteria take up residence in the small intestine where they don’t belong and where they ferment certain foods and cause gastrointestinal distress. However, these same foods that aggravate patients are also the ones widely promoted for gut health, making it confusing for patients and doctors. On top of that, food sensitivities and intolerances are highly individual, and few doctors test for these.
Eventually, he cut gluten and high-fructose corn syrup from his diet and rarely uses medication unless stress flares his symptoms. But it took time for him to make dietary changes.
“It’s been said it’s harder to change one’s diet than one’s religion in some cases,” Dr. Campbell told The Epoch Times. “These are hard things to do. Your gut is not a single double-blind placebo case study. We have many more nuances and influences like how we eat, what we eat, when we don’t eat, and when we sleep. All of these things affect our microbiome. So I can’t give people the same probiotic and expect the same result. That makes the science difficult and challenging.”
That doesn’t ease the frustrations of patients or their doctors, who are handcuffed to a rules-based system.
Dr. Kelly admitted an ideal medical practice is one driven by treatment decisions, rather than financial and insurance concerns. Ideally, it would be multidisciplinary with access to nutrition and psychological support, she said. For now, she encourages patients to avoid highly processed food and additives such as dyes, emulsifiers, and artificial sweeteners.
Personalized Treatment May Be Possible
Insurance doesn’t typically provide coverage for microbial composition analysis. Doctors in the survey pointed out that clear guidelines for this diagnostic tool could go a long way in guiding personalized treatment decisions.- Lack of reference values that might explain which bacteria are insufficient in the patient’s microbiome.
- Lack of insurance reimbursement.
- Lack of application to clinical practice.
- Difficulty interpreting results.
“It’s unlikely that taking a probiotic if you have SIBO will throw you into an acute situation where you need an ER visit. It will definitely make you more uncomfortable,” Dr. Evans said. “If you’re self-aware and you’re taking something that makes you worse, you stop taking it.”
Most patients, however, need more than a probiotic if they are having gut symptoms and may want the guidance of a functional doctor, he said. That could include being assessed to see if they lack fiber or the proper enzymes for digestion. Patients with SIBO often don’t know they should be taking a spore-based probiotic, Dr. Evans added.
Dr. Campbell said there is hope for IBD treatments that won’t require a lifetime of pharmaceutical use. The survey, she said, is reassurance that medicine is moving in the right direction.
“The flip side of that is what happens when we go too fast? If we take something that we don’t curate well enough and we implement it broadly into a community, we get a COVID vaccine debacle,” she said. “We don’t want the pendulum to swing too far on either side. We have to use science to our advantage, and science means asking questions and having open debate.”
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