SIBO Treatment Not Working? The Problem with the 4R’s Gut Healing Protocol

Is your SIBO treatment not working?

You’re not alone. If you’ve tried the 4R’s gut healing protocol for SIBO, IBS or functional dyspepsia and still feel stuck, there’s a reason for it.

What are the 4R’s of gut healing?

When I received my IBS, SIBO and Functional Dyspepsia diagnoses and started my natural gut healing journey, all I could find online was page after page on the 4R’s of gut healing. I thought this must be the answer, after all, they have been touted as the ‘gold standard’ for many years.

The 4R’s protocol ^[1] involves:

1. Removing mucosal irritants

• a strict elimination diet
• treatment of possible pathogens
• removal of medications

2. Replacing digestive support

• synthetically replacing digestive support

3. Re-inoculating the microbiome

• taking probiotic supplements
• utilising prebiotic supplements

4. Repairing the mucosal lining of the gut

• increasing fibre consumption
• taking supplements for mucosal support

Why is the 4R’s protocol popular for healing IBS, SIBO and Functional Dyspepsia?

For those with more mild IBS, SIBO and Functional Dyspepsia symptoms, the 4R’s can be a game-changer.

It is an extremely generic approach to gut healing, without delving into any root causes. If you have mild bloating after a short period of high stress, the 4R’s might be the quick reset you need. It is simple to follow, easy to implement, and relatively inexpensive to complete.

But it doesn’t work for everyone.

I tried the 4R’s protocol. 3 times in fact. Every time, I got worse. My gut pain notably worsened, my pain levels increased, and my histamine symptoms deteriorated.

So what was going wrong?

Why is your SIBO treatment not working?

My gut dysbiosis and dysfunction was severe by the time I started the 4R’s protocol. 

I tested positive for SIBO, a condition which recent research has shown to be a state of dysbiosis rather than an overgrowth ^[2]. I also had a gut microbiota test which clearly showed a microbiome full of fat and sugar-loving opportunistic bacteria, and low in fibre-loving commensal bacteria.

I diligently began stage one of the 4R’s protocol, ‘remove’. I used antimicrobial agents (antibiotics and herbs), combined with a strict elimination diet (high in fat, low in fibre). The result, unsurprisingly, was a worsening of this gut dysbiosis. I was set up to fail from the very beginning, which is why I experienced symptomatic deterioration every time I tried to implement this protocol.

The protocol also didn’t look at any of my root causes (which are different to your root causes). It didn’t address the impact of my nervous system on my gut, my gut motility, or the high levels of inflammation preventing almost any intervention from being effective.

What is the main problem with the 4R’s protocol?

The most fundamental problem with the 4R’s protocol is just that: it is a protocol. It treats all gut problems as the same, as if they have the same underlying causes, which need treating in the same order.

And this is just not how gut healing works for many of us. We need an individual plan to treat our IBS, SIBO and Functional Dyspepsia, based on what is going on in our individual gut, rather than a generic protocol from the internet.

It is true that for a few the 4R’s protocol can be very effective. I have noticed this to be most often the case with those with mild dysbiosis, or more short-lived gut problems.

For those with more severe dysbiosis and inflammation, the 4R’s often provides, at best, a neutral outcome, and at worse can cause symptomatic deterioration – as was the case for me.

With that said, I actually did utilise some elements of the 4R’s protocol in my own healing plan, but order matters. Even if you’re doing all the right things, if they’re in the wrong order, nothing will stick. I also required additional strategies far beyond those offered by the 4R’s protocol.

What should I do instead of the 4R’s protocol?

If you have tried the 4R’s protocol for IBS, SIBO or Functional Dyspepsia, but it didn’t work for you, don’t panic. You are not doomed, and you will not have these symptoms forever! You just need to work with a practitioner prepared to look beyond this formulaic gut healing approach and deeper into YOUR root causes.

For me, success lay in a BRAIN-BODY-BIOME approach to addressing gut dysfunction.

It is almost impossible to make shifts in your microbiome if you haven’t addressed your nervous system (brain), and body-based root causes (eg. digestive capacity, motility, immune function, thyroid function, adhesions, etc.) first.

Where do I start healing from IBS, SIBO and Functional Dyspepsia?

Start from the ground up, and ask yourself these honest questions.

Am I stressed right now? Am I making adequate time for self-care? Is there anything I can change in my life to reduce stress?
Am I experiencing joy and fun in my life every day?
Am I getting 7-8 hours sleep per night?
Am I doing some form of movement every day?
Am I eating an adequate number of calories per day?
Are those calories from a primarily whole foods diet?
Is my diet heavily restricted? If so, what can I add back in without severe symptom exacerbation?

Without these fundamentals being present, you are making gut repair very difficult. Alone, they will often not be enough to resolve your IBS, SIBO or Functional Dyspepsia, but without these in place, it will be very challenging to successfully implement any ‘body’ or ‘biome’ based strategies.

I would highly recommend reaching out to a practitioner with a personalised approach to SIBO treatment, avoiding those who work with the 4R’s protocol if you have already ascertained that it does not work for you.

To sum up:

The 4R’s is the mostly widely used gut healing protocol in the functional medicine space, and often it can feel like there is nowhere else to go if it doesn’t work for you.

This is not the case. It is instead a clear indicator that there is something going that needs addressing, and that a cookie-cutter approach to healing IBS, SIBO or Functional Dyspepsia is not for you.

1. https://www.fammed.wisc.edu/files/webfm-uploads/documents/outreach/im/handout_therapy_increased_intestinal_permeability_clinician.pd
2. https://pubmed.ncbi.nlm.nih.gov/31043597/