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This article contains additional reporting by Jennifer Chesak. “Why do I wake up in the middle of the night?” This is one of the top questions Parsley’s members have been asking recently. If you...

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Tired All the Time? Here’s What Could Be Behind Your Fatigue.

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<p>Common symptoms: Heartburn, difficulty swallowing, burping, nausea, disrupted sleep, dry cough, sore throat</p>

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Diverticulitis

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<p>Many people who are diagnosed with <a href="https://www.parsleyhealth.com/blog/what-is-small-intestinal-bacterial-overgrowth-sibo/" >small intestinal bacterial overgrowth (SIBO)</a> get treatment, feel good for a while…but then, all that <a href="https://www.parsleyhealth.com/blog/reduce-bloating/" >bloating</a>, flatulence, cramping, reflux, constipation, and diarrhea starts to make a seriously unwelcome comeback. Unfortunately, it’s common to have a <a href="https://www.parsleyhealth.com/blog/what-is-small-intestinal-bacterial-overgrowth-sibo/" >SIBO</a> recurrence (or relapse) in which—once again—too much bacteria starts to colonize the wrong part of the GI tract. Here’s why it might happen, what you can do, and how to help prevent it in the first place.</p>
<h2>What are the top reasons for SIBO recurrence?</h2>
<p>Unfortunately, SIBO recurrence is not uncommon. “Sixty-five percent of all SIBO cases require retreatment,” says <a href="https://www.parsleyhealth.com/team/sarah-steinberg/" >Sarah Steinberg, MDPhD</a>, a double-board certified internal medicine and gastroenterology physician at Parsley Health. This number can be lower if you’ve undergone some type of post-treatment maintenance program with the help of a health professional. But still, it’s hard to completely eliminate the chance of recurrence.</p>
<p><a href="https://www.parsleyhealth.com/blog/fiber-bloating-gas-cramps/"  target="_blank" rel="noopener noreferrer">As for why SIBO recurs</a>, there are several possibilities. A big one: “I see a lot of people who get SIBO and then just want to go back to their old life—eating late, eating whatever they want, not exercising,” says Dr. Steinberg. Here, we dive into why these habits—and several other factors—can prime you for a SIBO repeat.</p>
<h3>1. You were diagnosed with the wrong type of SIBO.</h3>
<p>There are actually three different types of SIBO—hydrogen-dominant, methane-dominant, and sulfide-dominant—which refer to the main type of <a href="https://www.parsleyhealth.com/blog/causes-of-excessive-gas/" >gas</a> produced by the unwelcome bacteria in your small bowel. Specific antibiotics and herbal antimicrobials are used depending on the type of SIBO someone has. “A lot of time I see patients with hydrogen and methane SIBO, but their treatment was just focused on hydrogen, so they probably got inadequate treatment and we need to try again,” says Dr. Steinberg.</p>
<p>There’s also a possibility you didn’t have SIBO at all. When someone receives SIBO treatment several times but makes only minor improvements, Dr. Steinberg explores whether they may actually have small intestinal fungal overgrowth.</p>
<h3>2. You received inadequate treatment for SIBO the first time.</h3>
<p>If you received antibiotics as your sole form of SIBO treatment, it may not have been sufficient. “If we just kill the bacteria and don’t address anything else that got you here, you’re definitely going to increase your risk of recurrence,” says Dr. Steinberg. She, and other clinicians at Parsley Health, like to do a “maintenance phase” after a combined antibiotic and herbal antimicrobial treatment, which involves appropriate <a href="https://www.parsleyhealth.com/blog/when-to-take-probiotics/" >probiotics</a>, <a href="https://www.parsleyhealth.com/blog/anti-inflammatory-supplements/" >supplements</a> for gut-healing, and supplements to enhance motility (movement of food through the GI tract).</p>
<p>Fun fact: Anything that slows GI motility causes too much bacteria to remain (and multiply) in the small intestine, which can trigger SIBO recurrence.</p>
<h3>3. You have an underlying condition that slows gut motility.</h3>
<p>Speaking of gut motility, “some people have impaired small bowel motility due to chronic constipation, or an underlying condition like type I diabetes, celiac disease, Crohn’s disease, or hypothyroidism, which can predispose you to SIBO,” says Dr. Steinberg. So, appropriate management of these conditions, and taking specific steps to improve GI motility, may be necessary to treat SIBO and avoid recurrence.</p>
<h3>4. You spend too much time sitting (and snacking).</h3>
<p>Remember how Dr. Steinberg said patients who go back to (or never stopped) their old, unhealthy habits after SIBO treatment, often experience a relapse? Well, sitting for long stretches and all-day snacking (which often go hand-in-hand) are two of the big ones. Here’s why:</p>
<p>Sitting reduces blood flow to the digestive tract, which slows GI motility. This allows food to remain in the small intestines longer, which means bacteria can take up residence (and grow in numbers) where it shouldn’t, which is a recipe for SIBO recurrence.</p>
<p>Snacking can impair one of our body’s most important mechanisms for digestion—the <a href="https://www.nature.com/articles/nrgastro.2012.57" >migrating motor complex (MMC)</a>. The MMC is a cyclic, recurring wave of movement that clears food out of the small bowel. It occurs every 90 minutes or so when your stomach is empty, but when you’re constantly adding food to your stomach, the MMC is inhibited and can’t sweep the small bowel clean like it should, says Dr. Steinberg.</p>
<h3>5. You got food poisoning.</h3>
<p>Interestingly, SIBO (and a SIBO recurrence) can be triggered by certain pathogenic bacteria. That’s because “an infectious insult, like a bad traveler’s diarrhea or food poisoning, can cause impairment in small bowel motility,” says Dr. Steinberg. Specifically, the bacteria that cause food poisoning such as E. coli, Campylobacter jejuni, Shigella, and Salmonella produce a substance called <a href="https://pubmed.ncbi.nlm.nih.gov/23106005/" >cytolethal distending toxin (CDT)</a>, which can damage cells in the intestines and impair the MMC in certain people.</p>

<h2>7 simple but effective ways to help prevent a SIBO recurrence</h2>
<p>There’s actually a lot you can do to stay healthy and after SIBO treatment and prevent recurrence (as long as you weren’t treated for the wrong type of SIBO to begin with)—and most of that involves making diet and lifestyle changes that support long-term healthy gut function and motility.</p>
<h3>1. Incorporate movement throughout your day.</h3>
<p>According to Dr. Steinberg, the number one way we can support healthy motility is through movement—but going for one jog or taking one HIIT class and then sitting at your desk the rest of the day is not going to cut it. You need to be moving periodically throughout the day, too. “We all need to be getting up every 20 minutes, and if that’s not possible every 40 minutes to walk around, do a few balance exercises, do a few Sun Salutations, something to get moving,” she says. Some people may also benefit from post-meal walks.</p>
<h3>2. Stop eating at least three hours before bedtime.</h3>
<p>When it comes to eating, the cardinal rule for improving motility is to stop eating at least three hours before bed. This allows that migrating motor complex (MMC) to clear out the small bowel while you <a href="https://www.parsleyhealth.com/blog/what-causes-insomnia-how-to-sleep-better/" >sleep</a>. “If you eat right before bed, you’re inhibiting the MMC and putting your small bowel at a tremendous disadvantage,” says Dr. Steinberg.</p>
<h3>3. Stop eating between meals (or try intermittent fasting).</h3>
<p>Another way you can help your MMC do its thing: Avoid snacking between meals. “Basically you want to put three to five hours between meals to give your small bowel time to push things through,” says Dr. Steinberg. Certain <a href="https://www.parsleyhealth.com/blog/intermittent-fasting-health-benefits/" >intermittent fasting</a> protocols may be helpful, as long as you’re not pushing your eating window too close to bedtime.</p>
<h3>4. Eat a plant-heavy, nutrient-rich diet.</h3>
<p>Specific foods aren’t thought to trigger SIBO directly, but a low-quality, highly processed diet may lead to constipation, which slows motility and increases risk of SIBO relapse. So what should you eat? While many experts recommend a <a href="https://www.parsleyhealth.com/blog/low-fodmap-diet-for-ibs/" >low-FODMAP</a> diet during SIBO treatment and for a short time after, Dr. Steinberg says it’s not a long-haul strategy since it can be restrictive. Over time, you want to gradually re-introduce so you’re eating a varied, plant-heavy, nutrient-rich diet with plenty of <a href="https://www.parsleyhealth.com/blog/fiber-superfood/" >fiber</a> and probiotic-rich foods to support <a href="https://www.parsleyhealth.com/blog/biohack-way-healthier-gut/" >gut health</a> and regularity.</p>
<h3>5. Manage your stress levels.</h3>
<p>When you’re experiencing stress, various hormones are released that <a href="https://www.parsleyhealth.com/blog/can-stress-cause-diarrhea-and-digestive-issues/" >down-regulate digestion</a> and trigger contraction of GI sphincter muscles, which can inhibit motility and slow food transit in the stomach and small intestines. Any steps you can take to manage stress—exercise, <a href="https://www.parsleyhealth.com/blog/prescribe-meditation-patients/" >meditation</a>, deep breathing—can help alleviate stress-induced motility issues, and thus, help reduce risk of SIBO recurrence. “I also really like self-hypnosis for SIBO or IBS in general,” says Dr. Steinberg, adding that some of her members at Parsley Health like <a href="https://www.mindsethealth.com/nerva" >the self-hypnosis app Nerva</a>, which is designed to help you retrain the <a href="https://www.parsleyhealth.com/blog/gut-brain-connection/" >gut-brain connection</a>.</p>
<p>Oh, and if you can do your stress-busting activity outside, that’s even better. Exposure to sunlight helps reset circadian rhythms, which is great, since circadian rhythm disruptions have been <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6189841/" >tied to digestive issues</a>. And avoid late-night screen time while you’re at it!</p>
<h3>6. Consider an intestinal massage.</h3>
<p>Sometimes the impaired GI motility that leads to SIBO recurrence is a structural issue that needs manual manipulation. For example, <a href="https://www.hopkinsmedicine.org/gastroenterology_hepatology/diseases_conditions/small_large_intestine/small-intestinal-bacterial-overgrowth.html" >adhesions and scar tissue</a> that remain after certain surgeries can impede the movement of the intestines and their contents. In these cases, a visceral manipulation therapist can be helpful, says Dr. Steinberg. These therapists are trained to help break up this scar tissue and massage the lower abdominal area in such a way that improves motility and does great things for overall digestion.</p>
<h3>7. Follow basic food safety guidelines.</h3>
<p>Since getting food poisoning can trigger a SIBO relapse, you’ll want to make sure you’re taking some basic food safety precautions when you cook and entertain. That means, heating meat and fish to the appropriate internal temperature, avoiding cross-contamination of utensils and cutting boards, following proper storage guidelines, and more <a href="https://www.fsis.usda.gov/wps/portal/fsis/topics/food-safety-education/get-answers/food-safety-fact-sheets/safe-food-handling/keep-food-safe-food-safety-basics/ct_index" >outlined here by the USDA</a>.</p>
<h2>Why working with a qualified care team is extra important when it comes to SIBO</h2>
<p>Treating SIBO and avoiding a recurrence takes real commitment, and going it alone can be incredibly overwhelming (and often unsuccessful). That’s why enlisting the help of a care team, like the clinicians at Parsley Health, can be smart—“everyone wants to do it alone, but because proper treatment for SIBO can be so individualized, it’s great to have not only an expert opinion, but a sounding board for what makes sense and what doesn’t,” says Dr. Steinberg.</p>
<p>Parsley Health clinicians can test (and retest, if necessary) for the different types of SIBO and treat accordingly with the appropriate antibiotics, herbal antimicrobials, or a combination of both. They’ll also walk you through a maintenance phase with appropriate supplements to support gut health and motility, and look for underlying conditions that may prime you for recurrent SIBO. All Parsley Health members also work with a health coach, who can help to personalize dietary recommendations and hold you accountable for lifestyle changes that can help prevent recurrence.</p>

Why SIBO Comes Back, Plus 7 Ways You Can Prevent SIBO Recurrence

<p>The <a href="https://www.parsleyhealth.com/blog/how-to-prepare-for-pregnancy/" >needs of pregnant women change drastically</a>, especially for vitamins and minerals. By design, prenatal vitamins meet the specific needs of pregnant women because <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7071347/" >vitamins and minerals</a> play important roles in the health of your growing baby.</p>
<p>Ideally, <a href="https://www.parsleyhealth.com/blog/pregnancy-diet-nutrition/" >the foods you eat</a> provide all the vitamins and minerals you need, but it can be challenging to meet these, especially if you’re experiencing morning sickness. Some women may also need additional nutritional support to get pregnant or carry a pregnancy. Taking a prenatal vitamin helps cover any nutrients missing from your diet, setting you and your baby up for <a href="https://www.parsleyhealth.com/blog/common-pregnancy-questions-answered/" >a healthy pregnancy</a>.</p>
<h2>When to start taking prenatal vitamins</h2>
<p>It’s recommended any sexually active female who could become pregnant take a prenatal vitamin to help prevent complications if an unplanned pregnancy comes up. If you and your partner decide it’s time to start trying to get pregnant, it’s the perfect time to start taking a prenatal vitamin. “Ideally, [you] would start taking a prenatal vitamin one month before getting pregnant,” says <a href="https://www.parsleyhealth.com/team/annemieke-austin/" >Annemieke Austin, MD</a>, a physician at Parsley Health.</p>
<p>Depending on your health status, you may also want to supplement with other beneficial nutrients. “Talk with your doctor about testing your homocysteine levels, <a href="https://www.parsleyhealth.com/blog/vitamin-d-deficiency/" >vitamin D</a>, and consider other nutrient testing before getting pregnant,” Dr. Austin recommends.</p>
<p>If your doctor recommends testing for these labs, it gives you time to correct any <a href="https://www.parsleyhealth.com/blog/nutrient-deficiencies-explained/" >nutrient deficiencies</a> <a href="https://www.parsleyhealth.com/blog/how-to-prepare-for-pregnancy/" >before becoming pregnant</a>. It may even help you become pregnant more quickly if you have a nutrient deficiency that affects <a href="https://www.parsleyhealth.com/blog/eating-for-fertility/" >fertility</a> such as, folate, iron, or vitamin D. If you didn’t take a prenatal vitamin before becoming pregnant, start taking one when you can.</p>
<h2>Benefits of prenatal vitamins</h2>
<p>Having enough <a href="https://www.parsleyhealth.com/blog/daily-vitamins-supplements-routine-tips/" >vitamins and minerals in your diet is important</a> at any stage of life, especially when you’re trying to conceive or when pregnant. Here’s how they can help:</p>
<h3>Fertility</h3>
<p>Vitamin and mineral deficiencies can impact hormone levels which in turn affect your fertility. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6480978/" >Studies</a> show taking a prenatal multivitamin helps restore healthy micronutrient levels and reduce oxidative stress.</p>
<p>A <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3601821/" >zinc deficiency</a>, for example, could affect the early stages of egg development, so taking a supplement with zinc helps with healthy egg growth. Oxidative stress causes damage to cells in your body and reduces fertility in both <a href="https://www.hindawi.com/journals/vmi/2011/686137/" >males</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/28513460/" >females</a>. Antioxidants work to reduce this damage by removing the free radicals that cause oxidative stress.</p>
<p>Vitamins A, C, and E, selenium, zinc, and copper are powerful antioxidants. These are included in prenatal vitamins and can help to lower oxidative stress. Taking a multivitamin won’t guarantee you’ll become pregnant, but it could increase your chances.</p>
<h3>Reduced risk for low birth weight and preterm birth</h3>
<p><a href="https://www.cochrane.org/CD004905/PREG_vitamin-and-mineral-supplements-women-during-pregnancy" >Research</a> supports that women who took a prenatal vitamin were less likely to deliver:</p>
<p>An underweight baby (less than 5.5 lbs)</p>
<p>A baby small for their gestational age</p>
<p>Before 37 weeks of pregnancy</p>
<h3>Protect your health</h3>
<p>Getting enough vitamins and minerals protects your health as well, like with calcium. If there isn’t enough calcium in your diet to support your baby’s growth, calcium is pulled out of your bones, leading to <a href="https://pubmed.ncbi.nlm.nih.gov/30649176/" >maternal bone loss</a>. “Low calcium and vitamin D levels have been associated with adverse health outcomes in mother and child,” says Dr. Austin, “but it is unclear whether low levels are the causal factor or a marker of poor health.”</p>
<p>Vitamin D helps your body to absorb calcium. Still, it’s important for more than just helping calcium levels. Adequate <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6003599/" >vitamin D</a> intake during pregnancy is important for the baby’s health for</p>
<p>Healthy birth weight</p>
<p>Bone growth</p>
<p>Lowered risk for asthma during childhood</p>
<p>Your vitamin A levels are also essential for your health because a <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-019-2663-2" >vitamin A deficiency</a> could lead to night blindness (trouble seeing in dim light or darkness). Anyone with a vitamin A deficiency can experience night blindness, but pregnant and lactating women are at a higher risk. Vitamin A also plays an important role in cell division, fetal growth, immune health, and both infant and maternal vision, explains Dr. Austin. During pregnancy, vitamin A needs increase by 20-30 percent to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6470929/#:~:text=During%20pregnancy%2C%20there%20is%20an,is%20available%20in%20several%20formulations." >800 µg per day</a>.</p>
<h3>Preventing neural tube defects</h3>
<p>The baby’s neural tube and spinal development happen in the first few weeks of pregnancy, usually before most women find out they are pregnant (hence, why taking a prenatal if you’re trying to conceive or could become pregnant is ideal.) Folate is a vitamin deficiency linked to neural tube defects. A supplement with folate (methyl folate) helps make sure your baby’s spinal cord and brain develop correctly.</p>
<h3>Supporting baby’s brain development</h3>
<p>Both choline and omega-3s are essential nutrients for the development of your baby’s brain. “Choline availability is crucial for the development of the central nervous system, with evidence of effects on cognitive function in infants,” says Dr. Austin.</p>
<p>A type of omega-3, docosahexaenoic acid (DHA), is “necessary for normal development of the brain and retina,” according to Dr. Austin. Fatty fish is the best source of DHA, but it’s “important women of childbearing age choose fish low in mercury and other contaminants,” like:</p>
<p>Salmon</p>
<p>Anchovies</p>
<p>Herring</p>
<p>Sardines</p>
<p>Eicosapentaenoic acid (EPA) is another type of Omega-3 fatty acid. During pregnancy, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2621042/" >EPA</a> helps to transport DHA and increase gene expression important for your baby’s developing brain cells. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2621042/" >Studies</a> show that taking a DHA and EPA supplement may lower the risk for preterm delivery.</p>

<h2>What to look for in a prenatal vitamin</h2>
<p>You <a href="https://www.parsleyhealth.com/blog/best-supplements-for-optimal-health/" >should </a>always<a href="https://www.parsleyhealth.com/blog/best-supplements-for-optimal-health/" > be mindful of which supplements you’re taking</a>, but it becomes even more important when choosing a prenatal. In general, <a href="https://www.parsleyhealth.com/blog/shouldnt-buy-supplements-grocery-store/" >pharmaceutical-grade supplements</a> are best, as they’re third-party tested, contain no fillers, dyes, or binders, and go through the same rigorous testing as pharmaceutical drugs. They’re also formulated to contain each ingredient’s most active and effective forms (which isn’t necessarily the case for prenatal vitamins you find at the grocery store). In general, look for prenatal vitamins with:</p>
<h3>Folate</h3>
<p><a href="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/folic-acid-for-the-prevention-of-neural-tube-defects-preventive-medication#:~:text=The%20USPSTF%20recommends%20that%20all,800%20%C2%B5g)%20of%20folic%20acid." >The U.S. Preventive Services Task Force</a> recommends a supplement between 0.4 to 0.8 mg of folic acid at least one month before and during the first 2-3 months of pregnancy. For the rest of the pregnancy, 0.6 mg of folate is recommended.</p>
<p>Dr. Austin recommends sticking with methylated b vitamins (folate) over folic acid <a href="https://www.parsleyhealth.com/blog/anti-inflammatory-supplements/" >supplements</a>. Folic acid is a synthetic version of folate that is often added to processed foods and supplements. Some people struggle to convert folic acid into an active form (folate), like those with an MTHFR gene mutation. If you don’t know your genetics, it’s safer to stick with folate supplements to ensure your body can use this important vitamin. According to Dr. Austin, “some higher-risk individuals need higher doses of folate, if [you’re] unsure, discuss with your doctor and consider taking a prenatal with 1 mg of folate.”</p>

<h3>Iron</h3>
<p>Look for a supplement with iron. Dr. Austin explains, “27 mg of iron is necessary for both fetal/placental development and to expand the maternal red blood cells.”</p>
<h3>Calcium</h3>
<p>Your prenatal should have at least 250 mg of calcium. Says Dr. Austin, “fetal skeletal development requires approximately 30 grams of calcium during pregnancy, primarily during the last trimester.”</p>
<h3>Omega-3 Fatty Acids</h3>
<p>Fish is the primary dietary source for omega-3 fatty acids. Both DHA and EPA support your baby’s brain development. For women unable to consume fish, there are fish oil supplements or DHA supplements synthesized from algae. An intake of 200 to 300 mg per day of DHA/EPA is recommended, including both your food and supplement sources, says Dr. Austin.</p>
<h3>Choline</h3>
<p>Choline is often absent or low in prenatal vitamins, says Dr. Austin, but because it’s important for brain health, it’s best to find a prenatal that contains choline. It’s recommended to have <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6722688/#:~:text=The%20choline%20adequate%20intake%20(AI,day%20during%20lactation%20%5B3%5D." >450 mg</a> of choline per day during pregnancy. You can also work choline into your diet. Good sources of choline include eggs, meat and fish, <a href="https://www.parsleyhealth.com/blog/dairy-and-inflammation/" >dairy</a>, navy beans, Brussels sprouts, broccoli, and spinach.</p>
<h3>Vitamin D</h3>
<p>A prenatal vitamin should have a minimum of 200 to 600 international units (IUs) or vitamin D, explains Dr. Austin. Most prenatal supplements have at least 1000 IU, but the safe upper limit is still being studied to help understand vitamin D needs during pregnancy. The safe upper limit is currently set at 4000 IU.</p>
<h3>Additional vitamins</h3>
<p>“In addition to these [the above] key nutrients, pregnant women need to get adequate amounts of vitamins A, E, C, B vitamins, and zinc,” explains Dr. Austin. Talk with your provider for specific recommendations for your pregnancy. At <a href="https://www.parsleyhealth.com/" >Parsley Health</a>, clinicians will also monitor your health through <a href="https://www.parsleyhealth.com/blog/prenatal-testing/" >prenatal tests</a> that ensure your prenatal vitamins are working and your lab work for other important markers during pregnancy look good.</p>

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