Sorry you are struggling. There is much overlap in symptoms with my case. Doctors sadly often overlook all this and do not have time to really dig in to underlying possible causes.
Please check for nutrient deficiencies or any malabsorption issues including pancreas function, exocrine pancreatic insufficiency (EPI), small intestinal bacterial overgrowth (SIBO), liver function, Candida yeast overgrowth, gallbladder function, stomach acid strength, Crohn's, food sensitivities, Celiac. Tests such as Genova Diagnostics FMV or Great Plains Lab Organic Acid Test (OAT) are great for an overview.
Exocrine Pancreatic Insufficiency (EPI), SIBO, Candida
EPI is definitely something to dive into and rule out. This thread has a lot of info on SIBO, Exocrine Pancreatic Insufficiency (EPI), Candida overgrowth, reflux, malabsorption issues:
Tests to Consider
Food and Drink
- Stool test pancreatic elastase
- Blood test fasting trypsin (to see if you produce enough enzyme for protein breakdown)
- Comprehensive Stool test for parasites, pathogenes, dysbiosis. E.g. Genova Diagnostics - Comprehensive Digestive Stool Analysis 2.0 with Parasitology (microbiome dysbiosis indicators), Fecal Fat Distribution (checks if you have issues with different types of fat intake and digestion), Elastase (for EPI, pancreas enzyme marker)and Chymotrypsin (for EPI, pancreas enzyme marker). Doctor's Data has similar tests.
- Stool test chymotrypsin (similar to, but not as accurate as elastase)
- Intestinal permeability. Intestinal permeability (a.k.a. leaky gut) is something that your Gastro can also test for. The one I did was: Cyrex Laboratories - Intestinal Antigenic Permeability Screen. It measures intestinal permeability to large molecules, which can cause autoimmune reactions, inflammation, food sensitivities, malabsorption, etc.
- Gallbladder function. Yet another element that is important in breaking down food and thus any gallbladder issues can cause malabsorption.
- SIBO and Candida overgrowth. With SIBO, both methane and hydrogen ones should be tested and tackled. Multi-pronged approach is needed as just antibiotics is not enough. A breath test for SIBO and something such as Genova FMV or Great Plains Lab Organic Acid Test (OAT) can be helpful here.
- Nutrient level and Organic Acid testing such as Genova FMV or Great Plains Lab Organic Acid Test (OAT)
- Fasting blood sugar tests: e.g. HbA1c, triglycerides, c-peptide, insulin, ketones, glucose
- Lactose intolerance: Have you tried dairy free for 4-6 weeks? Does it help if you add lactase pills with anything dairy?
- Food sensitivities: Any food allergy and sensitivity tests completed? What about gluten sensitivity tests?
- MRI of the abdomen with MRCP with contrast: It gives a 3D picture of the gallbladder and high resolution liver, pancreas, gallbladder, ducts, stomach intestines. Amazing test.
- Stomach acid: Is your pH low enough to start digesting food? If it is too high this will exacerbate any SIBO, candida overgrowths, and malabsorption. Are you taking antacids or PPI as these only cover symptoms, do nothing about root cause, and can make things much worse. Have you tried the following simple selftest:
A simple unscientific test to approximate acid level is by drinking a quarter teaspoon of baking soda (sodium bicarbonate) mixed in a glass of water on an empty stomach in the morning. This creates bubbles within two to three minutes when mixed with the hydrochloric acid in your stomach. If after five minutes nothing happens, there is a very good chance the pH of your stomach acid is too high (i.e., low stomach acid).
An HbA1c of 5.4% is still a bit high so have you taken a close, hard and honest look at absolutely everything you eat and drink.
Have you kept a food diary for a while and note how you feel and whether there are correlations? Have you lost muscle or bone weight? Have you kept track of body composition (e.g. with a scale that can indicate weight, body fat %, body water %, muscle mass, metabolic age, bone mass, visceral fat, and basal metabolic rate)? Have you tracked calorie intake versus your personal requirement? How many grams of carbs do you eat and drink per day and per meal? How many grams of protein?
The energy swings and carb craving are sometimes linked to a diet imbalance, and being a 'sugar burner' as opposed to an efficient 'fat burner'. Do you eat within a specific window of time during the day? How often do you eat?
Do you still eat in restaurants or cafes as there is no control on quality and ingredients that could be impacting you?
Do you drink any calories? For example, it is still surprising to me how many people think that drinking juice or low fat milk is healthy for you.
Of course smoking and alcohol are no-brainers when you are not doing well. I always thought I ate healthily and yet little did I really know until my health took a nosedive. And if you have trouble digesting and absorbing, dietary changes are tough to see results from in the short term. Do you ever have silent reflux or acid reflux (with heartburn feeling)?
What is the quality of your water? Are you drinking, e.g. mineral, well, tap, bottled (plastic or glass), chlorinated (all US tap water), fluoridated (all US tap water), reverse osmosis, reverse osmosis with minerals added back in, filtered (what kind?), restaurant or cafe water, etc.? Try a few different types of mineral waters (glass bottle of course as you don't want the extra hit of plastic particles and leached chemicals) to see whether that helps.
Another thread on diet that might be of interest where I also put a few posts: