We know that gut health is trending, it's pretty hot right now, right?! Well, tune in to today's episode as Mase explores SIBO with a bonafide SIBO doctor. Small intestinal bacterial overgrowth, it's a deep dive today, exploring what the heck is this actually?! Mason and Dr Nirala cover the nuanced approach required to treating SIBO, exploring why it may be overdiagnosed and other gut symptoms (constipation, food sensitivities and more).
If you've ever traveled to a third world country, got some sort of bug, 'fixed it' and then realised you never truly recovered, then today's episode is for you! (Also, if gut health and immunity are important to you, you are going to love today's episode.)
Dive in, here are some of the stuff discussed in today's episode:
Who is Nirala Jacobi?
Dr. Nirala Jacobi, BHSc, ND (USA) graduated from Bastyr University in 1998 with a doctorate in naturopathic medicine. Dr Nirala practiced as a primary care physician in Montana for 7 years before arriving in Australia and is considered one of Australia’s leading experts in the treatment of small intestine bacterial overgrowth (SIBO), a common cause of IBS.
Dr Nirala is the medical director for SIBOtest, an online testing service for practitioners. Dr Nirala is so passionate about educating practitioners that she founded “The SIBO Doctor”, an online professional education platform. Dr Nirala lectures nationally and internationally about the assessment and treatment of SIBO and is the host of the popular podcast The SIBO Doctor podcast for practitioners.
Dr Nirala is the medical director and senior naturopathic physician at The Biome Clinic, center for functional digestive disorders in Mullumbimby, New South Wales. Dr Nirala is the co-founder of the Australian Naturopathic Summit. When she is not actively researching, seeing patients or lecturing, Dr Nirala can be found enjoying the beauty of nature
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Check Out The Transcript Here:
Nirala Jacobi: (00:02)
Did I pronounce your name correctly?
Nirala Jacobi: (00:04)
Okay. Nirala Jacobi?
Nirala Jacobi: (00:07)
Nirala Jacobi: (00:12)
Okay. Guys, got to do it in person today, which is-
Nirala Jacobi: (00:17)
What were the chances of that?
Considering you live in Wilson's Creek, I think they're pretty good. But in terms of the chances of doing it, two people, that's a party but I think that's a legal party at these times, isn't it?
Nirala Jacobi: (00:29)
These days, it is.
Oh, pretty legal. Goji is sitting in the room if you hear Goj wrestling around, but dogs don't count. Guys, we're talking about SIBO. We got the SIBO Doctor here. I'm following you on Instagram for, I think, like three years.
Nirala Jacobi: (00:51)
Yeah. I've been aware of your work. SIBO has been one of those things I used to say, facetiously, that it got trendy about three years ago in terms of I don't know where you see the mass awareness come about in the naturopathic and medical circles or whether it's even really accepted in the medical circles but, obviously, you would have watched the trend occur and then the mass misdiagnosis and then realisation that we're actually able to test and find out that it is this SIBO, which we'll find out from you what it is. Why did it, all of a sudden, hit mass consciousness? What I see a few years ago anyway.
Nirala Jacobi: (01:42)
I'm going to go back nine years. I've been a naturopathic doctor for about 22 years now. I have practised in Montana and saw everything from heart disease to urinary tract infections to actual IBS or irritable bowel syndrome. We had really good result rates, but there was always a subset of patients that just did not improve. Then fast forward nine years ago, I sat in a lecture at one of our conferences and heard about SIBO. It was like a light bulb went on because it explained those cases that just didn't improve with conventional naturopathic approaches even to irritable bowel syndrome.
Nirala Jacobi: (02:27)
Then, I started to become an expert in SIBO. I moved here about 15 years ago, Australia, but I became an expert and started lecturing for other supplement companies and to practitioners and started a breath testing company because there was just nothing here at all about SIBO. I think one of the reasons why it has really exponentially grown the interest is if you think that about 11% of the world's industrialised nation has IBS. IBS, according to conventional medical texts and the conventional medical approach, has no real cure.
Nirala Jacobi: (03:18)
To find something that actually is the cause of IBS that is so profoundly responsive to treatment, I think, really gave hope to a lot of people. Now, of course, with that comes the fact that SIBO is often, as you mentioned, I do think there is an element of overdiagnosis. Everybody just basically treats according to the symptoms, which is not what I recommend at all. Because in that case, you can use antimicrobials and things like that for far too long.
Nirala Jacobi: (03:53)
I think it has to do with the fact that there really wasn't other options for people. They really improved when they began to treat SIBO, or I saw a dramatic improvement in my patients when we finally treated the cause rather than just giving probiotics and giving fibre and giving all of the stuff that we know how to do, and people were actually getting worse, not better with those approaches. That was really my journey into this.
That was probably about a time when I think naturopathic medicine got a little bit more integrated even. There were all these different pockets. All of a sudden, naturopaths, even though they were specialising in particular areas, became aware of just all these different specialisations, became I did say trendy for that reason, because it was about the end of that era where people were really trusting health coaches who would read up about the symptoms of SIBO and, therefore, put their clients onto an antimicrobial or whatever it was and just flying blind. You've got the breath test of your business where I see it's like if you're in Chinese medicine, you are doing pulse and tongue and the questions diagnosis. If you're in naturopathic medicine, you need that testing most of the time, I'd imagine.
Nirala Jacobi: (05:25)
Yeah. I'm a gastrointestinal specialist. I don't just do SIBO. I specialise in functional gastrointestinal disorders, so I do a number of tests. This, I think, is a big shortcoming of practitioners where they consider the finances of ordering a test for a patient. I always tell practitioners that I teach, "You're not their accountant. You don't know if they want to test or not want to test, but it's your job to give them the best options and the diagnosis," because if you're just reading, you're not going to get better because SIBO is a really distinct condition that requires a really strategic approach. There's different kinds of SIBO.
That's always what happens. Yeah. It's the same with PCOS or whatever it is. There's different arms. Obviously, there's different sources. There's mainly four major causes, is that right?
Nirala Jacobi: (06:25)
There's four major groups of causes.
Nirala Jacobi: (06:29)
But maybe what we should do is backtrack and really define what SIBO is, right?
Yeah, good idea. Well leading, you can tell you have a podcast.
Nirala Jacobi: (06:35)
Yeah. All right. Let's talk about ... so that people can really understand that it's not just bacterial overgrowth, and as soon as you kill the bacteria, boom, that's it, you're cured. In some instances, that's the case, but it's actually the exception rather than the norm. But SIBO stands for small intestinal bacterial overgrowth. It's a condition where bacteria that are typically usually found in the large intestine are, for some reason, found in the small intestine.
Nirala Jacobi: (07:03)
Now, the surface area of your small intestine is about the surface area of a double tennis court. Imagine having a massive bacterial overgrowth right where you absorb your nutrients, where you release your enzymes, where you do all of these different important digestive functions and, all of a sudden, that surface area is just chock-a-block with bacteria. These bacteria ferment the food that you're eating into hydrogen gas. There's a group of bacteria or a phylum called proteobacteria. The main gram-negative bacteria in that group are Klebsiella, Proteus, E. coli, those types of bacteria that are the biggest culprit for causing SIBO.
Nirala Jacobi: (07:47)
Why is this happening? This is how we get into the underlying causes. I think one of the main driving cause of SIBO is, imagine you've gone to Bali, you had a case of food poisoning, or if your listener is in America, you've gone somewhere else and you had food poisoning. You came home, it resolved, but then you still have ongoing digestive symptoms. Actually, over time, they become worse, you go to the doctor, they diagnose you with IBS. That is the classic scenario.
Nirala Jacobi: (08:19)
What happens there is the bacteria that caused the food poisoning are not the bacteria that are causing SIBO, but they're the bacteria that are damaging to the enteric nervous system, which is really the motility, the brain of your gut. You are meant to have this innate ability to clear bacteria from the upper gut, because the body doesn't want them there. You're supposed to sweep them all towards the small intestine. When you've had a case of food poisoning that results in this damage, you actually cannot effectively clear these bacteria from your upper gut.
What is it that's affected in the small intestine and it stops you from having the motility to move it out?
Nirala Jacobi: (09:03)
This part of the nervous system is called the migrating motor complex. It's a part of the enteric nervous system. Enteric just means digestive or your gut. It's basically the brain in the gut. This particular section of the small intestine is meant to clear these bacteria out every 90 minutes on an empty stomach. Imagine that you've had this food poisoning and it damaged that section or that particular part of what clears the gut out in the upper gut.
Nirala Jacobi: (09:32)
That actually can be tested with a blood test. We're trying to get it to Australia. Because of COVID, we've had some issues. But we do want to offer this test for people to test for these antibodies, because if you know that's the cause, the proper treatment for SIBO for you would be to have antimicrobials, whether that's the conventional antibiotics that are indicated for this or herbs. Then you must follow it up with something called a prokinetic, which is a medicine that aims to reset this migrating motor complex. That's probably the biggest group of people that have this as an underlying cause.
Nirala Jacobi: (10:10)
But then you also have people that just were totally stressed out for a long time. Chronic stress, as you probably have discussed this before, causes you to be in this chronic fight or flight. If you're in chronic fight or flight, you're not in rest and digest, it turns off your digestion. These natural antibiotic fluids, like hydrochloric acid, bile, digestive enzymes that are meant to kill bacteria are very poorly produced and, therefore, you suffer not just from maldigestion, but then also bacterial overgrowth. That's a different kind of cause of SIBO that then wouldn't necessarily require the prokinetics.
Like a stealthy, slow-grown...
Nirala Jacobi: (10:54)
I like that you're just actually bringing up those antibacterial fluids. I was going to ask you, and you did it straight away.
Nirala Jacobi: (11:04)
Yeah. Then the other one, there's more, the fourth group ... The first one would be a matter of a problem with motility. That is not just this, what we call, post-infectious IBS. It can also be hypothyroidism, other autoimmune diseases, mould exposure. All kinds of things can cause this problem with motility. Then you have these digestive factors, and not a big one because a lot of people don't think about this, but previous abdominal surgery that causes scar tissue known as adhesions that actually attach to the small intestine in the abdominal cavity and cause like a kink in the garden hose. That prevents bacteria from leaving the small intestine. Also for that, you would need prokinetics. You can see how it's so much more intricate than just, "Here are some antibiotics," or "Here's berberine and here's Allimax."
Nirala Jacobi: (11:59)
One last thing I'll say about SIBO before the next question is that there are two groups. I've mentioned the proteobacteria that produce hydrogen. There's another group of ancient organisms. They probably live on Mars, too. Honestly, they're like extremophiles. They live on the bottom of the ocean. There are these ancient archaea. They're not even bacteria. They produce methane. Methane, we know, causes constipation. If you're somebody that's been diagnosed with SIBO methane or SIBO-C or SIBO constipation, it's likely that your methane is high. That's a different kind of treatment. That's starting to be thought of as actually a separate condition. That's advanced SIBO discussion.
I like that. We always got this travelling of these bacteria up through the ... Is it the ileocecal valve?
Nirala Jacobi: (12:55)
Ileocecal valve. Is that a constant occurrence of reality?
Nirala Jacobi: (13:00)
Nirala Jacobi: (13:01)
No, that is not how it happens. These bacteria, they are normal in very, very small amounts. Nothing in your body is really sterile. Nothing really, even though we think it is, but it's not really.
But we've been told it is.
Nirala Jacobi: (13:17)
Nirala Jacobi: (13:18)
Yeah. It's like modern medicine at the time thought that's what it was, but it turns out that one of the most famous bacteria that survives the stomach is H. pylori. We know it can survive very well there. But you have maybe 1,000 bacteria or colony-forming unit per mil in the upper gut, just below the stomach, the duodenum. Then as you progress towards the large intestine, actually, the diversity and the sheer number of bacteria increases. That's normal.
Nirala Jacobi: (14:00)
These bacteria, even though gram-negatives that cause SIBO, are actually not pathogens. They're called pathobionts. Pathobionts are organisms that you normally find in low amounts. But when they get overgrown, they become pathogenic. I often tell people, my patients, I say, "Your gut is like a white supremacists neighbourhood. It's just one kind of bacteria, and you need diversity and you need low numbers of those organisms." That's what we're aiming for.
There's, I guess, an as above, so below, we've sterilised everything in our environment, in our house, and we have low bacterial biodiversity there, we're going to see low bacterial biodiversity internally. Is there a particular macro or even micronutrient cycles that that gram-negative bacteria ... What did you say? What was the group?
Nirala Jacobi: (15:02)
The group is called proteobacteria.
Proteobacteria. Is there anything that would feed them excessively?
Nirala Jacobi: (15:08)
No, it's basically food. Those bacteria are usually found in higher amounts in the large intestine. They're normal there. A pathobiont becomes problematic when it outgrows its environment or the other bacteria in that location. They've actually just did a microbiome assessment study on the small intestine. I think the other reason, just to briefly sidetrack to get back to your first question, why is this such a big deal now, is because we know so much more.
Nirala Jacobi: (15:44)
The Human Microbiome Project that's undergoing, it's like discovering the universe, because what happened before we were able to actually understand what was happening in the small intestine, we couldn't culture out these organisms because they would die. They were anaerobes. They couldn't be cultured out. Now that we have this different technology that uses RNA and DNA, we can understand far more. Now we actually understand the normal microbiome of the small intestine a lot more. It's totally fascinating to be in this field of microbiome research.
Of the large intestine bacterial testing and analysis of the biome, testing has got a little bit more efficacy with that, is that right?
Nirala Jacobi: (16:33)
Oh, way more.
Nirala Jacobi: (16:36)
Way more, because it used to be culture-based, it turns out it's like fairy dust of what actually is in the large intestine as a representation of the ... We know about Lactobacillus and Bifidobacterium. That is literally just 2% to 5% of your entire microbiome. There are so many more species that do fascinating things.
We've had the chat on the podcast a couple of times of why just throwing a probiotic in the gut is ... Quite often, you can get a little bit more sophisticated.
Nirala Jacobi: (17:09)
I think we're at that place now where ... I'm somebody who used to just do a probiotic. "Yeah, just a couple of Bifido, couple of Lacto, you're good." But now, I'm way more strain-specific. I would use Bifidobacterium lactis HN019 if you're constipated. I'm not going to necessarily give a whole combination of products, or I give you Lactobacillus rhamnosus if you have leaky gut and eczema, for example. It's a lot more fun now than it used to be.
Yeah, I can imagine. It's like rather than just having your shotgun, you got the Men in Black chamber. You walk and there's all different types of guns and grenades all over the wall, but in a more life-giving kind of ... Like a seed gun.
Nirala Jacobi: (18:01)
I like that. Actually, this brings up a really important point, is that even when I went to naturopathic medical school, it was taught to us that we could reseed the gut. Remember that?
Nirala Jacobi: (18:15)
We cannot do that. These Lactobacillus and Bifidobacterium, they are response modifiers. They actually do something that is not involving reseeding. If you've lost a lot of your native species because you were on chronic antibiotics for acne, or Lyme disease, or whatever that may be, if you've lost a lot of your species or have really reduced them, probiotics will not reseed what you've lost. You can't do that. It's a really important point because some practitioners still preach this method, but I had to really switch my thinking. I tell my patients, "I'm going to give you this probiotic for this symptom. I'm not going to give it to you because you're reseeding." You can't do that. Not if it's 5% or 2% of the gut.
In terms of it being for the symptoms specifically, is that because the probiotic is able to do it like having a short-term effect within the gut and then it's on its way?
Nirala Jacobi: (19:11)
Yes, exactly. Exactly. That's what probiotic research is really good at, is seeing what symptoms a particular strain can alleviate.
Obviously, we've touched that medication and antibiotics can be another reason why we could lead to SIBO and IBS.
Nirala Jacobi: (19:33)
Medications like proton pump inhibitors that stop stomach acid, there's some debate whether or not, but I have seen people definitely have a problem with SIBO after using chronically proton pump inhibitors, and others that are more slowing the gut down. Medications like opiates and things like that, morphine will really slow it down. But then that's pretty temporary, you're not going to see chronic SIBO with that.
Yeah. The stress factor, you're looking at a combination, mould exposure, stress, and antibiotic here and there, it's kind of a cocktail of reasons, I imagine.
Nirala Jacobi: (20:18)
This is always the overwhelming part for people. It's like, "Oh, my God, where do I even begin?" But this is where a really skilled practitioner can ... I actually have a questionnaire that you can get on thesibodoctor.com. That is a questionnaire about finding the cause for SIBO. You can download it, it's free, as is the diet that I've devised for SIBO. You can take that to your practitioner and it can whittle it down to what the possible causes are. It goes through these four groups of causes.
That's cool. Something that I really like about your approach is I'm hearing just on your website right here, you've got the patient course, practitioner course. Obviously, you're a practitioner and you've got a focus on the patient being able to understand it and get to the source themselves, getting, for lack of a better word, empowered around it, getting informed, and then bridging the way that they can then take that questionnaire and they can create a dialogue between them and their practitioner.
It's something we always ... You go there automatically. It's why I like your work. It's something we always try to do and talk about on the podcast when we're chatting with practitioners as well, because it diffuses it. You've even got great resources there of like once you've treated yourself, how are you going to stay out of that practitioner office, which it's overlooked quite heavily. I don't know what your thoughts are on that.
Nirala Jacobi: (21:49)
The SIBO Success Plan, which is the patient course, it's an eight-hour course that goes through everything from leaky gut to all these different things, it really was born out of a necessity. In a perfect world, everybody would have a practitioner that is SIBO savvy that can nail this thing for you. But I got calls from people or emails from people in Finland and from all over the world that just said, "There's no one here. No one can help me." This is the course that really had to be made for people like that. They don't have a practitioner.
You go straight to sibodoctor.com/sibo-success-plan/. So good. Eight hours?
Nirala Jacobi: (22:35)
It's eight hours because it's eight modules. One of the reasons I shouldn't say I love SIBO, because SIBO is a medical condition, but if a practitioner is listening to this, if you can master SIBO, you got the gut down. You understand practically most of the things that can go wrong with the gut, bearing in mind that there are other issues that are more anatomical problems and stuff.
Nirala Jacobi: (23:06)
But everything from, like I mentioned, leaky gut, the effects of stress on the gut, what to do when you're constipated, how to help yourself with different home treatments, I have an online dispensary guide that guides you through all the major products that are out there that are for SIBO, and pros and cons and stuff like that, and food sensitivities, histamine intolerance, salicylates, oxalates, SIFO. SIFO is small intestine fungal overgrowth, which often accompanies SIBO. There's a lot there that I had to cover to really make it comprehensive for people.
Do you do a leaky gut analysis on a patient as well? Is there always going to be a presence of SIBO and therefore-
Nirala Jacobi: (23:55)
Not always. No.
Nirala Jacobi: (23:57)
The thing is SIBO can cause leaky gut.
Can cause... Right.
Nirala Jacobi: (24:00)
But just because you have leaky gut doesn't mean you have SIBO. But it is a major cause of it. They've even done research on, all right, well, one month after clearing SIBO, the intestinal permeability was also resolved. If you have the wherewithal and the fortitude to get rid of SIBO, then you can also get rid of leaky gut.
I think it's important that you said you do love SIBO because it's, as I mentioned before in the podcast, we're at that point where my mum, she's nine years post-aneurysm, 24-hour care, in a wheelchair all the time. We've done well to keep her off medications and keep her going well, but it's just this bloating that's been there and it finally got to the point where we're like, "Right, we got to test for SIBO," and so we've got there. We're doing the breath test thing. Is it five days?
Nirala Jacobi: (24:52)
No, it depends on if you're constipated.
Nirala Jacobi: (24:55)
If you're constipated, it's a 48-hour prep for this test because what we want to do is have bacterial fermentation really down, really reduced before you then start the test, which is a three-hour test where, first, you get up in the morning, you drink this very sugary drink. That's a prebiotic substance that promotes the growth of those bacteria that you've starved over the past two days, one or two days. Then you're measuring your breath every 20 minutes. If we see a rise of hydrogen or methane before 90 minutes, that's the window of SIBO.
Yeah. If you get the methane, then we're going into that real nerdy, new sector of SIBO. Is that right?
Nirala Jacobi: (25:46)
For that instance, my stepdad, he's managing that and he's just looking at like, "All right, test, okay, we can handle it," and trying to get a bunch of carers to all unite and align on that and then looking at having the management of the diet. I think the SIBO diet is the thing. That's why I say I appreciate you saying that you love SIBO because ... But I am curious when you're approaching, how do you keep the excitement up with your patients when you're-
Nirala Jacobi: (26:21)
That's a really good question. I think that even just this morning, I spoke with somebody who has been ill for so long, and I'm not saying that just curing her SIBO is going to be the be-all, end-all. People are complicated. There's no one approach to it. You can have somebody who has childhood trauma. We know from studies that even childhood trauma can cause what they call adverse childhood events. It can cause a major shift in the microbiome, for example.
Nirala Jacobi: (26:53)
You can have somebody like that that you work with in finding a good practitioner around trauma and regulating their own nervous system. Then you have somebody who just discovered that their house was full of mould, or you have somebody who has an autoimmune disorder or chronic viral infection. It always is different presentations. It forced me to really become really good at all these different conditions, and that's why I think if you can really not just look at SIBO, but the underlying causes for me is where it's really at where I continue to learn also.
Yeah. I guess that's the exciting part, is knowing that you're not just going to have another random go at figuring out what's wrong with you, but you're actually ticking things off to be like, "Look, if it's not this, great. We know it's not this. We know it's not this. We know it's not moulds. That means you're getting closer." I think just the trouble is finding a good practitioner.
Nirala Jacobi: (27:56)
We have an answer for that. On thesibodoctor.com, we have also the SIBO Mastery Program for practitioners. After they've completed all three levels, they're eligible to be listed free as a SIBO doctor approved practitioner, so all the people that are listed in there. We had to purge a whole bunch. We had to start fresh from scratch this January. As we go along, this list will get bigger and bigger, but they all have taken these very extensive training courses that covers all of these topics. I think you're pretty safe. A lot of them do Zoom calls. I will say that. Nowadays, we're forced to do more and more virtually.
Which is amazing.
Nirala Jacobi: (28:39)
It's amazing. It has its drawbacks. I do, as a practitioner, a hands-on practitioner that does physical assessment and certain manoeuvres, I miss that part but-
Can you explain what the physical assessment and manoeuvres are?
Nirala Jacobi: (28:54)
In America, we're trained like physicians. We're actually like naturopathic GPs, if you will. We're trained in physical exams. I always enjoyed that part of my practise, too. Some people have things like the ileocecal valve problem, which is the valve between the small and the large intestine and it can be stuck open, and then you have this backflow problem with bacteria. You can easily manipulate that with using different manoeuvres, or the hiatal hernia manoeuvre, which is part of the stomach moving into the thorax. It's those kinds of things, as well as physical exam and stuff like that. You get a lot of information from looking at somebody's body, for sure.
Yeah, 100%. I can get the drawback, if we can get back to getting in-person as much as possible, great. Otherwise, if you're in Finland and you don't have a practitioner, "Oh, well, that's wonderful."
Nirala Jacobi: (29:49)
Honestly, well, 90% of my practise is virtual, and then sometimes I'm like, "Okay, stand up, lift your shirt, press there." That will have the work.
Yeah, you do what you have to do.
Nirala Jacobi: (29:59)
Do you ever recommend for people to be physically manipulating their own gut with massage as treatment?
Nirala Jacobi: (30:07)
That's a great question because let's hypothetically say ... Well, let me rephrase it. Yes, if it's for just the ileocecal valve. I do have a little video on my Facebook page, The SIBO Doctor, where I go through how to do it, how to actually release the ileocecal valve yourself. It's not going to be as great as when a trained practitioner does it, but it's good. The massaging of the gut, let's hypothetically say that you're a patient that's listening to this and you're like, "Oh yeah, I may have SIBO."
Nirala Jacobi: (30:45)
You may have had abdominal surgery for things like you may have had caesarian or you may have had your appendix out or you may have your gallbladder out or the myriad of other things that would be considered routine surgeries, and you have adhesions. That is not a good thing to massage your own belly because it can trigger more scar tissue formation, but light touch, we're just talking light touch. For that scenario, I usually refer to a visceral manipulation practitioner.
Nirala Jacobi: (31:19)
Visceral manipulation, so the viscera are the organ up in the abdomen. It's extremely light touch but they are trained to actually feel the rhythms of these organs. Don't ask me what that is.
Actually, Tahnee, my fiancée, she's a Chi Nei Tsang practitioner. Do you know that? It's Daoist abdominal massage.
Nirala Jacobi: (31:37)
Oh, okay. Yeah.
We've talked a little bit about it. I was wondering whether that's what you were talking about.
Nirala Jacobi: (31:41)
Right. No. Visceral manipulation, as far as I know, there's a group from The Barral Institute and they have a very specific technique to very gently break down scar tissue or break up scar tissue.
Okay. That's good to get that resource because there's people listening to the podcast, like Tahnee's not practising and she gets asked a lot about doing abdominal massage, so to be able to tune in with another group of practitioners that are doing this I think will help a lot of people. All right. Well, that's going to be in the show notes, gang. When we do get to treatment and, obviously, the dietary charts, there's different phases of healing of SIBO?
Nirala Jacobi: (32:27)
No, so what happened is, okay, so in a nutshell, the food that promotes or that feeds the bacteria are foods that are high in fibre. That makes sense. Those are healthy foods that feed our own microbiome. That's why we want to eat them. In a case of SIBO, the bacteria are like miles further up so they're fermenting in the wrong place, and so you want to minimise those foods. Those foods are known as from FODMAPs, so Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols. Did I miss it all? Did we miss one? Anyways, so these are fermentable fibres.
Forgot the A?
Nirala Jacobi: (33:09)
Nirala Jacobi: (33:13)
I know, right? Those are the foods that typically are to be avoided when you suffer from SIBO. What I did is I took that diet from Monash. Fantastic work that they did over there to really pinpoint this. Before then, we didn't really know. I took that and put my own spin on it because I found even with that, people were reacting. I made it more restrictive, also added in SCD stuff and that type of thing, because I'm a very structured person and I don't like wishy-washy, vague treatment plans, and so I needed to structure it for myself.
Nirala Jacobi: (33:49)
What I found is that I got very good results by having a diet that was in two phases. Then I called it the bi-phasic diet. Phase one was the most restrictive part where you have almost no grains and no fruit and really the high-fermenting foods, and you are basically getting tested for SIBO and you're waiting for your test result. I was already seeing dramatic improvement by the time they came back and yes, indeed, the test says it's SIBO, so then we initiated antimicrobials. That then prevented a massive die-off reaction of just throwing in antimicrobials in a system that was still really activated.
Okay. You've got them going for, what, a couple of weeks now?
Nirala Jacobi: (34:35)
A couple weeks, yeah. Yeah. I really did it for practitioners so that they could also tailor it. It still has different food ... Some people are very sensitive to histamines when they have SIBO, and that means no fermented foods, so no sauerkraut, those kinds of-
That was very confusing for people, I think, about 10 years ago when capers and sauerkraut and body ecology diet and all that were going off real big time, and then some people will just get these intense levels of bloating every time they'd eat sauerkraut and kimchis and they wouldn't get it. They're like, "What's going on? This is a healthy food."
Nirala Jacobi: (35:14)
"Persist. Persist. Keep it up. It's just your body detoxing." No, it's your body reacting.
Yeah. Herxing became the ultimate. Just, "Oh, it's just a Herx."
Nirala Jacobi: (35:20)
Yeah, yeah. Exactly.
Is that normally enough to reduce the die-off from being too hard for someone just recently getting on the diet for a couple of weeks?
Nirala Jacobi: (35:32)
It depends. The other thing is if somebody's really constipated, I don't start antimicrobials until at least even with the aid of magnesium oxide or something, I get their bowels moving, because if you add in antimicrobials in a really constipated system, you really are begging for a Herxheimer reaction because the river is not flowing, there's algae growing, it's muddy, it's not moving, it cannot clear out these toxins. I get the system ready before I add in antimicrobials.
That's the most important part, is getting the river flowing.
Nirala Jacobi: (36:11)
If you're constipated.
If you're constipated.
Nirala Jacobi: (36:12)
Yeah, I would say that that's often when people feel really horrible, when they start something like that and it's just not working. It's ironic because with these archaea or these methanogens as we call them, these organisms that produce methane, once it's actually reduced by the help of antimicrobials, you can expect that the bowel returns to normal, but you can't expect it if you're using some form of garlic extract to combat your methanogens. It will take you a couple of months, or if not longer, to really reduce that level to such an extent that you can have spontaneous bowel movements.
What antimicrobials are you normally using?
Nirala Jacobi: (36:57)
When we talk about treatment, there's three kinds. You have your herbs. You have your conventional antibiotics, and these are very specific antibiotics that are not for ear infections or sinusitis. Then you have a third treatment called the elemental diet. Herbs are usually berberine-containing plants, some essential oils like oregano, clove, those kinds of things. There's a bunch of herbs that I use and an extract or a low-fructans kind of garlic. Garlic typically is a FODMAP food, but if we use it with a high-allicine content, we can use quite a lot of it without a problem for these archaea, and we know that they're really effective for that. Then when you look at antibiotics, you're looking at rifaximin, which is a type of antibiotic that stays in the small intestine, doesn't get absorbed, and it's bile-soluble so it works in that perfect environment.
Like the way doxycycline works, I think.
Nirala Jacobi: (38:00)
No, doxy is way more broader and you will absorb some of that. Rifaximin is not absorbed. It stays in the upper gut. Then you have neomycin for the methanogens. Some people use metronidazole or Flagyl, and I shy away from that because I think as practitioners, we're the custodians of our patient's microbiome and we have to really respect that. Some people, I have seen some shocking microbiomes, let me tell you, by just looking at stool tests and things like that. Stool tests will not give you any information about the small intestine but, very often, it's not like it's only in the small intestine. Problems continue on with the large intestine.
You're going to have an overgrowth most likely in the large intestine?
Nirala Jacobi: (38:45)
Yeah. I've seen microbiomes that are completely denuded, like a clear-cut rainforest, and you're trying to regrow it and no wonder they're so reactive. You had actually mentioned my last podcast guest on my show was the guy who wrote Fibre Fueled, Dr. B., Dr. Will B.
Dr. Will B. Yeah, that's what I call him instead of [mumbling].
Nirala Jacobi: (39:11)
Bulsiewicz. I think it's Bulsiewicz.
Yeah, I can never... We were in Arizona.
Nirala Jacobi: (39:19)
I met him at the mindbodygreen weekend. We had a we called it dads gone wild night...
Nirala Jacobi: (39:28)
Oh, do tell. Do tell.
Yeah, it wasn't that exciting. It was just me, the DJ, and Dr. B just having chats about the gut and veganism and getting on the gluten-free beers.
Nirala Jacobi: (39:44)
All right. That sounds like a hell of a party.
Yeah, it actually was. I think tequila made its way at some point, which is wonderful.
Nirala Jacobi: (39:54)
You were in Arizona after all.
Nirala Jacobi: (39:56)
Anyway, I really appreciated having him on the show because here he was, a gastroenterologist, epidemiologist, highly, highly trained specialist, and he had a sort of "Come to Jesus" moment when he really started to study the microbiome and started to work on it for himself. Now, he's like a complete convert about protecting the microbiome and regrowing it. I just think he's done a really good job with that book.
Is that where his book is coming from? From that angle or-
Nirala Jacobi: (40:28)
Fibre Fueled, yeah. I'm not his publicist, but I have the book and I read it and it's pretty good. Half the book is recipes, so vegan recipes, and how to regrow it. One word of caution, don't start with SIBO with that. We had this conversation. You can listen in on The SIBO Doctor podcast if you want to listen to the Feeding Your Microbiome. That shift is slowly happening. There's a lot more respect for the microbiome. I know of a lot of physicians who look back on medicine, on what it's done with antibiotics with real regret of like this was the wrong thing to do to just prescribe amoxicillin for every child's ear infection, or to prescribe for sinusitis, for these types of things. Still, to this day, it's happening day in, day out not just here but across the world where it's just way over prescribed, and it will catch up with you.
It's an important part of any practitioner's arsenal to be able to reflect on what they're doing and not be too concrete and make sure you don't have too much morality and judgement of yourself if you did just follow the doctrine at the time, but make sure you've got the capacity to... motility to actually move on to what's important, because I know I wasn't really up on the conversation on testing the microbiome and I think we were chatting about that.
Since then, I've got a naturopathic friend who he's basically moved a huge amount of his practise over to testing the microbiome and talking about how it takes out a lot of the guesswork, not only is it the antibiotics and seeing exactly the effect that they're having, which is great as well because you know what you've wiped out, but just dietarily as well, if it's vegan, high-carb, if it's carnivore or just high ... Whatever it is.
Nirala Jacobi: (42:32)
Yeah, carnivore, I would never promote. Never because it is so hard on the microbiome. It just is. That's basically just meat, and unless you live in countries where, for centuries, that's what you did and I just ... Anyways, that's digressing but they are, and we agreed on that. We totally agreed that most diets, really if it already has a diet, then it's a fad mostly. What we know is where people live the longest and, to me, that's evidence and that's the Blue Zones.
Nirala Jacobi: (43:14)
That's Dan Buettner's work. He wrote a book called the Blue Zones where people lived to be the oldest in the world, fully functional, still doing their daily work, very cognitively attentive, and very happy. There were seven hotspots in the world. They all had different things, but what they all had in common was 80% plant-based diet. For me, I'd go by that. I'd go by that. If people do well on veganism, then do that because the more plants you can eat, the more diverse your bacterial blueprint will be.
That's always with the Blue Zones. Yeah, I first heard about it ... The book I got was Healthy Till 100, I believe it was. That book included a couple of other places. I'll put it in the show notes, guys, the scientifically proven secrets of, I think, the world's longest living people. Vilcabamba was in there in Ecuador, which I think isn't in there with Dan's work but, otherwise, it's like Okinawa, Sardinia.
Nirala Jacobi: (44:26)
Yeah, and Loma Linda which is like eating processed vegetarian food.
I think that their faith gets involved.
Nirala Jacobi: (44:33)
Yeah, I don't know, but they got there in there, Sardinia.
Maybe they're just right.
Nirala Jacobi: (44:38)
Maybe. Well, who knows?
Maybe their prayers are just better than health.
Nirala Jacobi: (44:41)
Yeah, respect Loma Linda, California.
Oh, that's right, John Robbins was the author of that book I was talking about. I like him. He balances out, because I think the thing with Dan's work which always I'm like, "So good," then he's like ... because I'm only talking about his behalf and it's like because it's 80% to 90% plant food and then 100% is the obvious conclusion, which I don't find to be the obvious conclusion.
Nirala Jacobi: (45:09)
No, because I think and I will say if you look at the standard bi-phasic diet just to keep it in the SIBO spectrum, the standard bi-phasic diet is very animal protein heavy. Then I created a vegetarian bi-phasic diet, which is very amenable to vegans, and it's not just about taking the meat. That was a lot of work that I co-authored that with our clinical nutritionist, Anne Criner, here at our clinic. Then we have a third one which is the histamine bi-phasic. But there is something.
Nirala Jacobi: (45:41)
A lot of people have tried veganism and it's just like, constitutionally, they just couldn't do it. I don't know what the answer is for those people because there are some people that just they get weak. Dr. B would probably argue that he thinks that everybody can live like ... I think, I shouldn't speak for him, but I don't know. I find that everybody is a bit different.
Yeah, I'm with you as well. I find if you take one part of the body and solely focus on it, same if you're only focusing on the large intestine and the microbiome and not cellular, in particular cellular markers, then I can see how it would be really easy to justify a vegan diet. I was vegan and raw foodist for quite a while and then moved away from that direction and just was really questioning my need to eat a certain amount of domesticated vegetable and fruit matter.
Then once I got back into the microbiome, I've really come to peace and to terms with the fact that, "No, you know what, that's ..." I was really rocking. I was rocking with that majority of my well-being, and even moving back into lentils and legumes and beans, which had a huge chip on my shoulder about. But then just staying open to ensuring there's potentially ... Like in the Blue Zones, meats are normally a side dish, and I like that.
Nirala Jacobi: (47:15)
Yeah. I do, too. I know myself, I haven't eaten red meat in 40 years probably but I eat chicken occasionally. That's my one and only animal that I eat because also the carbon footprint. It's whole 'nother conversation, Mason. Nothing to do with SIBO. But in a nutshell, the diet is a therapeutic diet. It's not a stay-on-it forever diet.
Greaaaaat distinction. I'm going to have to get excited about the diet. I'm going to have to get my mum, because I'll let you all know how. Maybe if I can have a chat again, get you back on here after, I'm going to use all your resources, all the listeners are going to ... I'll keep you in the loop of where mum's at, especially.
Nirala Jacobi: (48:02)
Yeah, I'll let you know on an intro at some point where she comes back with in the test. If it's positive, then we'll go on that journey together. With meat and impact. Have you tried a wild, invasive deer or anything from around here. It's like-
Nirala Jacobi: (48:21)
No, but I'm not opposed to it. I trust my body and I just have no affinity towards those things. Red meat, just no.
Yeah, that's fair enough.
Nirala Jacobi: (48:38)
We're really covering a lot of ground, but there's something about the whole blood type thing that I can tell you as a practitioner, that's been nearly a quarter of a century in practise that there's something about that. Blood type As tend to have a little bit harder time with digesting animal protein.
Is that just going back to the classic book, The Blood Type Diet?
Nirala Jacobi: (49:02)
Yeah, D'Adamo. That's right.
Nirala Jacobi: (49:06)
Yeah. Look, it's still got work to do, but I think there's elements that I certainly have seen be proved in practise. For me, I don't just need theories, I actually need evidence. For me, evidentially, I have seen that in practise, that people that are blood type O, they fade sometimes on a vegan diet because I don't know. I never got so fully into it that I can rattle off the science right now, but it has to do with rhesus factor and different ... Well, the theory was really that when we originated ... See, an evolution story.
Nirala Jacobi: (49:47)
When we originated in Africa, everybody was blood type O because you needed to be able to eat dead animals and stuff. You had a very forgiving type of blood type that was not very reactive. Then as we moved north and into Europe, it wasn't really economical to eat your animals, and so you became more farmers and started to grow things, and that was blood type A. Then as you move further north, you had natural refrigeration, and that was the AB type or the B type, which can handle dairy really well. That's the theory anyways. I can tell you that much.
It's a good theory.
Nirala Jacobi: (50:23)
It's a good theory.
That was always the thing with The Blood Type Diet.
Nirala Jacobi: (50:26)
It checks out.
It checks out. I remember The Blood Type Diet was a funny one because every practitioner I've talked to has said there is something to this-
Nirala Jacobi: (50:35)
Yeah, there's something to it.
But the science was never rock solid so it was open for criticism, yet anecdotally, it was on point. I love it. It's good to know. It's good to go into that world because as soon as you get into, as you said, you made that decision, it's why it's hard sometimes to listen to a practitioner talk about diet long-term because you know that the mindset is based on healing. Then as you said, this is a healing-
Nirala Jacobi: (51:03)
Therapeutic diet. Huge distinction because, otherwise, you stay in a "I'm sick" mentality long-term.
Nirala Jacobi: (51:11)
Right. Look, I always tell my patients when you travel ... Well, it's a different world now, but if you were going to see Paris, I don't want you on this diet. I want you to eat baguette and dip it in the cafe au lait. I want you to eat things that you enjoy. Most of the time, when people travelling and they suffer from food sensitivity, it actually miraculously goes away. Of course, celiac disease is a different story, but there is this element of you just having just more endorphins and your secretory IgA goes up and all of that, and people can tolerate a lot of foods that they would not normally tolerate in a happy setting and a happy live-your-life, I want you to drink wine if you're in Italy. Why restrict ourselves to this myopic thinking, it has to look this way?
It's refreshing. I like the way that you're bridging over there. It's something that I've always liked about your accessible approach because it's like bridge into what's actually going on and then I'm going to see your bridge out over there to live your life because, obviously, people do get addicted to being sick and something being wrong and then the fear of if I do something outside of the therapeutic-
Nirala Jacobi: (52:23)
There's a lot of fear. There's a lot of food fear and there's this whole new term of orthorexia.
Nirala Jacobi: (52:30)
That's a real thing. A lot of people are so concerned about having made some small error on the bi-phasic diet. I'm like, "You've made no error. It's fine." Not just the bi-phasic diet but also anything, really. They get very, very hooked on that they did something wrong, and there's a lot of food fear and that. Imagine, you're sitting down to eat your meal and you're already worried about the food. Sometimes, I tell people sit for two minutes and just appreciate the food, just take a moment and get into a rest and digest before you eat.
That's where the prayer comes in, the grace.
Nirala Jacobi: (53:16)
It used to be prayer, it used to be grace, all of that. That's all. It's a thing.
I feel like we go down this rabbit hole, that's probably another podcast talking about the orthorexia. I know it very well. I've had to go. I was so down the rabbit hole of raw foodism. I had to go and start eating things that I swore I would never eat again to start cracking myself out of just like that scrubbing myself clean with my diet. It's hardcore, and it isn't orthorexia, and it isn't eating disorder in varying degrees. But thanks for bringing it up, because especially when you're promoting a therapeutic diet, I always think the duty of care comes with making sure that people and patients are aware not to get stuck in it. Thank you for that.
Nirala Jacobi: (54:00)
I had really a lot of fun chatting with you.
Nirala Jacobi: (54:03)
I did, too. We've covered a lot of ground.
We've covered a lot of ground. We run really fast on this podcast. Look, let's just repeat it again. The SIBO Doctor podcast, and it was episode 64 and 65 that we just talked about with Dr Will B. Worth probably checking out.
Nirala Jacobi: (54:26)
It's on iTunes. It's on everywhere. You can go to The SIBO Doctor and just look around. There's resources. All the guides are free downloads, the handout on bringing that to your practitioner in terms of what caused you SIBO. It's a free download. There's a lot of videos, lots of stuff. I'm on Instagram, Dr. Nirala Jacobi, the SIBO Doctor.
Perfecto. Thank you so much.
Nirala Jacobi: (54:48)
Nirala Jacobi: (54:50)
All right. All right. That didn't work. That was a terrible mic drop.
Nirala Jacobi: (54:55)
No, that's a very sensitive, very fancy road microphone.