Do you have hydrogen or methane dominant SIBO? Understanding what type of SIBO you have is an important aspect of your treatment program and ultimate recovery.
In this episode of The Healthy Gut Podcast, Rebecca Coomes talks to Australia’s leading SIBO specialist, Dr. Nirala Jacobi about testing options and her diet protocol, the SIBO Bi-Phasic Diet.
In Episode 4 of The Healthy Gut Podcast, we discuss:
✓ Why it’s important to take a 3-hour SIBO test
✓ The difference between hydrogen and methane dominant SIBO and their respective herbal treatment options
✓ Why you can see a drop in methane but an increase in hydrogen after treatment for your methane dominant SIBO
✓ Does die-off really exist and what causes it
✓ Small Intestinal Fungal Overgrowth (SIFO): testing, treatment and whether you can have both SIBO and SIFO
✓ What to do when you react to everything and why it’s important to address increasing food sensitivities when they occur
✓ The SIBO Bi-Phasic Diet protocol and why Dr. Jacobi doesn’t feed the bacteria during treatment
✓ What supplements and herbs to take to support your Migrating Motor Complex
✓ Why taking responsibility for your own health is so important
Dr. Nirala Jacobi is recognised as Australia’s leading SIBO specialist. She is the founder of SIBO Test, an online SIBO testing facility. Her website is full of useful information and resources. Take a free quiz to find out if you have SIBO, or find a practitioner near you. Dr. Jacobi offers Skype consultations, which can be organised via her website.
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Rebecca Coomes is an author, entrepreneur, passionate foodie and intrepid traveller. She transformed her health after a lifetime of chronic illness, and today guides others on their own path to wellness. She is the founder of The Healthy Gut, a platform where people can learn about gut health and how it is important for a healthy mind and body and coaches people on how to live well with SIBO. Rebecca is the author of the world’s first cookbooks for people treating Small Intestinal Bacterial Overgrowth (SIBO) and the host of the SIBO cooking show and The Healthy Gut podcast.
REBECCA: Welcome to the show Nirala.
NIRALA: Thanks Rebecca. It’s really great to be here.
REBECCA: Yeah. And just reading through your bio, like you I am just so busy. You have got so much on.
[1:14] NIRALA: this year it seems to be. Yes. There is a lot of SIBO related conferences and talks and everybody seems to be very interested in the topic these days which is great.
[1:21] REBECCA: which is wonderful and being one of Australia’s leading specialists on SIBO, there is no surprise that you are in high demand for your knowledge on all things SIBO. So I would love to talk about your journey and how you ended up becoming Australia’s leading specialist on SIBO. What got you interested in the first place?
[1:44] NIRALA: well that is a great question because as a naturopathic doctor we do focus on the gut as a primary target of treatment for not just digestive disorders but for many different disorders. So I have always had a great interest in treating the gut. And one of the naturopathic tenets is that the gut is the root of the tree and if you treat the root then the tree can be healthy. So even when I practice in Montana, I just had a large practice of digestive difficult patients that would come in and there was always a subset that…. This was before we really knew anything about SIBO. This was in the early 2000s late 90s that I really started to focus on digestive disorders and this was before I knew SIBO. So I would treat disbiosis and I would treat different digestive disorders and would get good results. But there was always a subset of patients that just did not respond to treatment or they would have relapses and it just didn’t make sense to me.
So when went to the American Association of Naturopathic Physician conference in 2011, this is something I go to every year (It’s in America obviously), and I listened to Dr. Siebecker and Dr. Steven Sanberg Lewis gave their first talk on SIBO to our naturopathic community and I was just really completely dumbfounded that I have never heard of this. And it answered so many questions for me of why some patients just do not respond to some of the very common products or dietary advice that we give to patients when they suffer from very certain digestive disorders. So that made a lot of sense for me and then from then on I was just hooked in terms of, “Wow this is just like a brand new kid on the block and I need to figure out everything there is to know about SIBO.”
And as the research extends, I am just so thrilled to have this as a possibility, as an underlying cause for so many of my patients because as I have mentioned the gut is so related to so many different disorders. So I see people that have maybe their primary concern is they get frequent colds or flus or they have an autoimmune disorder or they have joint pain or they have mood disorders and often time SIBO links that altogether. It is an underlying cause in so many different disorders. So that’s very very helpful. And the more you know about a condition and obviously the more you start to really kind of see it in lots of different places.
[4:32] REBECCA: Definitely. So how do you treat, or how do you test your patients for SIBO when they turn up and present the symptoms that are common to SIBO. What do you do to commence that testing process?
[4:47] NIRALA: well that was one of the reasons I started SIBOtest.com which is an online testing facility were practitioners can sign up or patients can order the breath test themselves. But the reason for that was really because the way I understood it and the way I learned how to test for SIBO was different than some of the breath test labs were offering here. And so I just decided to do it exactly as Dr. Pimentel and the SIBO center in Portland were doing it. And so I basically set up my testing facility here in Australia and started to offer the service to other practitioners. So it’s pretty easy for me now when I have a patient to just recommend SIBO testing and we have a very quick turnaround time because of that, because we are right here. So that’s very helpful but basically the testing assumes that you have bacteria in the first part of your small intestine where they are not meant to be and bacteria that are there are fermenters. They are ferment fibers.
So if we prescribe a test to a patient, what they would do is basically have a day of a very restrictive diet to kill the bacteria a little bit. Then they fast overnight and in the morning they would commence testing which is drinking a test substance and then capturing samples of their breath every 20 minutes for three hours. And then when we analyze it, we can see where the hydrogen or the methane gas occur sin those samples. Now hydrogen gas and methane gas are not produced by humans. They are produced by bacterial fermentation. And some of that is normal if it is in the large intestine. But if we capture it in the first 80 to 90 minutes of the person having drank the substrate, then we can be fairly sure that we have captured bacterial fermentation in the first part of the intestines.
[6:53] REBECCA: and why does the test take 3 hours if you are looking at the first 80 or 90 minutes?
[7:00] NIRALA: that is a good question. And that is really subject or up to debate in the scientific community. There are people that have very very disrupted peristalsis or migrating motor complex in the small intestine and so they will not … their substrate will not reach to the large intestine within 2 hours. So what we do is again we copy sort of what the SIBO center does in Portland and so they have extended it for 3 hours. Very often we see a rise much earlier than that and classically we would expect a rise within the first like 90 minutes. This is really what we are hoping to gauge.
Now methane is a little different because methane is produced by a different organism that sort of not really a bacteria but more of an ancient species that has been with humans for a long time but happens with methane producers is that they actually use the hydrogen from the hydrogen fermenters to produce methane. So we can see that pretty much throughout the digestive tract. And we are starting to think of methane producers a little bit differently especially if we see that throughout the testing period and not just a rise in the first 90 minutes or so.
[8:24] REBECCA: And is that why some people when they have their initial test they might be dominant with hydrogen, they got through some SIBO treatment and then they retest and their methane has increased. Is that why that methane can increase once they are eating up hydrogen? Is that how it works?
[8:43] NIRALA: It’s actually kind of the other way around. Because if you are killing… if we think that methanogens or organisms which is basically methanobrevibacter smithii, it’s usually one species that produces methane. If they are present in the small intestine and let’s say you have a test result that reads as a high methane but very very low or single digits sort of hydrogen all throughout the test, and then you are treating for methane and you are retesting and all of a sudden the methane is lower and the hydrogen is up, that is because you killed the actual methanogens that would otherwise use the hydrogen to produce methane.
So that is pretty common. So we do sort of a bit of waffling back and forth sometimes when we do retest. And you do want to retest if your patient, if you are a practitioner listening to this or if you’re a patient that is kind of educating your own practitioner. You want to go through your treatment and then if you are 80, 90 percent better, you can just go on maintenance and use prokinetics which will get in to a little but later. Or if you are not 80% you probably want to retest to ensure that you are actually making progress with methane or hydrogen production otherwise you need to change your treatment.
[10:07] REBECCA: That is so interesting. And do the symptoms change depending on whether you got hydrogen or methane dominance?
[10:17] NIRALA: Well you know classically what we see with methane dominant SIBO is constipation and that we know also from research that if poor laboratory animals, if their digestive tract is infused with methane gas is instantaneously constipating. So we do know that the gas itself is very disrupting to the normal movement of the large intestine as well. So that’s classically what we see. With hydrogen you can see either constipation or diarrhea or sort of an on and off sometimes a day of constipation or a couple of days no bowel movement followed by a couple of days of loose stools. And I think one of the reasons why we see really alternating patterns with hydrogen but also sort of…
Generally, I’ve had a few cases of methane that were dominant that were not constipated. We can’t always just say it’s just SIBO. This might just be that you have also fungal overgrowth in the small intestine or the large intestine. You might have as well an overgrowth of gram negative bacteria in the large intestine. So typically when we see SIBO that is very classically in the small intestine but it is not resolving as quickly. You might want to consider doing the stool test to ensure that there isn’t some other level of disbiosis in the large intestine as well.
[11:48] REBECCA: I think that is a great advice. And so the treatment for hydrogen and methane, are they different? do you treat them differently?
[11:58] NIRALA: Yes we can treat them differently. Sometimes what I do is I start with…I talk to practitioners that are on all sides of the spectrum. I talk to GPs, I talk to naturopathic practitioners. So I have sort of my herbal treatments and then you also have conventional treatments which includes the use of antibiotics. Some of which I really think are a great idea and some of it I really don’t endorse, not so much endorse but I don’t see the need of it because I think our herbs used… when you use them correctly they work really really well. So I don’t like to use broad spectrum antibiotics or recommend the use of them just because you can get in to more problems down the road with fungal overgrowth which you don’t really get in to with the herbs.
Do you want me to go into like sort of specifics of treatment or….
[12:56] REBECCA: yeah. I’d like to. I think that would be handy for the listeners to understand specifically how to do it.
[13:04] NIRALA: First of all I will say that the best results and I can say with really a lot of conviction in doing this for five years now is work with the practitioner that is very well versed in the new answers of SIBO treatment because even though we have protocols I really want to emphasize that I don’t just follow protocols I always individualize each treatment to each patient because we are all different and we have different needs and we have different presentations. and even though my herbs may stay the same I might rotate them more or I might add other supportive nutrients or I might treat something that may seem totally unrelated but is related. So I do encourage your listeners to seek out somebody that has had a lot of experience of SIBO treatment under their belt.
On SIBOtest.com there is a database of practitioners that we do endorse that have done testing, that has done some further training and that understand the complexity of SIBO treatment. So generally speaking if you have a hydrogen dominant case, meaning that your breath test comes back and within 90 minutes and some practitioners extend that to 120 or even 3 hours. And we are just a testing service and we can recommend but practitioners can interpret that as they see fit.
So for hydrogen case we often recommend berberine containing herbs and that might be Oregon grapefruit or berberis vulgaris. There is a whole probably 6 or 7 herbs that we frequently recommend. And you need to go fairly strong with those herbs and again I can’t really recommend or give you dosages it depends on where you get your herbs from and what complexes you use. Also essential oils like oil of oregano and thyme oil. Those will be helpful. Clove oil and cinnamon etcetera. And what I like about those is that they also tend to be very effective in the treatment of SIFO which is small intestine fungal overgrowth.
And one small study showed that 63% of patients that tested positive for SIBO also have SIFO. So that’s a pretty big number and often see people when I treat my patients for SIBO, the people that respond the strongest to the killing phase, meaning the classic die off symptoms very often have SIFO as a really strong component of their case.
So berberine herbs are more for hydrogen, very strong extract of garlic without the FODMAP component of garlic. Often I use the product called Alimax for methane dominant and you have to dose that fairly high and you would do that about 6 weeks. Four to six weeks we can expect a drop in gases. I tis fairly predictable with methane. Each course of Alimax might drop at about 30 to 50 parts per million. And that’s less predictable with the other herbs.
So those are your two categories. I mean we have a lot more in our arsenal when it comes to herbal medicine but I would say the berberine herbs are very classically used for hydrogen and your garlic extract for methane.
[16:49] REBECCA: You talk a little bit about die off and I have read online some great debate about whether die off actually exists. Do you belief that there is such a thing as die off and that people do experience symptoms when the bacteria is dying off in their intestinal system?
[17:09] NIRALA: You know being a practitioner I have been in practice for almost 20 years. In my experience, it is not even debatable whether or not it exists. It definitely, it does exist and some patients have it stronger than others and I think there are reasons for that. So one of the components in a bacterial cell wall particularly the gram negative bacteria which are quite prevalent in SIBO is a substance called LPS. So LPS is just part of the bacteria and when that bacteria dies and it releases LPS and let’s say you do have leaky gut as an underlying factor as well, then you are going to have more absorption of this quite…it’s one of the most strongest triggers of inflammation that we know.
So people that have die off can feel 48 hours or even longer quite flu-like or brain fog, achy, quite sick and so this is one of the reasons I cave actually developed the biphasic diet to minimize some of that. But I have had people not have any reactions at all and that might be because they don’t have leaky gut. They just have SIBO and SIBO is associated with permeability that is abnormal of the digestive tract but not everyone has that. And then the other factor is I do think that the die off or what we would more scientifically call the “Herxheimer reaction” which is just again you are kind of reacting to the byproducts that are being released in the process of dying. So fungal elements tend to be sometimes stronger in their die off provoking mechanism in my experience.
[19:07] REBECCA: and I think that leads nicely into SIFO which is small intestine fungal overgrowth. Is there a way for that to be tested for?
[19:17] NIRALA: Not really. We don’t have any… we could test carbon dioxide but we don’t really. And there is not method to do that. Usually candida or fungal elements, they do ferment as well but they produce more carbon dioxide and that is just very difficult to get an accurate measure in the way we measure with our breath trackers. And also, if we were to do let say, candida antibodies or stool tests, you are still not getting a clear picture as to where they are located. So I often do… this is the beauty of the natural protocol. Because by definition you are treating SIFO as well. You are doing it with diet and you are doing it with the herbs. So I like that approach because it has been really helpful for many many of my patients.
[20:11] REBECCA: and do you aim to treat one first over the other or because it is a natural protocol do you feel that you are getting both of them at the same time?
[20:22]0 NIRALA: for the killing phase it is definitely both at the same time because you are using herbs and essential oils and stuff that has effect for both. But then you have sort of like a rebalancing usually after I treat for SIBO and SIFO, I also start incorporating probiotics and other nutrients that help to stimulate the immune system and help to up regulate the intestinal mucosa and immune system so that we start prevention as well and that can be… it is not really specific to SIFO or SIBO and this is where I start to really individualize for each of my patients because everyone needs that either. But I think let’s say you are a conventional practitioner and you are only using rifaxamin. Rifaxamin is the antibiotic of choice for hydrogen dominant SIBO. It is very very effective. And for methane dominant, it is not as effective and so they often incorporate another antibiotic called neomycin and some other practitioners use metronidazole or other antibiotics which can then kill off some of the other beneficial bacteria in the large intestine. And so breeding or laying the groundwork for breeding more fungal species because if you eradicate beneficial bacteria that are meant to be there in the large intestine that are keeping yeast in check or fungal elements in check, you are…it is very easy to get a fungal overgrowth. So a lot of practitioners and holistic or integrated GPs do a combination where they Rifaxamin and use Alimax or use essential oils or oregano to prevent some of these fungal overgrowth. Or even use Nistatin which is a pretty common prescription antifungal that is not too bad. It has worked pretty well as well.
[22:21] REBECCA: and can you have SIFO without having SIBO? It sounds like the two commonly go hand in hand but can you have the fungal overgrowth without the bacterial overgrowth?
[22:34] NIRALA: You know, I think you can but it is difficult to know that for sure from a scientific base unless you do a small intestinal aspirate which is just a sampling of fluids in the small intestine. But we could reason through that meaning that, let’s say that you have somebody that has been on proton pump inhibitors for years. Proton pump inhibitors are probably one of the most commonly prescribed medicines in doctors’ offices today especially in America. This is an acid blocker. So acid blockers work by stopping the production of hydrochloric acid which is your stomach acid. So if you do that for years on end you create a real PH or acid base balance in your small intestine. When in fungal elements are… they just love warm moist environment whether that is behind your fridge or inside of your gut. So if it is a moldy shower that is warm and moist and dark and the same thin in your gut. So they are just opportunistic infections that are in small amounts not harmful but if you are overrun with fungal elements then yes, it becomes a problem.
So I could see a scenario where that happens although the use of proton pump inhibitors has definitely been linked to an increase in SIBO. So I can’t tell you whether or not I have ever treated someone who has just had SIFO because I have just treated them and they got better. So I sometimes treat people that had very classic symptoms of SIBO but their test was negative. So either the test was just negative because no test is always just positive, there is always some false negatives or it required a different substrate to really pick up the bacteria or it was just SIFO.
So I am still a naturopath were if I have somebody that presents with very classic symptoms and my treatment is harmless, I might just give little trial to see how they respond. And if they respond I carry on.
[24:40] REBECCA: Great! And I guess it comes back to the individual approach were you are looking at the individual and what their own unique body requires rather than taking a cart blanche approach of where I have tried this on everybody.
[24:45] NIRALA: Exactly. Because you know over the last I’d say the last 2 to 3 years, I have seen some of the sickest patients I have ever seen in my life because I specialize in SIBO. People that have restricted themselves to 5 foods. They have completely painted themselves into a corner when it comes to foods because the more you restrict the more you react to everything that is put before you. So I had to really negotiate and navigate through reactions and kind of coaxing people back into more of a varied diet and…it gets really tricky once you go down there road.
[25:36] REBECCA: From what I understand you do see quite often some more challenging cases with patients that they are perhaps their own practitioner is finding it difficult or challenging to treat them and isn’t sure why they are sick. So could you talk a little bit about the types of more difficult challenging cases that you see commonly.
[25:57] NIRALA: I’d say the most commonly referred patient would be one who reacts to everything that they are given. So whether that is herbs or certain foods, they become…so we think about how that develops is let’s say they have SIBO and they started to really look for answers and look through all the online stuff about paleo and it was bone gross and they became more sensitive to histamines and then they become more sensitive to salicylates. So they are without ever really addressing their SIBO and the SIFO and has become more and more sensitized to foods. And what happens there is that we know with disbiotic bacteria… actually I am not explaining that very well. Let me just back up.
So foods have natural components, especially plant foods have components in them that the plant used to defend itself against invaders and pests and so forth. And these are for example histamines or oxalates right? These are naturally found in green leafy vegetables. A lot of different vegetables have salicylates and the most average person will never know any difference. Plant foods are very healthy for us.
But when you become very overrun by either bad bacteria or fungus, you actually become more and more sensitive to these salicylates in particular. They are very you know little spiky kind of substance or components that can actually do some damage in a very sensitized digestive tract. So I find the most challenge that I have is with people that very reactive to histamine which is normally found in certain even healthy foods like spinach. It is very high in foods that have been sitting on for a while or cured meats or tinned fish, that kind of thing. Histamines, we know that can induce allergies but in foods it can cause a lot of other symptoms like bloating, like swelling, like itching, like insomnia and so they start to react to that.
Then they react to oxalates which are also little tiny sort of crystal like little substances in especially leafy green vegetables. And then next thing you know, they can only eat gluten free bread and chicken. So it becomes very challenging because what has happened there is they have selectively only fed a handful of bacteria rather than this huge diversity that is supposed to exist in the large intestine. So they have now really selectively fed only a handful of bacteria in their large intestine. So what happens anytime you start put in either herbs, most herbs are very high in salicylates. So these people will always react to the berberines and the Alimax and anything else. And you also can’t really… and every time they introduce certain foods they react.
So those are the most challenging I will tell you. And that just takes time and miniscule doses and I use homeopathics and I use desensitization and I use a lot of different techniques to get these people at least out of what I call “Out of the basement” right. So I get them on the first or second stairs so at least I can see their kitchen door. And then it takes a little while to take these cases around sometimes.
[29:37] REBECCA: and is there anything that people can do to help prevent themselves from ending up in that situation?
[29:44] NIRALA: I’d say the big alarm bells that would go off for me is like you become more sensitive. You are eating, you have restricted your food already, next thing you know you are starting to react to the food that you have restricted yourself to. That means you are becoming less diverse in your micro biome which is what is meant to happen in your digestive tract. And there is common misconception that you can just….
Well let me actually back up. So we are talking about two different conditions. We are talking about SIBO which is a condition of abnormal bacterial growth in an abnormal location. It’s in the small intestine where there is not much action usually with bacteria. You are supposed to have trillions and trillion of bacteria in your large intestine that keep you healthy, that do a lot of different functions and what we know about disease development, is what we now know from the human micro biome project and the research that is coming out every day is that the more diverse your micro biome is in your large intestine, the healthier you can be in general. So that’s really the key. And the more you restrict your foods and the more you only eat foods that you don’t react to, the more difficult it becomes with species diversity.
[31:00] REBECCA: so really the flag to anybody listening to this podcast is if they are experiencing that restriction in foods that they can tolerate that they need to get on to it immediately. What would your advice be for them to do? Is it to go on find a practitioner that they can work with that will understand out of this?
[31:19] NIRALA: yeah. Look I have to say that my learning curve as a practitioner was also very steep when I first…when I first learned about SIBO, I didn’t really thing about histamine and I didn’t really think about salicylate. This was early days and as my understanding broadened the more I started to realize there is so much going on on a mucosal level and micro biome level that we’re affecting if we are also treating SIBO. So I had to just increase my understanding of it. I worked with a nutritionist that has a good understanding of salicylates and food rotation and safe reintroductions and so forth. So I would definitely say work with somebody who understands the foods also not just the protocol from a medicine perspective but also understands how to negotiate around your food restrictions and how to safely reintroduce foods.
[32:20] REBECCA: definitely. I think that is great advice. And while we are on the subject of food. I would love to talk about your SIBO biphasic diet protocol. So tell me why like how that came about, how you developed that and why?
[32:34] NIRALA: And we got a lot out of it haven’t we Rebecca?
[32:39] REBECCA: We have. It’s such a journey and I am so grateful to you for having written such beautiful books based on that because it just makes my life so much easier as a practitioner. So thank you for that.
[32:50] NIRALA: My pleasure
So the way this came about was that when and for those of you who don’t know what we are talking about, it’s a diet that’s divided into two phases as the name implies. And initially, it has been an evolution of the biphasic diet but my frustration was that exactly what I just mentioned, I had patients that were very very reactive and I couldn’t add the herbs in yet. So the diet is based that when you first get diagnosed with SIBO, you start with phase one and phase one is further divided into two categories. One is strict and one is less strict. Let’s just keep it there. And so you start with restrictive approach which is very much just protein and vegetables. For all intensive purposes, that’s what it is. And as soon as you improve, so this could be three days, could be two weeks, could be a month. Then you move into the less restrictive part of phase 1.
So that gives the practitioner and opportunity to not yet jump into treatment as far as antimicrobials but more into gut balance. And that could be digestive support in the form of enzymes, or hydrochloric acid or gut healers. They have a lot of reactions like salicylates. I would think about glycine or you know different kinds of nutrients that stabilize the mucosal membrane. And in terms of digestive support I would think of… I use a lot of herbal bitters which are herbs that stimulate your own process of digestion. And so you have sort of a nice elegant way of compartmentalizing your treatment without overwhelming your patient because we have all seen it. people come in and they leave with 20 products and that’s not the kind of practitioner I aim to be. Sometimes it is intense and it has to happen but only for a short period of time. That is not a long term strategy to leave with tons and tons of products.
So I usually like to do it in stages. The first stage would be gut healing. And the second stage is more really going after the remaining bacteria and yeast. So by the first phase when you are restricting your diet, you are already by definition starving some of these organism and then we you are going into the antimicrobial phase which is phase two, the diet opens up a little bit and you feel like you are in the land of the living and you are allowed certain nice foods like some grains and some fruit and perhaps some cheese. So life becomes a lot more tolerable at that. And I find that to be very effective. To have divided the treatment like that. And so it really came out of necessity for me because just giving people a FODMAP diet just wasn’t satisfying enough because it often doesn’t work and also for how long are you supposed to do this.
So it gave me really a lot more control over what am I actually monitoring when should I retest. So it really is very helpful that way.
[36:08] REBECCA: there are several diets out there that people will commonly follow when it comes to SIBO treatment. Is this diet or protocol similar to any others?
[36:20] NIRALA: it’s similar right? And the universal sort of approach, I would say that most diets have in common is the low fermentable fiber aspect to the diet. But how it is different is that it is divided into these two categories. The other aspect to that… this is somewhat open to discussion and some dispute because Dr. Pimentel a couple of years ago at the SIBO symposium mentioned that he basically tells people to eat anything that would feed a bacteria whilst he is giving them Rifaxamin.
You know in all good conscience I am a naturopathic doctor, I just can’t do that because most of my people would flare up. So I just never have really… there were two reasons why I didn’t want to do that. Number 1, the risk of flaring people up with other underlying issue. Then the other reason was, that if they have SIFO they would definitely get worse on that approach. And his idea was, ok you need to feed the bacteria whilst you are killing them otherwise they would go into what is called senescence and that is like a dormancy. And I really haven’t seen that very much a factor in my treatment. I still do before and after testing and I get very good results. So I decided not to do that but that is one common I would say argument out there. It’s like, “No you should just eat potatoes and rice and sugar and all that just to feed the bacteria.” And I would disagree with that approach.”
[37:53] REBECCA: And I think that probably comes down to the individual person as well. I know that when I started my SIBO treatment and went on to your protocol, I felt so much better by removing those foods that would have been feeding the bacteria. So I know for myself, I was really happy to be on your diet. Even though it took a little bit of mental planning or figuring out what I was going to eat but gosh I felt the symptomatic improvement was worth it.
[38:19] NIRALA: that’s great to hear and a lot of people tell that. You know the thing is now my practice has really come to a point where I mostly see people that have already been treated. So these are the tough tough cases right? So I yearn for the days were somebody is just very easily treated with just diet alone. I mean it still happens but the tough cases definitely outnumber the easy cases these days.
[38:45] REBECCA: and those touch cases they need your help because they are generally feeling pretty unwell I would imagine.
[38:52] NIRALA: they really do. People are very sick they are very limited in just their enjoyment of life and that’s… food is part of the enjoyment of life. So I really feel for them.
[39:07] REBECCA: Exactly! And it’s one of the reasons why I put together the cookbooks was that I love cooking, I love sharing food with friends and family. And food is such a joyous experience as well as being our nourishment and I wanted to remind people that even though where we can be limited and some people are more limited than others that there is still food glorious food that we can enjoy while we are going through our SIBO treatment.
[39:32] NIRALA: Right. That is right. The other important point to that though is that there should an end to treatment at some point. Let me rephrase that. There are some cases of SIBO were relapse is so common because there is a damage to this migrating motor complex which is the normal motion in the small intestine that propels all content of the small intestine towards the large intestine. So that is the normal cleansing wave. When that is damaged from a past case of food poisoning or gastroenteritis, then it’s very difficult because patients have to be on a maintenance diet. But the fact is that when strict fibers that are fermentable from the large intestine or from the micro biome that lives in the large intestine, they are not going to be happy either. They don’t have anything to eat then.
So I always endeavor to tell patients, “Look, even though this might take us some time, there is an end inside or at least my goal for you is that there is a time where you can open up your diet and you can enjoy certain foods that you are restricting right now because they are still healthy foods.
[40:51] REBECCA: I think that is great advice. It is not a life sentence.
[40:57] NIRALA: I hope not. Sometimes, it sure seems that way for people but sometimes it is also relative right? What you and I would think of just a perfectly healthy diet is like a complete life changer for other people who are eating processed foods. I mean I barely see people like that anymore but back when I lived in Montana, I saw people that ate the standard American diet. And so even if you just removed sugar they felt like a million bucks you know after two weeks. So there is like a relative scale to what we would consider food restrictions in our vocabulary I think.
[41:35] REBECCA: yeah that is so true. We talked a bit about this migrating motor complex and the cleansing wave through the intestinal system, are there things that you can take to help support that wave?
[41:47] NIRALA: Yeah. And that’s you know… so the migrating motor complex is part of the normal nervous system in your small intestine that ensures that you don’t get SIBO just by eating bacteria in food. And so normally bacteria that are on food are supposed to be killed by the hydrochloric acid and bile and by digestive enzymes. And when some of that is disrupted you can develop SIBO but it’s more sinister when you have had a case of gastroenteritis. Like a really severe case of food poisoning that you remember and you have never been well since. That is very indicative of having developed SIBO as a result of damage to this particular cleansing wave and that occurs because of basically an autoimmune response when the body mistakenly attacks something called vinculum which is part of the migrating motor complex instead of the toxin that the bacteria releases of the food poisoning.
So in essence it damages your cleansing wave and so you can’t adequately flush out the remaining bacteria after you have eaten something. So if that is the case then we use medicines or herbs called prokinetics and prokinetics basically just means they are promoting the forward motion of the small intestine. So you know, I wish I could say I have full proof herbs that work every time. Like for example like Alimax, it almost… I would say more than 90% of the time it works for methane. But I don’t have something like that for prokinetics and neither does conventional medicine. It’s really an area that needs more research. I have a lot of tools in my tool belt but it doesn’t work for everyone. So something will work 50% of the time and then I have to try something else.
But generally speaking, if I had something that was full proof for everyone, it’s not even true that everyone would need it because not everyone has SIBO because of food poisoning right? So it’s really only those that need to reset their migrating motor complex that require long term use of prokinetics. But typically my protocol does include herbal prokinetics which could be ginger, we also use acetyl-L-carnitine which is just a nutrient, which is a component of some of the neurotransmitters that are involved in peristaltic movement. I use also a combination of herbs that stimulate the upper gut generally. There is also a product called iberogast which is pretty easy to find over the counter which has some promise. I don’t see it working every time. there are some thoughts on melatonin. There are some thoughts on limenine. So there are lots of discussion in the SIBO community and we don’t really have a consensus yet. So there are things that we will try and sometimes it is also probiotics that seem to be helpful. There is not one size fits all.
[45:04] REBECCA: and on the subject of probiotics, should everybody have probiotics or is it again an individual case and when would you use probiotic in treatment and there is a lot of discussion on online forums about probiotics. I love your thoughts on them.
[45:21] NIRALA: So the common misconception that I find around the subject of probiotics is that they will replace what you have lost in the large intestine and that is just simply not true. If I were to take a sample of stools form the average person the vast majority of bacteria would not be the bacteria that we find in probiotics.
That’s just a tiny sliver and that is just because we haven’t studied everything yet. So we don’t have much in terms of being able to supplement with certain probiotics. So what we do know about probiotics is that they are really pretty powerful. So this is like the bacillus species, bifidus bacterium species are very, what we call, biological response modifiers or they modulate your immune response. And so I often use certain strains like lactobacillus planterum. Those kinds of strains.
If I see a lot of inflammation for example. If I see a lot of large intestinal issue I tend to favor more the bifido bacterium species. So it gets really individualized with the types of… I have probably in my fridge in my clinic probably 10 to 12 different probiotics right now or complexes, different products. And I am playing around with different spores and things like that, not playing. I am experimenting. But so you know it is a lot more individualized but the take home message is that we do know through research that they have been studied actually a lot in IBS and SIBO is just a subset of IBS. So we will see certain aspects, or certain strains be really helpful in certain symptoms. So for example with cramping or with constipation or certain symptoms associated with SIBO. But I have not seen any data that conclusively tells me that you using probiotics is a treatment for SIBO.
[47:30] REBECCA: that is very interesting. And I have also read a lot about prebiotics for the foods that you take or foods that you take before probiotics. Do you use prebiotics in your treatment?
[47:46] NIRALA: yes of course. Prebiotics are actually not things that you take before taking probiotics. They are food for probiotics. So prebiotics like, it used to be FOS or fructo oligosaccharide and inulin and that is still used in a lot of probiotic formulas. Those prebiotics are put into those formulas to ensure that those organisms actually survive. So the way it normally works is, you are supposed to have a wide variety of species in your digestive tract that ferments your fibers. That is a natural process. That is meant to happen in your large intestine and fermenting those fibers, frees something called short chained fatty acids. And those are prebiotics. They are all food for your normally occurring bacteria then. So using prebiotics has been very controversial in the treatment of SIBO because we don’t want to feed the bacteria that are in the wrong location. And there definitely is…I think that is really valid argument.
There is some thought and this is actually an area where Dr. Jason Hawrelak would… I think he is a wealth of knowledge in this regard and he is one of the speakers at the SIBO summit in Melbourne and Sydney in October. And he will be talking exclusively about probiotics and prebiotics and I think there will be a lot of myth busting going on at that time. so I am looking forward to that. I do use very selective prebiotics under certain circumstances. So I don’t use probiotics that contain prebiotics in my active treatment. So during my active treatment in SIBO I don’t use probiotics or probiotic formulas that contain prebiotics because it doesn’t make sense to me to not feed the bacteria that I am so desperately trying to get rid of at that time.
I basically, during the active phase of my treatment, I don’t recommend using probiotic compounds that contain prebiotics for the simple reason, you don’t really want to promote the growth of those organisms. So I think there is a place for them afterwards but I like to target them with more specific prebiotic substances such as galacto oligosaccharide which is a very specific prebiotic that is targeting bifidobacterium. So there are very specific prebiotics that do certain roles that aren’t just universally feed everything. so that is where i think the movement will be more towards or the research will go more towards that rather than just using compounds that contain all sorts of prebiotics.
[50:43] REBECCA: and what is your view in terms of the future if SIBO? Where do you think we are going to go with this condition? It is still relatively unknown in Australia. It has a greater awareness in the states but relatively speaking, not many people know about it. What is your view on the future?
[51:02] NIRALA: Well you know, one of the real gratifying events that have sort of taken place in my years of practice is this massive research that is going on into the micro biome and I would think of SIBO, one of the reasons it’s got so much air time is because it is part of that continuum and that spectrum. So what has happened is more and more focus on digestive disorders and the real important role that bacteria play in our health and in disease as far as the digestive tract is concerned. The other aspect of that is if you have been diagnosed with SIBO, that is not the end, that is just the beginning because ideally you want to find out what has caused SIBO because that is how you really become SIBO free is when you treat the underlying cause of SIBO. And that could be some people never find out if it was because of food poisoning. But it could be because of adhesions which are the scar tissue that has built up in the abdominal cavity die to surgery, removal of the appendix or the gallbladder. So you could have scar tissue that just builds up inside your abdomen that causes structural abnormalities of your digestive tract or it could be because of medication or because you have very high levels of stress.
So I would invite your listeners to think about SIBO is caused by something. So continue to examine what is going on in your lifestyle that may have contributed to it.
[52:42] REBECCA: that leads me nicely on to my final point which is around – when I started this journey to health; I realized there were 5 key areas that I needed to address. Awareness, nutrition, movement mindset and lifestyle. I’d love your thoughts Nirala on those 5 key areas and if you think there are any others that we should be focusing on when we are looking at our own journey to health.
[52:57] NIRALA: Well, I would actually like to hear from you how you would classify those categories because I have my interpretation of those categories and it would be nice to hear how you would summarize them in a few seconds.
[53:11] REBECCA: For me awareness was around actually reconnecting with my body. So listening to my body, really taking note of what it was saying and not hiding or masking any of the symptoms with over the counter or prescription pharmaceuticals like I had for many years. My nutrition, whilst I was pretty healthy in terms of what I ate it wasn’t necessarily the right nutrition for me at that point in time. And likewise as I healed and recovered from SIBO I needed to readdress my nutrition to support a healthy micro biome.
My movement, I had been pretty sluggish. I have been sick for such a long time that I really wasn’t getting out and moving my body and that for me wasn’t necessarily about going and pumping weights at the gym. It was around just moving like getting out, going for a walk and again that helped with the awareness because I was able to reconnect with how my body felt. And the mindset piece was pretty important to me because I realized I was in a negative state. When you feel sick for a long time you can often focus on all the negative things that are happening in your life rather than the positive things. So I had to start really actively focusing on positives and to start with, they were small. It was the sun shining today. Hurrah!
[54:37] NIRALA: I think that is beautiful. I think that encapsulates it pretty well. I would add to that probably, responsibility. Taking ownership and responsibility of your body which means that even though… I think we have been trained to some extent in western medicine to abdicate our responsibility that we go to the doctor to get one pill for our headache and another for this and another for that. So to really kind of take stock of how you contributed to the development of whatever happened in your life, whether that is your health issues or relationship issues or however, I think we need restart being more responsible in active participants in all these aspects. And it doesn’t mean that we have to blame the victim, but it is more to say that, “You know what? Yeah maybe this time I am really going to change my diet to reflect really those values and both approaches I want to take in my life.”
So I think that is really well put. I do think that obviously in my profession I do see people that have done already a lot of that and certainly people that have advance cases have examined a lot of that. I also consider… oftentimes I talk about emotional aspects or people that are ruminators, people that are just sort of have… they think they have given up or they think have processed a certain event in their life and they really haven’t and that is contributing to their levels of stress in their body or their depression or their reaching for unhealthy foods. So really examining all parts of your life if you have a chronic illness I think is paramount because that is how you get true and lasting health benefits. Not just on a physical level but really in an emotional and spiritual level.
[56:39] REBECCA: That is so true. Thank you for that wonderful advice. Nirala it has been fantastic having you on the healthy gut podcast today. I have really thoroughly enjoyed it. I have also learned a lot. Every time I think I know something I learn more about it which is just wonderful. How can people find your website to learn more about your diet protocol or your testing facility? How can they find you?
[57:05] NIRALA: My personal website is NiralaJacobi.com. this is my practice where I see patients and so that is NiralaJacobi.com but to find out more about SIBO and how to get tested for it and also do a free quiz or direct your practitioner to maybe sign up, to get more educated about it, you can go to SIBOtest.com. That’s S-I-B-O-T-E-S-T.com. And there is a lot of information there. And I do regular webinars and regular practitioner education seminars. There is also as I have mentioned before the SIBO summit, and I know you will be there Rebecca… so hopefully everyone listening can join us there, meet you in person and meet us in person. That would be in Sydney on October 10th, in Melbourne October 8th. That is a whole day long in person intensive primarily for practitioners and really sort of a crash course in how to treat SIBO and we have got Dr. Allison Siebecker flying over all the way from Portland Oregon to join us. We’ve got Dr. Jason Hawrelak as I have mentioned who is really an expert in pre and probiotic use. Myself and other guests speaker, we’ve got Alyssa Tate who is a phenomenal physical therapist talking about adhesions and sort of the structural components of SIBO. And we have other guests practitioners sharing their case studies with us. So it will be a really wonderful day “everything you ever wanted to know about SIBO but we are afraid to ask kind of day.”
[58:53] REBECCA: And I think what is really exciting about the SIBO summit is that it is Australia’s first SIBO event. So it is going to be a really great landmark event here in Australia to teach practitioners everything. Like you say everything they need to know about SIBO.
[59:11] NIRALA: Yeah, we really look forward to it. Its two more months to go. And we are really excited.
[59:19] REBECCA: It’s going to be great. I am looking forward to it as well. Nirala thanks so much for your time today and I am sure my listeners have gleaned so much information from the show. It has been an absolute pleasure to have you here. So thank you very much for your time.
[59:33] NIRALA: My pleasure. Thanks a lot for having me.