One of the most frequent SIBO Made Simple listener questions I’ve received revolves around the timing of treatment and diet. Is it better to feed the bacteria while on herbal or conventional antimicrobials by eating normally, or starving them with a low carb approach?
In today’s episode, I’m joined by Dr. Nirala Jacobi, one of Australia’s leading SIBO experts, and the founder of The SIBO Doctor, an online professional education platform. More importantly regarding today’s topic, Dr. Jacobi has pioneered the SIBO Bi-Phasic Diet that has helped patients and practitioners better use the symptom reduction of diet and the killing power of herbal antimicrobials in tandem.
For those trying to understand the role of diet in SIBO healing and treatment, this is a must listen.
A quick taste of what we’ll cover:
- The bi-phasic diet and how it came to be
- Why we should feed versus starve our bacteria and how to time this strategy with other treatments
- Why diet isn’t a treatment in and of itself but a way to manage symptoms
- Leaky gut and its relationship to food sensitivities
- Why histamine intolerance and mass cell activation syndrome are common with both SIBO and candida or fungal overgrowth
- Die-off and how to tell if you’re reacting to endotoxins from bacteria or the treatment itself
Resources, mentions and notes:
- Dr. Jacobi’s website and clinic
- The SIBO Specific Diet from Dr Allison Siebecker (also listen to episode 1 with Allison!)
- The Underlying Cause Questionnaire
- Histamine Bi-Phasic Diet download
- Mass cell activation syndrome
- Leaky gut healing kit: L-glutamine, Zinc carnosine, Saccharomyces boulardii
- Die-off kit: activated charcoal
- Visceral manipulation (we discuss in episode 7!)
- Inner balance device by HeartMath
- Hypnotherapy – Monash IBS study
- Meal spacing (we discuss in episode 5!)
- Join the SIBO Made Simple Facebook Community Page
- Subscribe to receive a free download of the episode transcript
This episode is brought to you by Fody Foods, my favorite resource for condiments, sauces and spice blends that are low FODMAP and use real ingredients to promote digestive health. Everything is Gluten-Free, Dairy-Free, non-GMO, and most importantly, delicious. The garlic-infused oil and tomato-basil sauce are my personal favorites. Use code SIBOMADESIMPLE at checkout for 15 percent off your order!
THE SIBO BI-PHASIC DIET WITH DR. NIRALA JACOBI
PHOEBE: Welcome to the podcast, Dr. Jacobi. I’m really happy you could join us from all the way across the world.
JACOBI: Thank you for having me.
PHOEBE: Before we begin getting into the subject of diet and its role in SIBO recovery, I would love to hear a little bit more about how you became a specialist in SIBO.
JACOBI: That’s an interesting question. I like many people that go into the healing profession, we also have health issues, and so my health issue was – I mean, I was always very interested in nutrition in my 20s. I had gastritis and so forth. When I became a naturopathic doctor in ’98, I joined a practice in Montana, was a primary care physician there, and I really focused on the gut a lot. That was always my passion is to understand how the digestive tract works. As naturopathic doctors, we think of the gut as the root of the tree, and so even with other conditions like rheumatoid arthritis, or diabetes, or whatever that may be, we often look to the gut as a source of inflammation and toxicity, etc. I’ve always had that on my radar.
In 2011, I went to the American Association of Naturopathic Physicians and heard Dr. Allison Siebecker and Dr. Steven Sandberg-Lewis talk about SIBO, a condition I’d never heard about, and as a naturopathic doctor with a specialty in gut health, I was really dumbfounded that I’d never heard of it. Then I became very passionate about it because it explained why so many people that I was treating – a lot of them were getting better, but there were just a subset of my patients that were not improving. That explained a lot why. It had to do with diet. It had to do with bacterial overgrowth, and the rest is history. I then started to lecture in Australia about this topic and became more and more interested and more and more focused on SIBO and IBS and now have a clinic that’s really a center for functional digestive disorders.
PHOEBE: Wonderful, well, you have made a name for yourself with a specific dietary approach to SIBO, which we will get into completely in a few minutes. First, diet is a subject that confuses a lot of people in terms of what its role is, whether it’s to kill or to heal. Can you tell us a little bit about your approach and what role diet plays in treating SIBO?
JACOBI: One of the diets that we started out with was the low FODMAP diet. The low FODMAP diet, as many of you know, is basically a diet that removes fermentable carbohydrates. It stands for fermentable oligosaccharides, disaccharides, and monosaccharides, and polyols. These are all fibers and fermentable carbohydrates that in IBS patients tend to cause a lot of problems because they are fermented by bacteria. When we first started, that was our starting point, and Dr. Allison Siebecker already way back in 2012 or 13, I can’t remember, came out with her version of the SIBO Specific Food Guide, and she combined the FODMAP with SCD. It was like this massive project that was – for me, as somebody who likes to be very structured, it was a bit difficult to overlook and oversee for my patients and to give proper guidelines as to what they could and could not eat, and so I created my own version that put this diet into two phases. It starts out as very, very restricted and used not just SCD and FODMAP but other influences to create this diet, but it is based on Dr. Siebecker’s SIBO Specific Food Guide.
In Phase 1, basically, it’s the strictest part of the diet, and that’s further divided into restricted and semi-restricted. Phase 1 has actually two parts to it, and then Phase 2 is a lot more generous in terms of foods. That’s really when we start to use antimicrobials. The purpose of this was that when I see patients I like to already – while I wait for test results, breath test results, I wanted to already give them something to use to help reduce bacterial activity. The strict diet, Phase 1 really allows for that. Because it is a grain-free part of the diet, we see really pretty dramatic symptom reduction early on. Then when the patient comes back and the test result is indeed positive, then we can move straight into Phase 2 and the antimicrobial phase, and that was so that you add a few carbohydrates back in so that you actually promote some bacterial activity while you kill them.
PHOEBE: How long is Phase 1?
JACOBI: Stepping back a little bit, I really created this diet for the practitioner. It’s a starting point. It’s customized to each patient, and this is what I often tell my practitioners when I train them is this is not the be-all-end-all. You can adjust it as you see fit for each patient. Some patients can’t really tolerate a very carbohydrate restrictive diet because they’re already underweight. Some people have food intolerances, so you really need to adjust it. Generally speaking, each phase is about six weeks, six to eight weeks I would say, but often times, the first phase can be as short as two weeks. It’s really just a preliminary stage before you start antimicrobials, so it’s not that it has to be observed for the full six weeks, and as soon as you are feeling better, you can go into the semi-restricted diet. Then as soon as you’re on antimicrobials, you really want to be in Phase 2.
PHOEBE: Probably most people listening to this podcast are patients who, hopefully, are getting some sort of guidance from their practitioner. For those who are maybe shooting in the dark, have found your diet, and are wondering if it’s for them, could you explain anything you might look for in a profile that would say – maybe point to a more – a less restrictive approach at first or just a sit and wait?
JACOBI: A lot of patients or just people with digestive disorders and suspected SIBO, they – especially overseas, I find that in Europe there’s just a paucity of practitioners that are really skilled in treating SIBO. People are more online and are in these support groups and find out more about some of these dietary approaches and download it. Really, from all over the world, people are downloading the diet from thesibodoctor.com, and it’s really interesting to see how they’re managing it. I can understand that they really want to get some help. They don’t have any practitioner that helps them, so of course, they want to help themselves. I don’t really have – it’s a diet in and of itself, and it’s very explanatory. The whole front page actually explains the concept of it. I don’t think any further guideline is necessary unless you’re with a practitioner, and the practitioner determines that you need to be not using eggs, for example, or if you’re a vegetarian, what to do then, or if you’re hydrogen sulfide, what to do then.
It’s really a starting point for people, but for basic SIBO, it’s a great diet. We have so many thousands of practitioners that are using it and getting very good results with it. I’m really happy to have been able to offer it for free for people just to download it and try it out because the need was really there.
PHOEBE: Yes, it’s an amazing resource, and those of you at home should absolutely download it just to check it out, even if you are maybe at a different stage in your SIBO journey. It’s free and also just very interesting resource. Back to the question of to feed or to starve, this is another point of confusion that I often get asked about. The phasic approach is slightly different than what some practitioners use. Do you find that even on the low FODMAP section of the diet with a few more grains added back in that that’s enough carbohydrate activity to actually feed the critters? I know there are some practitioners who recommend not doing anything low FODMAP or making really any dietary changes while you take the antimicrobials.
JACOBI: Yeah, I know that that was actually originally proposed by Dr. Pimentel, who’s a primary SIBO researcher from Cedars-Sinai. I really haven’t felt the need to do that because every time – initially, when I first started, I tried that, and patients were just horribly symptomatic. I haven’t needed to do that at all. There is a theoretic concern that if you starve the bacteria, “starve” – you’re not really starving them. You are not providing a substrate for them. That’s true. If you have a really tremendous amount of SIBO, I do think that you will see some bacterial reduction, but most of the time, what happens is they go into – they just become less active.
If you have SIBO, it’s unlikely that diet alone is going to completely rid you of SIBO. We use it a lot for symptom control but bearing in mind that the diet is not meant to be forever. Even though you may see benefit, you really have to address the underlying reason why you have bacterial overgrowth to begin with. That is true healing. I mean, the bacteria are just there as a consequence of something. For example, if you have some sort of digestive deficit like low stomach acid, for example, which is a fairly common condition with a chronic gastritis, for example, most of the time or a lot of the time there is a component of hypochlorhydria and not enough stomach acid, which then lends itself to you losing the primary bacteriostatic fluid that kills bacteria on contact, really. If that’s gone, it’s just a natural consequence that you would have bacterial overgrowth. That’s, for me, much more exciting now rather than – killing the bacteria is still, of course, very necessary, but I’m much more excited about looking at underlying causes for people because that’s where true healing and stopping that constant cycle of relapsing really happens for people.
PHOEBE: Does any sort of dietary modification ever heal one of the root causes, or is it just a separate lane?JACOBI: The diet will not address the underlying causes. I mean, I can’t say – I can’t think of a single underlying cause, and there are many. I have them divided, and maybe we can talk about that a little later. I mentally divide them into four groups of underlying causes. I do have a free questionnaire that people can download called What Caused My SIBO?, which addresses all of these four categories of underlying causes, and then it’s a little easier for the practitioner to then deal with what the potential underlying cause is. Sometimes it’s not possible to find out what the underlying cause is. The diet really just manages symptoms, and it does so really, really well. For me, it’s part of the whole treatment picture. It’s not a standalone treatment in my book. I mean, if we’re talking treatment, dietarily, that would be the elemental diet. The elemental diet is a misnomer because it’s not really a diet for SIBO. It’s an actual antimicrobial treatment for SIBO.
PHOEBE: Does the restrictive phase and certainly maybe part two as well, does it have any other kind of healing effects, maybe not of the root cause but of some of the issues that arise after SIBO is already present? I know people ask a lot about leaky gut and diets associated with that. Can you talk a little bit about how the Bi-Phasic Diet fits into the whole picture there?
JACOBI: Yeah, for me, it was also important that it’s a whole foods diet. It is not like a packaged diet. It’s all based on whole foods. Barring eggs, it removes all major food allergen groups or potential food allergens, which are gluten and soy; unless they’re vegetarian, in which case we do often use soy. It’s not meant to be a low allergy diet, but it happens to be a low allergy diet. For that reason, it often reduces inflammation in the digestive tract.
I mean, the leaky gut diet is really just a diet where we’re removing these individual food sensitivities that arise due to leaky gut. I mean, leaky gut, again, has also lots of other causes. I’m always somebody who looks at causes, but you can have bacterial dysbiosis. SIBO itself causes leaky gut, so by just removing bacterial overgrowth, you are addressing leaky gut. There isn’t a permanent diet for leaky gut, but there is a diet that removes potential allergens and inflammatory substances that are very irritating and then providing nutrients and potential probiotics that tend to help with healing leaky gut.
PHOEBE: Yeah, I mean, it’s something that I’ve always wondered about. I’m curious if you actually have patients that during the testing period, before you really have an answer, are doing the restrictive phase and feel better but then end up not having SIBO. Does that ever happen?
JACOBI: It happens sometimes. Yeah, it happens sometimes, but I’d say most people feel better on the diet if they haven’t already started it. Also, these days, I get mostly – my patients are mostly treatment failures, people that have been referred to me, and they’re already on massively restricted diets and tons of supplements. Gone are the days where I just get a cold case of SIBO where it’s really easy. You’re like, okay, you just do Phase 1, and they’re already waving the happy flag. Those days are much more rare these days, but yes, you do often see symptom improvement. I think you’re right; there is a component of potentially that’s removing food allergens, dairy and gluten, and they may not have SIBO.
PHOEBE: Have most of your patients or any of your patients done a basic elimination diet that just covers those main allergens prior?
JACOBI: Yes, some have done that. We have a diet here called the Royal Prince Alfred Diet, which is a pretty good systematic approach of removing dietary allergens, but not everyone. Let’s say somebody comes to see me, and they suspect SIBO, and they’ve already been on the Bi-Phasic Diet. I’m not going to run food allergy panels because they have already removed a lot of those allergens. You got to start looking elsewhere then.
PHOEBE: Do people’s food sensitivities and intolerances change after the Bi-Phasic Diet and certainly after ridding themselves of SIBO?
JACOBI: Yeah, there was, actually, some research that looked at leaky gut and SIBO, and what was found in this research study was about a month after completely clearing SIBO the leaky gut is healed. I would say that that’s much more likely if you’re replete in all nutrients that allow you to heal your body, and a lot of people are zinc deficient and Vitamin A deficient and so forth. It varies in how quickly people can recover. It should not be that difficult to heal leaky gut, and it should not be that you’re on a permanent leaky gut diet, in my experience, but it can take a little longer than a month. In my experience, it takes about six months, and I have patients that are extremely sensitive. They were only eating five foods, Brussels sprouts and chicken breasts and olive oil and, literally, nearly just a handful of food.
As soon as you actually address some of these underlying causes like SIBO or – I often see histamine intolerance actually far more frequently than salicylates, and that also goes hand in hand with candida overgrowth. Candida is a very invasive organism that is an opportunist and very often is present alongside SIBO. I often see histamine intolerance and candida be very linked, and so once we get on top of that, people definitely can start to introduce some of these foods again that they were very reactive to.
PHOEBE: Interesting, and I had histamine intolerance on my list of things I wanted to ask you about. I was wondering what the relationship was with SIBO, but perhaps it’s more correlated with candida, you’re saying?
JACOBI: No, not at all. It is often a consequence of SIBO. The way it works is that simple histamine intolerance occurs when the enzyme diamine oxidase that sits right at the tip of the microvilli in this shaggy carpet that is your small intestine is damaged by the gases that are produced by SIBO. Very often, all of a sudden people become a lot more reactive to histamine containing foods like canned product, canned fish, for example, cured meats, certain vegetables like spinach and tomatoes and things like that. I realized that there were actually a lot of people that have a lot of symptoms of SIBO, but those symptoms were not caused by bacterial overgrowth. They had already treated it. The tests are coming negative, but their symptoms persist.
I started looking much more into histamine intolerance and found, in my experience, occurs a lot in my SIBO patients and created a diet called the SIBO/Histamine Bi-Phasic Diet. It’s the histamine version of the Bi-Phasic Diet with my co-author Heidi Turner, in which we go into histamine liberators and histamine foods. It’s probably one of the more restrictive diets that we do, but it is for those extremely sensitive patients. Very often, with histamine intolerance – I don’t what you see, Phoebe. Once you remove histamines, your symptoms are controlled fairly quickly or at least alleviated fairly quickly.
PHOEBE: Do people recover from a histamine intolerance? What is a histamine liberator, never even heard of that?
JACOBI: Yeah, the histamine liberators are – I know, right? It just gets so complicated when you’re dealing with these things. This is something that, actually, my co-author is really an expert in, Heidi Turner. She did a podcast. I think it was about MCAS or mast cell activation syndrome last year sometime. If you look at thesibodoctor.com, there’s some podcasts there on this issue. Histamine liberators like citrus, for example, are foods that tend to liberate histamine from food, and some people have real reactions to those foods, more so in some cases than histamine containing foods.
The first part of that diet, of the SIBO histamine diet, is pretty restrictive. We really have to work hard to come up with a viable diet for people. It is something worthwhile to check out if you have histamine intolerance. The connection, just to go back to candida, is that – let’s say that people, a person has SIBO, and they develop histamine intolerance. You treat SIBO, and their histamine intolerance improves. Then you have people that had SIBO histamine intolerance. You clear SIBO, but their symptoms don’t improve. You have to consider SIFO or small fungal overgrowth as a potential underlying cause.
When people have candida overgrowth, which of course is so common these days, what happens is the endotoxins that are produced by candida have to be detoxified through the same – a similar pathway or in the same pathway that histamine goes through, with is the aldehyde pathway. Sometimes, when people have a lot of candida, they’re killing it. It clogs up that pathway, and histamine can’t get cleared, and so you become much more sensitive to histamine. It’s just a side effect, really, of candida in many cases.
PHOEBE: Besides clearing up the SIBO and the candida, is there anything else you can do in terms of adding foods or supplements to help overcome a histamine intolerance?
JACOBI: I mean, a true histamine intolerance that’s basically due to the loss of diamine oxidase, which is this enzyme that lives in your microvilli. You can give precursors to give to your patients like B-6 and copper. It’s a copper dependent enzyme. That’s pretty slow going. There is a commercially available product called Umbrellux that is a – it’s basically diamine oxidase. I often give that to people just as a little stopgap until it’s healed, so yes, you can give certain things. There are mast cell stabilizers to prevent you from releasing histamine, and that would be quercetin and Vitamin C. There’s a whole host of things that we do. It’s like histamine intolerance is on a spectrum. On one end is histamine intolerance, and on the other end, I think of mast cell activation syndrome, which is a lot more of a system gone way more out of control than just diamine oxidase.
PHOEBE: Back to leaky gut for a second, you mentioned different things that you can do to slowly over time, over six months get your gut back into shape. Are there any examples there of foods you can add or supplements people can focus on to healing that damage even after SIBO has been rid from their system?
Dr. JACOBI: Yeah, I mean, a whole foods diet. What I mean by that is nothing really packaged. Then it’s in its original form is definitely a better approach and as many vegetables as you can tolerate. Meaning to prevent disease, you need about eight to ten cups of vegetables a day, which is a lot of vegetables, but this is where we have the most concentrated polyphenol activity and minerals and absorbable vitamins. I’m huge fan of large amounts of vegetables if you can tolerate that. Certain families of vegetables are specifically rich in things like glutamine, glutamine, of course, being a really supreme mucosal healer, although many of the formulas on the market are much too low in glutamine content, L-glutamine. You need about 15 to 20 grams, which is about 2 tablespoons a day of pure glutamine. It’s an abundant amino acid that’s in a lot of foods, but it tends to be especially rich in cabbage, and so doing things like vegetable juices with adding a bit of cabbage in there or also doing things like bone broth if you’re not too intolerant of histamine due to the collagen that’s in there. Yeah, those I think would be my top recommendations in terms of food based.
Then supplements, pure supplements, I would say zinc carnosine is one of my favorites and, obviously, L-glutamine itself is very important. I usually give that separate to my other gut healers, and things like Vitamin A and certain probiotics have also been very linked to healing leaky gut like Lactobacillus rhamnosus and Saccharomyces boulardii. It’s a whole other podcast, just leaky gut, but the thing what people don‘t realize is it’s – the skin on the inside should be – it should heal almost as quickly as the skin on the outside. You actually shed your internal skin in about 48 to 72 hours, so you renew yourself all the time. If that’s not healing, the reason why you have it is not resolved, and sometimes that’s a microbiome disorder. Sometimes that’s medication. Sometimes that’s food allergies. There’s a lot of things. I mean, it’s only a one cell layer thick lining that we have that protects us from the outside world. It’s amazing.
PHOEBE: Switching gears for a second, I know that you mentioned in your handout, which I’m the proud owner of, that part of the reason or part of the strategy behind the Bi-Phasic Diet which you developed was to limit symptoms of die-off. That’s something we haven’t really talked much about. I would love to hear more for those who don’t know. What is die-off? What are the symptoms, and what about your diet helps to alleviate them or wiggle around them?
JACOBI: That’s a really good question. Die-off is symptoms that are experienced when either bacteria or fungi die and spill their endotoxins. Particularly Gram-negative bacteria, like klebsiella, e-Coli, those kinds of organisms in their cell wall have something called lipopolysaccharide or LPS for short. It’s actually a very researched molecule because it’s one of the most potent triggers of inflammation, depression, anxiety that we know. If researchers want to induce inflammation in animals, they inject it with LPS, more or less. LPS is just one of the strongest endotoxins that we know. Candida has a number of them too like tartaric acid and those kinds of things.
What happens is your body becomes overwhelmed by these dying organisms, endotoxins, and they all have to be detoxified. It’s like all of a sudden you’re just overwhelming your liver’s capacity to handle that. Also, if you do have leaky gut, clearly you’d absorb a lot more of this LPS than if you didn’t. Actually, when you have a condition called sepsis, which is a life threatening bacterial infection in your bloodstream, that’s a real risk of killing the patient with antibiotics because of die-off. The endotoxins are more toxic than the live bacteria often. We know it’s a real thing. Anybody that’s ever been on antimicrobials for SIBO or for SIFO, SIFO tends to have much worse die-off symptoms. Candida tends to be somehow a lot worse.
They will tell you it’s feeling like you have the flu. You just feel off. Some people experience it worse than others, and some people don’t have it all. That’s sometimes testament to their detoxification ability, or perhaps it’s not as bad leaky gut, or perhaps the bacterial overgrowth is not quite as severe. Not everyone with SIBO will get die-off with treatment, but it’s always a good sign that things are working when they do. It’s something that we look out for, and I tell my patients. Sometimes we give them things to bind endotoxins if things get too tough for them.
PHOEBE: What are some of your suggestions there?
JACOBI: Things like activated charcoal is a good option. There are different binders on the market now that are really pretty good.
PHOEBE: When should you take that so it doesn’t conflict with the actual treatment for SIBO?
JACOBI: Yeah, it doesn’t really matter. I haven’t found it to be that interfering with antimicrobials. You can take it away from the antimicrobials, or you can take it alongside. I don’t do it for the entire treatment. I just do it for maybe two weeks or so.
PHOEBE: Are there any digestive symptoms of die-off, or it’s a whole separate sensation as you mentioned like you have the flu and extreme fatigue and whatnot?
JACOBI: Yeah, fatigue but, no, you can get your – all of a sudden, your digestive symptoms can get much worse. Often, when people that are not under the care of a practitioner, they stop the product thinking that they’re reacting to the product. Constipation is really common, for example, bloating. Those kinds of things or symptoms are very common as well. It’s something that I usually – first thing I do is, if somebody has very severe die-off, I have them stop the product for 24 hours or reduce it to a very low dose and add binders. The idea is not to blast your way through there as fast as possible. It has to be tolerable by the patient.
PHOEBE: Is that what it is most of the time? How do you tell if it is die-off or it’s the treatment itself, some of the herbs or whatnot they’re reacting to?
JACOBI: Yeah, that’s a good question. You can have sensitivities to herbs, especially people that are salicylate sensitive or oxalate sensitive, and so sometimes it is a trial and error. Certain herbs are more reactive than others. Berberine containing plants are – people can have a lot of nausea with that or get anxiety with that, especially if they have certain genomic variance, meaning that they can’t – it tends to affect people with issues around monoamine oxidase. That’s a bit more complicated. I now know what to look out for, so I can spot die-off versus a plant reaction pretty easily, and that’s maybe advanced. I can’t give you very specifics. It’s just, if you have a really healthy patient, generally healthy, just has SIBO, you don’t really expect them to have salicylate and oxalate sensitivities if they don’t exhibit that with their diet so those kinds of clues, for example.
PHOEBE: How does the Bi-Phasic Diet help with die-off? Is it just by approaching it simply through food and the restrictive phase to help to clear out some of the bacteria so that it’s not quite as intense a population being held in Phase 2?
JACOBI: Yes, that’s it. Yeah, so that’s partly it. The other one is that we are already addressing inflammation to some extent for some people. People with a lot of inflammation in the gut just tend to have worse die-off because they absorb a lot more LPS. If you’re already addressing that to some extent, then it’s lessened, but yes, you are reducing bacterial colonies by just reducing the substrate that they feed on. Like I said before, you can’t completely clear SIBO with a diet alone, but you can initially reduce, I think, the numbers. I don’t have any proof of that, but I’ve done this now long enough to know that what I think is true, which is that people that have been on a Phase 1 for about four weeks do not have as much die-off as people that didn’t do that so two to four weeks, I’d say.
PHOEBE: Let’s say someone at home without the help of a practitioner, not recommended by either of us but the scenario exists, is actively going through some sort of antimicrobial be it herbal or one of the antibiotics, and they’re experiencing this die-off in a very intense way but haven’t really done much dietary intervention. Is there anything that they can adjust in order to help at that point, or do you just have to ride it out?
JACOBI: There’s a lot one can do, but it’s so individual. It’s so individual. I always hate to make sweeping generalizations, and then people try something. It doesn’t work out because it wasn’t the right thing for them. Things like enemas, for example, especially in constipated patients. Here’s the important tip. It’s like, in a constipated patient, I rarely start antimicrobials because the die-off will be much worse for them. It’s such slow transit. Those kinds of things you need to know before you really start an antimicrobial protocol.
PHOEBE: That’s really interesting. Anything to naturally help motility and constipation if you’re experiencing die-off is going to be helpful?JACOBI: I think so, yes. In many people, I have to use some laxative or something to help – or enemas or things like that to really open the gates, so to speak. That will help. The thing is that certain types of SIBO like methane dominant SIBO are constipating themselves. It’s more like you won’t get natural relief from constipation until those methanogen numbers have dropped quite significantly, which of course requires you to kill them. You do need to have some antimicrobials, but I usually use some other products and stuff to help things move along, or prokinetics, or so forth.
PHOEBE: Got it but, just generally, if you’re experiencing those symptoms, don’t freak out. Keep on going, and maybe make a few other adjustments along the way that can help clear the passageways. Okay, so before I let you go, is there anything else you can tell me about maybe some pro tips, whatever you have to recommend to patients who are trying to implement the Bi-Phasic Diet at home that’s not covered on your free handout? I know you’re working on a course eventually for patients to better be able to implement this at home, but I’m just curious if there’s any advice you could give to people listening who are just starting off with this diet.
JACOBI: Oh, gosh, I mean, generally, I think I actually gave you a lot of pro tips just now. Specifically, I’m the first one to say this is a diet that’s meant to be used by practitioners to adjust to patients. I created it for practitioners, and then I released it to the greater world because there was such a need for that, but at the same time, I still think people are best in the hands of trained practitioners. Not just anyone who has read a blog about SIBO but somebody who actually is trained in how to actually look for those pitfalls and stuff. Yeah, I’m not so sure if I have any more specific tips about the Bi-Phasic Diet, but just remember that it is adjustable. For example, if you’re vegetarian, you can just replace the meat portions with non-GMO plain tofu or tempeh if you can tolerate soy because those products are fairly low in fermentable carbohydrates. Those kinds of adjustments can be made easily.
PHOEBE: Do you generally recommend that people don’t get too caught up in the rules and complying perfectly and be willing to experiment?
JACOBI: Yes, absolutely, especially with the length. For example, I’ve done a Phase 1 as short as one week and a Phase 2 as long as four or five months. The timing is just general recommendations.
PHOEBE: How do you know when someone should begin the reintroduction process, and what does that look like for you?
JACOBI: The norm is that, if a patient comes back after, let’s say, six weeks on antimicrobials and Phase 2, they come back and they say, doc, it’s a miracle. I’m 90% better. I’m 100% better. You’re not going to need to retest them. You know that SIBO is gone. If they say I’m better but I’m not 100% yet, I’m about 60% better; I often do a retest of a breath test just to see if we’ve actually cleared SIBO. Believe it or not and for reasons that we’ve already mentioned in this podcast, sometimes people, they’ve cleared their SIBO, but they’re still symptomatic. Then that’s really important information to know is to actually dig deeper and look at these other issues that we’ve talked about like histamine intolerance, SIFO, and those types of things. People that have just been on rifaximin and neomycin, for example, two antibiotics that are used for SIBO, totally miss SIFO with that, so it’s a big deal to know whether or not you’ve cleared SIBO.
Then to answer your question, if they’re still symptomatic, I might actually change antimicrobials to include more antifungals, and then I say let’s stay on Phase 2 a little while longer. Then I would introduce – the first thing I do is say, okay, you can just increase your portion sizes of the limited foods. Rather than one stalk of asparagus – who does that? I don’t know, but that’s what’s allowed. You can have five.
PHOEBE: Another question, yes.
JACOBI: Yeah, right, you can have five, and you can experiment with that. Then you can start putting in other grains, and then from there it’s fairly easy. Also, as a parting thought is, really, the most important thing is to understand your underlying causes. For example, if you’ve had any sort of abdominal surgery, whether that’s even a laparoscopy to look for endometriosis, or you’ve had your appendix removed, or your gall bladder removed, or you had a cesarean or a hysterectomy, those are all invasive surgeries that often cause adhesions, and they’re very much linked with SIBO. That was actually a recent study that showed that even minor abdominal surgery causes adhesions, and breath tests were often abnormal after that. That would then require a visceral manipulation person that can work with you to help alleviate those. Then you’re done with SIBO treatments. Otherwise, it might a revolving door for you.
PHOEBE: Then in terms of the diet piece itself and getting back to a new normal, increasing the portion size, I take it as Phase 1 of introductions. How do you go about testing different foods, or is it not was much like a testing process for you as maybe some people that talk about the low FODMAP diet and more just like a slow reintegration?
JACOBI: I think it’s more of a slow reintegration. You can just tell that their vitality has returned. They feel really good. They can move quite fast through this. It would typically be like this. I went traveling and ate anything I wanted, and it was fine. They went from Phase 2 to just, well, I’m fine now. Then there are those that you have to go very slowly, and then sometimes there are setbacks. Really, it’s, again, individualized to a patient’s vitality and resilience and how much they can handle.
PHOEBE: How do you get people to not fear food? I find that it’s probably a larger population than the ones who are willing to just dive right back in who are a little trepidatious, since being symptom free feels great, about the idea of reincorporating more foods that might cause them to feel some discomfort again. What is your advice for people, for patients who are moving into the next phase without fear?
JACOBI: There again, there’s a spectrum of people that have been on severely restricted diets for a long, long, long time. There is a real issue around fear of food. I completely acknowledge that. That actually develops with this. I often tell people to get something called an inner balance device, which is something that’s developed by HeartMath, which is a research institute that looks at the physical effects of stress. It’s just this device that you clip to your ear. You download this app, and you plug it into your phone. It measures your heart rate variability, which is a measurement of fight or flight.
I tell people to do it for about two minutes before meals, and with this app, you can see whether or not you are in fight or flight or rest and digest. You are much less likely to react to a food if you are in rest and digest. That’s just even retraining the enteric nervous system. If you keep telling yourself you’re going to react; you’re going to react; you’re going to react, you will react. It’s slowly. It’s mindfulness. It’s sometimes even affirmations that this is nourishing food for me. Yes, I might have a little bit of reaction, but it’s healthy food for me.
There was actually some studies and I do a lot more now with hypnotherapy. There were two studies that looked at the effects of hypnotherapy on IBS, which were astounding. Patients had over 80% reduction in symptoms with about six to ten sessions of hypnotherapy, which basically is evidence that a lot of symptoms can be controlled with dealing with the subconscious mind and with the enteric nervous system. That’s just an extension of your nervous system that innervates your digestive tract, and so just calming the nervous system is a huge part of the journey for many people.
PHOEBE: Wow! Do you think hypnosis can cure SIBO all on its own?
JACOBI: Cure is a relative term.
PHOEBE: Okay, yes.
JACOBI: If for example, you have a very anxious person that then developed SIBO, then, yes, I do think it can. If it’s just a part of – I mean, the enteric nervous system is involved in almost all issues around SIBO because it’s either motility, or anxiety, or all those things really have an effect. We do hypnotherapy here at The Biome Clinic just to offer that to people as an adjunct to their treatment, especially those that area highly anxious. I think it’s a really good adjunct, and we’re looking into other neurofeedback techniques. That study that came out of Monash, with Monash University here in Australia and one from the UK that looked at this effect was I think really profound. Even though we know that 80% of – 60 to 80% of people with IBS actually have SIBO. To have their symptoms controlled to such an extent for an actually extended period of time, they measure – they monitor them for five years, and they had ongoing improvement with just hypnotherapy. That tells me that that’s a major aspect of at least experiencing symptoms.
PHOEBE: Wow! I’m going to have to do a follow-up podcast just on hypnotherapy and SIBO. Thank you so much for mentioning that study and bringing on to everyone’s radar. We’ve talked about specifically foods, what you’re eating. I know that, for me personally, besides just the mindset and the stress piece, I had to change a lot of ways about how I was eating in terms of spacing meals, chewing my food, and whatnot. Are there any pitfalls and pieces of advice you would give to people in terms of that prong of tackling the food element diet piece?JACOBI: I think you just said that perfectly. Yes, you have to, basically, chew your food well. Don’t swallow it whole. Don’t rush when you’re eating, all of that. You have to be in – you’re meant to be, actually, in a very relaxed state when you’re eating. The other thing about SIBO is that we try not to eat in between meals because the housekeeper wave or the migrating motor complex which is a cleansing wave that sweeps through your small intestine and clears any remaining bacteria and food left there out works best between meals. If you’re constantly snacking, you are not really optimizing that part of your enteric nervous system. Those are all good pieces of advice. Eating in a relaxed manner, chewing food well, those are the primary ones, I’d say.
PHOEBE: Wonderful, well, thank you so much for joining us the show, Dr. Jacobi, lots of things to think about in terms of all of our healing plans for SIBO. Thank you, again, for taking the time, and I hope you have a great day.
DR. JACOBI: Thank you so much for
Disclaimer: The information in this podcast does not provide medical advice, professional diagnosis, opinion, or treatment. The information discussed is for educational purposes only and is not a substitute for medical or professional care.