Recently I interviewed Dr. Nirala Jacobi, and we talked about SIBO and the Biphasic Diet. If you would prefer to listen the interview you can access it by Clicking Here [1].
Dr. Eric Osansky:
I am very excited to chat with Dr. Nirala Jacobi about SIBO, as I have been following her on her podcast for a number of years. Previously, I interviewed Shivan Sarna, and we covered some of the basics of SIBO, including the symptoms, causes, the low FODMAP diet, prokinetics. Here, we will go in a little different direction.
First, I want to share Dr. Jacobi’s impressive bio. Dr. Nirala Jacobi is a naturopathic doctor and internationally recognized expert on small intestinal bacterial overgrowth (SIBO). She is the creator of the SIBO Bi-Phasic Diet, a resource that has helped tens of thousands of SIBO sufferers around the world. Dr. Jacobi is the host of The SIBO Doctor podcast and the founder of The SIBO Doctor, which is an online educational platform that includes a practitioner certification program. She is the medical director of SIBO Tests, providing innovative testing options for SIBO and IBS. Dr. Jacobi is known for her systematic and effective approach to diagnosing and treating SIBO and other functional digestive disorders.
Having received her naturopathic doctorate in 1998 from the esteemed Bastyr University in Seattle, she brings more than two decades of clinical experience and expertise to her clinic, The Biome Clinic. Thank you so much for joining us, Dr. Jacobi.
Dr. Nirala Jacobi:
It’s a pleasure to be here. Thanks for the invite.
Dr. Eric:
You are very welcome. I’d like to start off, Nirala, by just chatting and getting a little bit of your background. How did you start focusing on SIBO?
Dr. Nirala:
It’s an interesting story. When I first found out about SIBO, I had been in practice for about 15 years. I found out about SIBO in 2010 or 2011. I went to a conference, the American Association of Naturopathic Physicians, and heard Drs. Allison Siebecker and Steven Sandberg-Lewis talk about SIBO.
It was like a thunderbolt because it was like the missing link that I found that many of my patients seemed to have, where very well-intentioned protocols that we usually use for digestive disorders and dysbiosis and things like that were not working for these patients. It was really an aha moment for me. Wow, this is actually a really big deal, and it’s going to be a really big deal for many people.
Up to that point, as you may remember, there wasn’t a whole lot out there for the treatment and even the diagnosis of IBS. What we now know is that a large percentage of these IBS cases are actually SIBO. Because it’s a diagnosable condition with a breath test and a very treatable condition, all of a sudden, we have all this good news for IBS sufferers that were always told to eat more fiber and learn to live with it.
Dr. Eric:
You’re right about SIBO being a bigger deal than some practitioners, including myself- It was probably 2016 when I really started getting into SIBO and was surprised to see at summits- NUNM.
Dr. Nirala:
Yes.
Dr. Eric:
I guess it’s more of a conference. Anyway, since then, and before then, there has been so many conferences and summits. There is a lot of information out there because it isn’t easy to get rid of SIBO and address it. You can’t completely get rid of it sometimes. Can you talk about the different types of bacterial overgrowth? What is the difference between having an overgrowth in the small intestine compared to the large intestine?
Dr. Nirala:
Let’s talk about what the normal physiology is, and maybe that’s helpful to your listeners to get an idea of what’s going wrong then with the normal physiology and the normal terrain of the digestive tract.
When you’re eating, you’re starting to secrete a lot of digestive juices that are meant to keep a lot of food-borne bacteria at bay and kill bacteria on contact. Because of that effect, there is a very low level of bacterial growth in the small intestine.
The other reason is because it needs to be bacteria-free more or less, or very low bacteria levels in the small intestine because that is where you break down your food and absorb your food. Too much bacteria in that area is not very helpful for absorption and so forth. That’s one thing is where digestion is really impaired, for example. You’re not secreting enough digestive juices, and that can lead to local bacterial overgrowth in the small intestine.
The large intestine is where you’re meant to have a lot of bacteria, something to the order of three billion per mil of stool. There is a lot of bacterial activity in the large intestine.
We have these two places that are very different from each other. It’s like the rainforest in the colon and the desert in the small intestine. When you have different reasons for SIBO, either digestive deficits or motility problems or structural issues, then you can end up with a local bacterial population. These are normal in small amounts, but when they overgrow, they cause a lot of problems. We know so much more about SIBO now than we did when we first started to learn about it. We’re down to understanding what bacteria produces which gas and treatments. It’s been a long road, but we are understanding a lot more now.
Dr. Eric:
When a practitioner does a comprehensive stool panel, and we see a lot of opportunistic bacteria, that is completely different than SIBO. You can’t conclude that that person has a lot of opportunistic bacteria in the large intestine, so they might have SIBO. The only way to know is by doing a breath test, correct?
Dr. Nirala:
Yeah. A stool test will give you no information about the state of the small intestine in terms of bacterial overgrowth. It simply is not equipped for that. A lot of practitioners try to deduce that there is SIBO because potentially either E. coli or Klebsiella or Desulfovibrio are overgrown in the colon, which is not normal but is often the case, as we know. Those happen to be bacteria that cause SIBO. Just because they are high on a stool test is in no way the implication that they are also high in the small intestine.
Dr. Eric:
Can you talk about some of the hidden causes of SIBO? I heard you talk about this in your SIBO course or your podcast. I have been following you for quite some time.
Dr. Nirala:
Sure. That’s where my sweet spot is in terms of practice and education. I think we owe it to our patients to find the underlying cause. I always tell people, “Look, the bacteria are not that hard to treat, but it is a very frequently relapsing condition. We have to understand why is it relapsing?” The causes of relapse are different for different people.
As I mentioned, the one, what I would say, category of issues is you have a problem with digestion, or you have a problem with motility of the small intestine, or you have some structural issues like scar tissue from an abdominal surgery or endometriosis or anything that increases scar tissue formation in the abdominal cavity that then can disrupt the way the body moves through the entire digestive tract.
If you think about the causes in those three categories, it gets a little easier. By far, the biggest is the motility problem. Let’s talk about that for a moment. The small intestine is equipped with something called the migrating motor complex, which is a part of the enteric nervous system that sweeps the contents of the small intestine toward the colon. Different conditions can damage or hinder or impede the migrating motor complex. That is one thing.
Then the other aspect of this motility might be conditions like hypothyroidism or issues with vagal tone, where we have vagal tone dysfunction with extreme stress or mold toxicity or chronic viral infections that affect the vagal output.
Under this umbrella of causes, you have three categories. Under each category, you have the actual problem, if you know what I mean. It’s a bit complex. It’s certainly not a one size fits all. I think the more we understand about what causes SIBO for an individual patient, the more we can actually resolve this issue for them once and for all.
Dr. Eric:
It’s not as simple as just following a low FODMAP diet or treatments such as antimicrobial herbs or Rifaximin. Either way, you want to address the underlying cause, or you could and very well probably would relapse if you don’t address the cause.
Dr. Nirala:
In many cases, that’s what I see. Some people have relapse rates of every 2-3 months. Some people have relapse rates of once every year or two years. That also differs depending on what the cause is. Because the biggest issue is motility, that’s where I often find the people that do the most relapse.
When you have digestive issues, like let’s say a typical case of digestive issues would be somebody who has had extreme stress for a few years potentially due to their job or their relationship, whatever that may be, or trauma. We have all experienced different degrees of trauma. It’s been heightened. I don’t know if you have experienced that as well. Their whole baseline of anxiety is way higher after COVID seemingly than it was before. This chronic stress can tell the body it’s not time to digest anything. It’s time to deal with the stressor. People just are walking around with chronic stress and are not digesting their food properly. That’s a real thing. That’s relatively simple to correct because we have supplements and herbs that aim to support digestive processes: hydrochloric acid, bitters, enzymes, etc. We know how to do that as practitioners.
Let me finish up with that other category. The hardest thing about those cases is really inducing a parasympathetic nervous system response. I often refer to modalities like hypnotherapy and trauma work and different kinds of vagal toning and brain retraining. That is a little bit more involved if it involves the central nervous system and the vagus system.
Dr. Eric:
Just out of curiosity, have you noticed over the last few years increased incidence of SIBO with all the stress post-pandemic?
Dr. Nirala:
I definitely saw more relapses after COVID. I thought that was stress-related. Generally, there is so many changes and worries that people are carrying these days. It isn’t just COVID and lockdowns, but the state of the world is very frightening for a lot of people, understandably so. Learning how to downregulate or ground yourself and learning how to work with your nervous system is one of the biggest skills that people can develop.
Dr. Eric:
I agree. I’m glad you mentioned this. There are some people who think it’s all about diet and don’t relate stress management with SIBO.
Dr. Nirala:
It’s not like I’m over it. I just find that stuff not difficult. Occasionally, I do have patients who fail treatment, and they fail every single one of the treatments. I can count those cases on one hand over the last 15 years or so.
The majority of people will respond well to the treatment. It’s about treating the cause of the problem.
Dr. Eric:
Let’s talk a little bit about the Bi-Phasic Diet. When I spoke with Shivan, we spoke more about low FODMAP. There’s also Dr. Siebecker’s SIBO specific diet. I forgot exactly what we chatted about. We definitely didn’t get into the Bi-Phasic diet. If you could talk about why you created the Bi-Phasic Diet. I know you have a few different variations like a histamine one that relates to histamine, a vegetarian version, etc.
Dr. Nirala:
The Bi-Phasic Diet came about because there were just too many instructions and too much confusion about low FODMAP. I put people on low FODMAP, and they would still be symptomatic. I had to come up with a way to structure my treatment because I found that when a patient came to me, I would give them a breath test to take home. The first point of contact where we are just assessing whether or not it is SIBO.
I found that just supporting their digestion and putting them on a very restrictive diet, so this would be phase one of the Bi-Phasic Diet, which is stricter than a low FODMAP. It’s virtually grain-free and free of all the main allergens—dairy, gluten, and so forth. Egg is still allowed. It’s very strict, low FODMAP, but beyond that. I do a lot of supportive therapies during that phase.
Then people would come back and feel so much better. The test would come in, and we found that yes indeed, it’s SIBO. Then we could immediately move to phase two, which is more the antimicrobial phase, where you are introducing again a few of the FODMAP foods. You can expand on the diet also, so you can have a little bit of bacterial growth. You want them to be active when you’re blasting them with antimicrobials.
I found this approach really helpful, especially for sensitive people that often have an issue with die off, that condition where you’re feeling the effects of bacterial death and absorption of the endotoxin LPS that triggers so much inflammation in the body. When you already reduce their fuel source, you are getting some bacterial downregulation. I found that approach really helpful.
Now that has expanded. I just recently released an e-book that incorporates both the vegetarian and the regular SIBO Bi-Phasic Diet. The purpose of that was why are only vegetarians learning how to sprout their legumes and not having all these other foods available to them? I’m a big fan of plant foods. I think plant foods are ultimately, as we know from many different studies, where we get our fibers and nutrition from that are important for the microbiome in general. Anyway, it was a labor of love to put this e-book out. It incorporated both the diets with a lot of updates. That recently happened.
The histamine diet, I did with Heidi Turner, who is an excellent dietician who works a lot with mast cell activation syndrome. I found that often is a comorbid condition in people that are really extremely sensitive and have SIBO. We needed something for those patients, but also people who have histamine intolerance, which is actually quite common in people with SIBO or IBS. That is the history of the Bi-Phasic Diet.
It’s a structured approach that allowed me to have people do this in a stepwise fashion without having them leave with 10 different supplements on day one. I really didn’t want to do that. I wanted to navigate it a little bit gentler.
Dr. Eric:
Each phase is 4-6 weeks?
Dr. Nirala:
That’s adjustable by the practitioner. I’ve had people just do a two-week phase one depending on how they’re responding, and then move straight to phase two. You can do it as long as you’re improving in phase one. It starts with a very restrictive part, which is the restrictive phase one. Then it’s semi-restrictive, which is a self-guided process. As soon as people feel better, they can go to the second part of phase one and incorporate some more vegetables.
Whenever you start antimicrobials, you do want to move to phase two. A lot of people find the Bi-Phasic Diet really helpful when they have acute flareups, or they have had Christmas or one of those holidays that involves a lot of food. They have a bit of symptom control to do. They do a couple weeks of Bi-Phasic. That’s also a useful tool for that.
Dr. Eric:
The first phase kind of sounds like a combined paleo and low FODMAP diet. You said eggs are allowed, but you’re avoiding grains.
Dr. Nirala:
And specific carbohydrates. It’s sort of all of that. You’re reducing inflammation. You’re wanting to start that process. I find that really helpful when you focus on just supporting digestion and reducing inflammation before you go in there with harsh herbal medicines. Some of these essential oils can be quite full-on for people. That’s been super successful for me and for many of the practitioners that have completed the program and are recommending this diet to their patients.
Dr. Eric:
The second half is when you are starting the antimicrobials. It depends on how the person is responding. Someone might be on the antimicrobials for potentially a few months?
Dr. Nirala:
Each round is about six weeks. If you have very high gas levels, you may have to do two rounds, so it’s three months. The second round, you might want to add in some biofilm if you retest after the first round, and you have not made significant progress. If you have made no progress, I would change antimicrobials.
It really is case by case. I am always very hesitant to give absolute numbers for how long you have to do it because it’s adjustable. Some people need more carbs for example from the get-go because they have blood sugar regulation issues. That’s also possible.
In the e-book, I mention all these different things you can adjust and make it a little bit more manageable for yourself. I do have a self-help SIBO success plan, which is a self-guided SIBO treatment for patients. I really want them through the Bi-Phasic Diet very meticulously.
Dr. Eric:
There is also SIFO, small intestinal fungal overgrowth. Does the Bi-Phasic Diet benefit people with SIFO as well?
Dr. Nirala:
SIFO is also very common. It is often morbid and exists with SIBO. It has exactly the same symptoms, I’d say. It is a diet that lends itself very well to the treatment of candida and other fungi. Phase two of the Bi-Phasic Diet, you can introduce honey and maple syrup. I usually say don’t do that yet if I know somebody has SIFO.
Dr. Eric:
That’s one reason you like the herbs because the herbs can help with both, whereas the Rifaximin would just help SIBO.
Dr. Nirala:
Yeah. Mainly for hydrogen SIBO. Hydrogen or hydrogen sulfide. It’s a good antibiotic, and it’s really specific to small intestinal problems. It doesn’t get absorbed. It has a minimal impact on the large intestine unless you repeatedly use it. It’s obviously a popular antibiotic for a reason. It works really well for hydrogen dominant SIBO. It’s still an antibiotic.
Ultimately, the problem with SIBO is you have a dysbiotic microbiome of the small intestine because the bacteria that cause these problems are not pathogens per se. We know that. Were they the kind of pathogens that don’t cause food poisoning, like salmonella, Campylobacter, E. coli. You have normal amounts of E. coli in your gut that are important players of the microbiome. When you have bacteria that are meant to be in small amounts that all of a sudden overgrow because of the reasons I mentioned before, then we run into issues. They are normal players of the microbiome. For that reason, we really need to focus on rebalancing a normal microbiome of the small intestine.
Dr. Eric:
One question I have. You mentioned that Rifaximin is mainly for hydrogen dominant SIBO. Then I learned years ago when I first started learning about SIBO that if someone has methane dominant, they could take Rifaximin or Metronidazole. Can someone mix the antibiotics and herbs? Can they take allicin with the Rifaximin if they have methane dominant?
Dr. Nirala:
Absolutely. I actually prefer that. My usual routine with mixed SIBO where you have both hydrogen and methane dominance, if they opt for Rifaximin, is to do that two-week course, but more like a six-week course of the Allimed, or high content allicin, not just the garlic extract. They are not all made the same way. Methane does take a little bit longer. Maybe add in a biofilm buster and potentially also something like Nystatin or maybe even oregano oil. A little bit more involved. You can absolutely mix and match.
Dr. Eric:
With the biofilm busters, do you recommend it just for methane dominant SIBO or also hydrogen dominant?
Dr. Nirala:
With just the first round, I don’t. I want to see how they respond and what their relapse rate is. Usually in those cases, where they’re relapsing right away, within a few weeks or so, then I will do it. I will add in whatever SIBO that is. If it’s hydrogen dominant, I will also add that in sometimes.
Dr. Eric:
What are your thoughts on elemental diet? Is that something you sometimes recommend?
Dr. Nirala:
Yes. It’s a great tool. What people don’t realize is it is an actual antimicrobial. Don’t be fooled by the word “diet.” It’s not that you’re adding this to your diet, or you’re doing this while you’re doing other antimicrobials. It is a standalone antimicrobial treatment. The idea here is that those ingredients are so predigested that they basically get absorbed as soon as they hit your small intestine. When you drink it, it gets absorbed really rapidly. There is no food left over for bacteria. When I first heard about it, I was quite skeptical. It is actually quite dramatic, the degree of reduction of gas.
The problem is you have to do it for two weeks minimum. A lot of people at that point are over the sweet taste. It’s quite sweet. There are different versions. Some people are great with it. It is a great treatment, don’t get me wrong. Talking somebody into doing it, sometimes repeatedly, is hard.
Dr. Eric:
I guess it also depends on the severity of the SIBO and if the person has tried other things. Have they taken antimicrobials, and it hasn’t worked?
Dr. Nirala:
I often give the option. Here are your options: Here is your conventional recommendation. Here is what I would do, the herbs I can give you. Here is the elemental diet. These are the three options we have. Sometimes, the second time around, people will opt for that, with minimal movement of the gas levels.
Dr. Eric:
Bloating is pretty common, as is gas. It could take time for the Bi-Phasic Diet, the antimicrobials to kick in. Do you have any quick solutions? If someone is really dealing with a lot of bloating, something they could do to get some relief sooner than later.
Dr. Nirala:
There is lots of different causes for bloating. Sometimes, it is the gas that is produced by bacterial fermentation. With SIBO, there is no doubt about that. But sometimes it isn’t that.
You may be really deficient in these digestive juices that help you break down food. I’ve seen that a lot. I see a lot of people with suboptimal hydrochloric acid production, bile production, bile flow, pancreatic enzyme output, brush border enzyme output. There are all these different substances your body produces in response to food. When they are really deficient, and you are not breaking down these bigger particles, then you have all of this food actually arriving in the colon. Colonic fermentation can also give the sensation of bloating. Then the treatment is different than SIBO.
Sometimes, it is the neurological wiring that is basically in this fight or flight, where nerves aren’t communicating very well. Things like hypnotherapy we know in research in certain cases can dramatically improve symptomatic relief for IBS sufferers. These studies use gut-centered hypnotherapy to improve IBS symptom scores. It’s just amazing. If that’s the case, I would really recommend doing things like working on that vagal toning and nervous system downregulation.
If it’s digestive stuff, then I would start with something like a bitter tonic to help with the production of these digestive juices.
If it’s just you’re bloated, and you’re going to a wedding, and you have to fit into a tight dress situation, then I’d probably use something like a charcoal binder. Charcoal is pretty good because it’s simple, easy to get, and does tend to bind gas. Also doing certain exercises like wind relieving exercises, yoga poses, things like that.
Oh, and I have a tea. I forgot about this. I have a video about how to create your own carminative tea. Carminative is a word that we use in herbal medicine that means “wind-relieving,” actually reducing gas. It’s three seeds: caraway, anise, and fennel. You mix them in equal portions. You put them in a jar. You take one teaspoon and put it in a mortar and pestle. You grind them up, bruise them, and put them in a cup. You put hot water on it, steep it for 5-10 minutes, and drink that after a meal.
That’s an easy thing to do if you go to a bulk seed store. You can just buy them. We have bulk stores where I can get my flour and different seeds and different spices and herbs and put them in a paper bag, take them home. You mix them up and make yourself a cup of tea.
Dr. Eric:
Obviously, start with one cup. Will some people need multiple cups?
Dr. Nirala:
You can even brew it properly for like 10 minutes in a teapot. You make yourself a big teapot and drink one cup after each meal. It doesn’t have to be hot. You can drink it cool as well. It’s pretty pleasant tasting. It can really help with the reduction of bloating.
Dr. Eric:
You mentioned bitter herbs. Would something like apple cider vinegar work to stimulate the body’s own production of stomach acid?
Dr. Nirala:
When I think about different degrees of increasing stomach acid. Let me just back up. Your normal stomach pH, when you’re at normal resting state, is supposed to be the acidity of car battery acid, which is around 1 on the pH scale. If I were to stick my finger into your stomach, it should get digested all the way down to the bone. It should get broken down. That’s a normal, healthy stomach acid.
Now all of a sudden, if you’re not putting out enough, your pH starts to go up, meaning more alkaline. We have certain things like lemon juice and apple cider vinegar to help with the pH of that, but it doesn’t do much to stimulate your own parietal cells of the stomach to produce hydrochloric acid. Herbs like ginseng and all the bitter stuff—dandelion leaves, berberine, Oregon grapes. It’s a great bitter, but it’s also a mucosal tonifier, and it has some antimicrobial activity. I would use that because it directly stimulates the parietal cells to increase their stomach acid output.
The next level from there would be actual hydrochloric acid supplementation. Different things do different stuff. Apple cider vinegar, while it’s fantastic for some people, it really helps with improving the stomach feel. Some people are sensitive to the histamine levels of fermented foods.
Dr. Eric:
That’s a good point. Thank you for explaining the differences. I know berberine is used as a treatment for hydrogen dominant SIBO and has benefits for the gut microbiome. You mentioned it also stimulates the body’s own production of stomach acid as well.
Dr. Nirala:
Berberine is the ingredient or constituent, as we call it in herbal medicine, that is present in many different plants. There is a berberine-containing plant family. Some of them are big trees, like calodendrum, and some are brushes, like the Oregon grape root is basically a bush. Different plants, but they can be extracted. Berberine is then the active ingredient that has these antimicrobial activities. If you use the whole plant, like Oregon grape, which has traditionally been used as a bitter, a stimulant, and a mucosal tonifier, you get all this added benefit of good effects on digestion in general.
Dr. Eric:
I have a couple of quick, true/false questions for you. You could feel free to expand on them. I don’t think we mentioned that you’re in Australia, so this question might differ based on the location. I’m not sure. True or false: Most gastroenterologists, GI doctors, are familiar with SIBO.
Dr. Nirala:
I think that’s false. Or they often dismiss it. It’s a tough one because I see pretty extreme cases, so they have gone to different gastroenterologists. Some do the breath test. I think that adage of any new discovery in medicine takes at least 20-30 years to filter down into the actual offices of medical doctors. It takes a long time. We’re only 15 years in or so at this point.
A lot of functional doctors are familiar with it at this point. Some medical doctors and some gastroenterologists, we have some absolute superstars like Lenny Weinstock or Dr. Bulsiewicz, who wrote Fiber Fueled. They are more into microbiome restoration rather than SIBO, but at least awareness of microbial issues is starting to take hold, I should say, in some of these modern or conventional minds.
Often, I see patients that say, “I was told this is not my problem.” Then we do a breath test, and lo and behold, it’s a problem. When we treat it, their problems go away. Some people are very upset by that because they should have been told it is a thing.
That was not a true/false question. That was a very long-winded answer to a short question.
Dr. Eric:
I expected you to expand and not just say false. I brought it up because some people might go to the GI doctor hearing SIBO, and the doctor might dismiss it and say, “No, you don’t have SIBO,” but they didn’t do a breath test. Maybe they did an endoscopy, or they didn’t do anything at all. They just dismissed it because they are not familiar with it.
True or false: It’s okay to randomly treat someone with SIBO rather than do testing.
Dr. Nirala:
100% false. Well, okay, nothing is ever 100%. Here’s my pitch for testing: First of all, you need to know that it’s SIBO. Now that you know you have these three different categories of causes, it’s important to know if it’s actually SIBO so that you can then explore the reason why SIBO is there to begin with.
Second reason is you need to know which gases are dominant, so you know what you’re actually treating because the treatment varies with different gas types.
Those are my two main arguments for testing. Testing is super accessible. It can be done at home. It’s available on all major continents. It’s a do at home test. It couldn’t be easier.
Dr. Eric:
They do offer some testing for hydrogen sulfide. If someone is experiencing more constipation, would it be okay to just do the traditional SIBO test?
Dr. Nirala:
Absolutely. Unfortunately, there is only one lab right now in the world that does hydrogen sulfide testing. That’s always a bit limiting in all ways. Also, I’d like to have more labs that then corroborate the fact that this is a valid test. I’m not saying the test is not good. I would just say that not everyone needs this particular test that checks for hydrogen sulfide simply because what we can expect in terms of symptom-wise for hydrogen sulfide is a diarrhea dominant type of SIBO.
Somebody that is constipated may have hydrogen sulfide production in the colon because it causes constipation when the solvent-reducing bacteria (which is confusing because they are not reducing, they are just biochemically reducing sulfur) are present and overgrown, they can cause constipation in the colon. But a breath test for hydrogen sulfide will not pick up that level. Or very rarely. It’s really the cases that are not positive or maybe barely positive on a normal lactulose breath test, and they have diarrhea and some other symptoms that maybe give you a suspicion of hydrogen sulfide, such as sulfur sensitivity, burning type symptoms, that kind of stuff.
Dr. Eric:
I brought it up just because I kind of expected you to say that. I wanted others to hear it because I’ve had a few people bring up the test. Just because it sounds great. Now you have the new test that tests for three different types of SIBO. I have also mentioned where not everybody needs to do that test.
Dr. Nirala:
No.
Dr. Eric:
I wanted to hear it from the expert, someone who is dealing with SIBO on a day-to-day basis.
I got one more true/false question. I know the answer to this, but it’s another area of controversy. It doesn’t specifically have to do with SIBO, but it does have to do with the gut. True/false: Everyone should be treated for parasites.
Dr. Nirala:
No, that’s false. Two of the most common things are D fragilis and blastocystis, right? We see them not too infrequently on stool tests. It’s actually not, depending on what subtype you have, associated with an unhealthy microbiome. Certain subtypes can be a great benefit to have on board.
I have blastocystis. I don’t have any symptoms. This overfocus of the bug as the cause of all of your problems is a reductionistic and conventional approach. “Oh, it’s the bug that’s the cause of all of this issue.” It’s really not. It’s the terrain. I’m not saying that nobody has parasitic issues, but I think it’s been popularized by the online wellness industry to some extent.
I do a lot of testing. I don’t see parasites too often. When I see blastocystis, let’s see what else is there, really learning how to interpret not just the stool test, but a shotgun genomics test, which is really a true measure of the microbiome. That’s where it becomes much more interesting and takes a bit more finesse and understanding of the microbiome.
Dr. Eric:
I asked you this because I heard you say this on one of your courses about the parasites. I knew the answer was going to be no. There are some practitioners, some who I have interviewed for this podcast, and I don’t treat everybody for parasites either. I like to get different perspectives. Someone might hear a podcast episode where I interview someone who says, “Yes, everyone needs to be treated for parasites.”
Dr. Nirala:
That’s just a foreign concept to me. First of all, it’s interesting. There is a study that shows African immigrants came to America and started an American diet. I can’t remember now, it’s been a while since I read that study. What stood out to me was that when they started having digestive symptoms, and they went to the doctor and did the fecal multiplex PCR that looks for the parasites and the food poisoning bacteria, and they had parasites, they were given antibiotics, and everything went to hell in these people.
Some of the parasites are actually ancient organisms that have coevolved with us. The problem is that the terrain of the gut has been so mismanaged or is in such poor shape with such low microbial diversity for example and overproduction of different toxic metabolites that the environment that leads to the growth of some parasites. I’m certainly not trying to make the blanket statement for all parasites. It’s more the thought process that leads to why do we need to find the one bug that’s causing this, and all the problems are over? I just don’t subscribe to that idea.
Dr. Eric:
I agree. I appreciate you taking a few minutes to address the true or false questions. I know there is so much we could cover, but anything that we didn’t cover that you really wanted to bring up? Any last words that you wanted to mention before you tell everybody where they can find you?
Dr. Nirala:
Well, I think you did a pretty good job with the questions, especially if you have other episodes of your podcast that go into more symptoms and causes. I would invite people that have SIBO that are struggling with it to start focusing on finding the underlying cause. There is a free handout they can get from TheSIBODoctor.com about what caused my SIBO. It’s a very rudimentary questionnaire that you can complete and give to your practitioner. They can at least get some idea about what the problem is, because that’s really where true healing is. It’s not always about chasing bacteria. That being said, some people who have a damaged enteric nervous system or migrating motor complex may need repeated doses of antimicrobials. At least you know then what the problem is, and you can address it correctly.
Dr. Eric:
Definitely check out her website and her podcast. Amazing podcast. I have taken a few of her courses, including the histamine master class with Heidi Turner. That was a good class as well. Also, you’re in practice, too. TheBiomeClinic.com. You are still seeing SIBO patients.
Dr. Nirala:
Yes. I am planning on going on a sabbatical at the end of this year. That’s been a recent decision I’ve made. I have been in practice for a long time, and I need to take some time off to rejuvenate my enthusiasm for everything and also focus on other courses that I want to update. I am in the process of updating the SIBO mastery course for practitioners. I still have a lot of juice for the topic because I have four different businesses and things I have my fingers in. I need to downsize a little and not see patients. Patients, as you know, are often complicated and time-consuming. It’s wonderful. It’s very rewarding. I have decided to take a little bit of a break.
People can find me on TheSIBODoctor.com. That’s where a lot of the courses and free resources are. The Bi-Phasic Diet e-book now has a charge to it because it’s expanded, and I have put a lot of effort into it. That’s available. There are some other free resources you can find.
The SIBO Success Plan is a course for patients that I have put a lot of energy into, so people get a good education. I expand on a lot of things we talked about here today.
Dr. Eric:
Thank you so much, Nirala, for sharing your knowledge with regards to SIBO, the Bi-Phasic Diet, putting up with my true/false questions. I appreciate your time. As usual, I always learn a lot from chatting with people here. Definitely learned a lot from our conversation here.
Dr. Nirala:
Thanks for the invite, Eric.