143: SIBO 101 with Dr. Nirala Jacobi

Dr. Nirala Jacobi 0:05

The bacteria in the stool are very, very different from the small intestinal ones.

Dr. Stephanie Gray 0:13

Welcome to the Your Longevity Blueprint podcast. I'm your host, Dr. Stephanie Gray. My number one goal with the show is to help you discover your personalized plan to build your dream health and live a longer, happier, truly healthier life. You're about to hear from Dr. Nirala Jacobi who is the SIBO Doctor presently in Australia. I recently completed her practitioner certification program and have been listening to her podcast and I just had to have her on the show. So today she'll be sharing about the importance of a healthy diet microbiome and we'll dive into SIBO and SIBO let's get started.

Welcome to another episode of The Your Longevity Blueprint podcast today. My guest is Dr. Nirala Jacobi who is a naturopathic doctor an internationally recognized expert on small intestinal bacterial overgrowth, also known as SIBO. She's the creator of the SIBO biphasic diet, a resource that has helped 10s of 1000s of SIBO sufferers around the world. Dr. Jacobi is the host of the SIBO Doctor podcast and the founder of the SIBO doctor, an online educational platform that includes a practitioner certification program, which I recently completed. She's also the medical director of SIBO test 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 best year university in Seattle, USA, she brings more than two decades of clinical experience and her expertise to her clinic, the biome clinic. Welcome to the show. Dr. Jacobi.

Dr. Nirala Jacobi 1:46

thanks so much for having me.

Dr. Stephanie Gray 1:48

So you are the SIBO doctor. So we must discuss SIBO today, but I think we should start with the importance of gut health in general, my listeners now they've heard this several times from me before that in chapter one of my book, Your longevity blueprint, I'm comparing the foundation of the home to the gastrointestinal system and the body. So I'm sure you agree that our gut is our foundation of health. So today's show is going to focus on that improving gut health for whole body health. But I'd like for you to share more or less how or why. So specifically, how does that help improve overall body health?

Dr. Nirala Jacobi 2:17

Yes, and it's probably a good place to start there. As you mentioned, you know, we not just functional practitioners, but naturopathic doctors and practitioners around the world, we believe that the gut is really the root of the tree. And this is often sort of a metaphor, we use that the you know, the tree cannot be healthy unless the gut is or the root is healthy. So so that's really the foundation of naturopathic medicine, I really fell in love with the gut when I became a naturopathic doctor because it involves virtually every other system. And you know, the whole complicated symphony of events that takes place in terms of digestion, and immune system and your endocrine system, your nervous system and involves all the other systems just to turn non self into self, right, so food, we eat food, and miraculously, we extract all the raw ingredients to power our bodies. So not just that, but we also have this interface, where we have this connection to our immune system and how the immune system reacts to potential pathogens, and also our microbiome. So it's like you never get bored reading about the gut, it's just always an incredible source of amazement of how we actually processed foods and extract nutrients and also become more resilient to pathogens. But more specifically, the obvious is if you're not digesting, right, due to different reasons, SIBO being one, but if you're not digesting your food, right, you're not actually extracting those nutrients and ingredients that we know, are absolutely essential for health and longevity, then obviously, also the microbiome which is, you know, for all intents and purposes, another organ, it's actually considered an organ because it releases so many different metabolites and hormones and neural peptides and different substances that influence how we actually function in the world. So from mitigating, you know, inflammation to blood sugar control to all all these different aspects that we associate with health and longevity are influenced really by the microbiome.

Dr. Stephanie Gray 4:34

I know you do specialize with digestive disorders, SIBO being one of them, so let's kind of transition to that. So what is SIBO and kind of how does it relate to irritable bowel syndrome?

Dr. Nirala Jacobi 4:45

Okay, so irritable bowel syndrome is the umbrella term given to basically the syndrome of different digestive issues related to irritable bowel SIBO is considered by some to be about 60 to 80% of people that have been diagnosed with IBS is could be considered SIBO. And SIBO stands for Small Intestine bacterial overgrowth, and it's a condition where bacteria that are normally found in the colon, and for whatever reason, overgrown in the small intestine, and that's really a terrible place to have a bacterial overgrowth. Because as I just mentioned, it is the the very interface where we absorb nutrients where we activate our immune system where all these very crucially important functions occur. And so when you have a bacterial overgrowth there, you not only have digestive symptoms, but you can also end up with other systemic symptoms.

Dr. Stephanie Gray 5:41

And I know there are lots of causes, which again, I'm talking before the show, we could do a whole episode just on causes I've had, you know, took a 17, probably like 17, or 18 hour course of yours. So I know we can't dive into all the root causes, but can you just mention a few of the root causes?

Dr. Nirala Jacobi 5:56

Yeah, and you know, this is really my sweet spot when I talk to practitioners. And when I talk to patients, it's yes, SIBO. It's bacterial overgrowth, and you treat it by treating the bacterial overgrowth, but more importantly, you must address underlying causes to really cure it for good because it is a chronically relapsing condition. For some, what I've done is I've sort of categorized all the different groups of causes, because it's not just one cause, right? It's a lot of different things that can lead to bacterial overgrowth. So if you think about motility disorders, right, anything that impacts the normal motility of the small intestine, and you normally under normal circumstances have several different mechanisms to clear out the small intestine from potential bacterial overgrowth. It's just a natural, either cleansing wave or vagal tone or vagal influence that causes normal contractions. So lots of different ways that the body helps to clear this small intestine because it's so vitally important that bacteria don't overgrow. So these kinds of safeguards are in place that the body has. So if you have a condition that affects motility, such as hypothyroidism, or having had a case of food poisoning, before that damaged your what's called migrating motor complex, which is a really specific form of motility in the small intestine, or you have mold illness, that's, that's causing gut toxicity and slow motility, you know, so many different causes that cause slow motility. So and for each cause it's a different treatment. And then you have also another category of underlying cause, which is sort of called digestive deficit, which some of the first line anti microbial aspects are shields that the body has in place are deficient. So for example, hydrochloric acid, which is stomach acid, and it's sort of like the vat of acid that kills bacteria that are found in food or oral bacteria are also killed by that. And if you are chronically stressed, or you have a genetic condition that causes hypochlorhydria, on low stomach acid output, then that is compromising your ability to kill bacteria and other digestive juices as well, bile and pancreatic enzymes also function in that capacity. The other one is obstruction, what what I would call obstructive situation, which is not really an obstruction of your small bowel, but it's an anatomical deviation from normal because of scar tissue. So let's say you've had a hysterectomy or you've had your gallbladder taken out, or you had any number of abdominal surgeries or endometriosis. And it's it's a condition or a you know, when surgery happens, or endometriosis happens, it triggers adhesions and scar formation, and that can then attach on the outside of the small intestine and create what I call a kink in the garden hose. So things are not moving effectively through the small intestine and also leave bacteria in the small intestine. So these three different categories of causes encompass a huge number of different conditions. And that's why some people, you know, they're sort of in this merry go round of treatment and relapse and never really get to the bottom of what's causing their SIBO. And that's been really my mission with a lot of the trainings I do.

Dr. Stephanie Gray 9:22

What about medications? Can Medications also contribute?

Dr. Nirala Jacobi 9:25

Yes, so these are mostly substances that slow motility that's for the most part, opioids and certain painkillers and morphine and those kinds of things can really affect mortality. But that's more minor because it's a temporary situation for for many people, and that can be remedied by just replacing that medication with something that doesn't cause that

Dr. Stephanie Gray 9:47

and then differentiate different types of SIBO. And then we can kind of get into testing as well. But I know it's not just like you have SIBO there are different types of SIBO that can be treated a little differently. So can you kind of differentiate those

Dr. Nirala Jacobi 9:59

for us? Yeah. A lot of what we know right now is that there are three types of gases that are produced by different organisms. So you have your main hydrogen producers that are typically produced by a specific type of bacteria like E. coli and Klebsiella. And then you have methane gas that's produced by MF antigens, which is a different type of organism. And then you have hydrogen sulfide gas, which is produced by hydrogen sulfide produces like the cell for Vibrio and fuse Areum. So these types of gases, it's important to know what kind of SIBO you have because each type of gas requires a different type of treatment. Hydrogen sulfide and hydrogen are similar in treatment. But the archaea are myth antigens require a slightly different one. So typically, when we see hydrogen dominance on a breath test or a higher hydrogen than anything else, it usually means that the person has either diarrhea or a normal stool pattern. Typically, with methane we see almost always constipation. And then with hydrogen sulfide, which really I don't even often talk about. Well, I do talk about it. But because there's only one lab in America that tests for this, it's difficult because I wish there were other labs to really corroborate some of the, you know, the evidence of the efficacy of that type of testing, because we just don't have enough labs available to offer that test. So usually, I just talked about hydrogen and methane, because they're very easily accessible through testing. So then when you talk about different types of treatment, it's pretty easy. So it's either hydrogen or mixed hydrogen, methane, or it's methane dominant, what we now call Emo, or intestinal metallic and overgrowth, which typically causes constipation.

Dr. Stephanie Gray 11:50

Thank you for differentiating those symptoms, too. What about other clues? In general, I know you mentioned a lot of clues in your course, that could cue a practitioner into knowing you know that their patient has SIBO. So for listeners, what are some of those clues?

Dr. Nirala Jacobi 12:03

Yeah, so for example, if the person is eating a lot of getting a lot of symptoms with a high fermentable fiber diet, so what we call the FODMAP diet, if you are eating a lot of very healthy, wonderful vegetables, but you're getting very gassy, very bloated after meals, that may be a clue or if the practitioner actually prescribes a type of fiber, and the person reports more bloating immediately after taking it or prebiotic kind of bloating. So that's a big clue. Another one is if you have been prescribed antibiotics, or an unrelated condition, like sinusitis, but lo and behold, your IBS symptoms resolved or improved greatly. That's also a clue. So sometimes those are not necessarily diagnostic, but they're they're great little light bulbs for the practitioner to help them to consider testing for SIBO, which is just so easy these days.

Dr. Stephanie Gray 12:59

I like those I know you also mentioned, you know, symptoms that worsen with sugar alcohols, that was me and I was kind of how I ended up finding that I had cryptos intolerance and SIBO. And then you also I think, mentioned something like patients who are diagnosed with celiac who go gluten free, you know, who continue to have symptoms, that's a cue, there's still something else going on that hasn't been found and treated.

Dr. Nirala Jacobi 13:16

Yeah, that's probably the broadest of all of those clues, because you know, you could have other reasons you could have lipo lipo is large intestine bacterial overgrowth, and typically, the treatment is not necessarily very different. But I think the dietarily, we would probably treat that a little different.

Dr. Stephanie Gray 13:35

What are some other conditions that SIBO is associated with? I was really shocked to hear these in your course.

Dr. Nirala Jacobi 13:41

Yeah, so these are not conditions that have caused SIBO. But there are a number of conditions that are just highly associated with SIBO, meaning that they're often seen together. So if you have a, if you're a practitioner listening to this, and you have somebody, for example, with acne rosacea, that's actually one of the four that I would consider a test for SIBO regardless of the degree of digestive symptoms, because it's so highly associated with SIBO. Another one would be interstitial cystitis, or fibromyalgia. And now, as the years go on, we have hundreds of conditions that are associated with SIBO varying degrees. So you already

Dr. Stephanie Gray 14:20

mentioned some of the symptoms of different types of SIBO that can we expand on some of those just general symptoms that patients with SIBO may be experiencing? Yeah,

Dr. Nirala Jacobi 14:30

so it's pretty classic IBS symptoms, and I would say, top of the line would be bloating after meals and pretty pretty soon after meals, not just hours after meals, but like 1020 minutes after meals, you have bloating starts that will be probably the primary symptom and then we have a lot of bowel issues in terms of either too fast or too slow constipation or loose stools. Then we have also abdominal high Per sensitivity or abdominal pain, and sometimes that's gasp pain, sometimes that's just the hypersensitivity. We also have a lot of upper gut symptoms like reflux or gastritis. Those types of symptoms are really really common as well.

Dr. Stephanie Gray 15:17

What if someone can't tolerate sulfur rich vegetables and foods? What What could that tell us?

Dr. Nirala Jacobi 15:23

Well, that can be you know, that's a really complicated situation because it's it can be an overgrowth of sulfur, we call them confusingly, we call themselves a reducing bacteria, but that's a chemical term, but they're, they're sulfur, or hydrogen sulfide producing bacteria. Sometimes when they're overgrown, it can mean that the patient is sort of sensitive to sulfur containing vegetables and foods in general. But it is a more complicated issue, because sulfur is such an important aspect of everything from connective tissue integrity, to detoxification, to brain health. So it's very, very important mineral. We look at complicated pathways, when we're looking at things like Theil sensitivity and sulphide sensitivity in general, but just simplifying it for the gut symptoms would be to look at hydrogen sulfide producing bacterial overgrowth.

Dr. Stephanie Gray 16:18

Sure, okay, let's transition to testing options, you kind of already alluded to the breath test, but can you can you kind of break that down how we do the breath test why SIBO can only be tested in the breath, and then kind of what results we're looking for, for positive finding on that. Okay,

Dr. Nirala Jacobi 16:33

so the breath test is based on the fact that when you when you consume a test substrate, like lactulose, or glucose, or fructose, these substances are very readily fermented by gut bacteria. And what happens is you're taking the substrate, bacteria fermented produce hydrogen, or methane gas that's absorbed into your circulation that's carried to your lungs, and you're breathing it out. And that's a timed event. So it's a really easy to do at home test, where you basically do a prep diet for one or two days, depending on if you're constipated, it's recommended that you do the prep diet for two days, not just one day, and then you have an overnight fast and in the morning, you do the test. And it's basically you consume the sugar and every or test substrate and every 15 to 20 minutes, you're sampling your breath in a tube. And that then gets sent to the lab. And we can determine from this time demand, where in this three hour breath test your gases, if at all have risen, and that can give us the indication off methane SIBO or emo or regular SIBO, which is hydrogen dominant.

Dr. Stephanie Gray 17:54

Thank you. And then what about findings on a stool test? So let's say a practitioner orders a stool test, because this patient has IBS. So their first kind of look into the colon before they consider doing a SIBO test. What other kind of clues on a stool test might lead the practitioner to know that SIBO should be next explored? Yeah,

Dr. Nirala Jacobi 18:13

and it's really important to preface this by saying that a stool test cannot diagnose SIBO. It's not like you can do a stool test and E. coli is high and therefore say, oh, E. coli often also causes SIBO. Therefore, this person also has SIBO, it's just not possible to do that. The bacteria in the stool are very, very different from the small intestinal once. So there are a few, I'd say also sort of kind of red flags that would indicate, especially if the symptoms fit to consider a breath test. Next would be if your patient has very high levels of short chain fatty acids, which are microbial metabolites, in products of fermentation or fiber. So that could be could be that it's SIBO. But it could also be that your patient has large intestinal overgrowth, which would then be evident on that CDSA. So that would be my primary one. You know, I sometimes also see people that have higher levels of Secretory IgA, which would indicate a leaky gut scenario, and SIBO causes leaky gut. So that could be another potential, but that's not all as red flag II as maybe the short chain fatty acids.

Dr. Stephanie Gray 19:28

Sure, or that yeah, bacteria in general. What about the I can never pronounce this, but the methanol brevi vector?

Dr. Nirala Jacobi 19:34

Oh, yeah. From the doctor. Yeah. The thing about mufaddal brevi factor, which is the main species that produces methane, and they are real survivors, and they actually normal inhabitants of the gut microbiome. It's not that these pathogens really important to remember. When they are overgrown, they produce methane and they do that by actually concentrating Hydrogen gas for every methane molecule, it requires four hydrogen atoms, so it can concentrate it effectively. But that causes constipation. It's not uncommon to see methanogens in the stool. But if they're really overgrown, they can cause constipation in the large intestine. And they won't have necessarily been overgrown in the small intestine. In a way, it doesn't matter. Because wherever you find with antigens that can cause constipation. So the treatment would essentially be the same for that,

Dr. Stephanie Gray 20:34

well, let's move on to treatment options. And maybe we could start with diets. So can you kind of describe I know you've created the SIBO biphasic diet and kind of tell us a little bit about that, essentially, what foods should be restricted and avoided, which I think are kind of most important, and also discuss the elemental diet, as the first part of the treatment process, elemental diet, people

Dr. Nirala Jacobi 20:53

should just forget the word diet with, it's actually not a diet that you follow. It's an antimicrobial treatment, it's not something that you do, in addition to antimicrobial treatment. So anyways, but the the primary diet, and the reason I developed the biphasic diet is because it was very confusing for patients, you know, what to eat, what when they're going through treatment, and even people on a strict FODMAP diet, we're still symptomatic. So what I did is I devised this treatment, which is a three month treatment into two parts, which is phase one and phase two. And phase one really was aimed at the practitioner, seeing this patient for the first time, they can sit there suspecting SIBO, they're ordering a breath test, and then want to just start on the most symptom controlling diet, there there is, which is, in my opinion, phase one of the biphasic diet, which basically is no starches, no allergens, and basically just low FODMAP vegetables and protein. And then they would also do digestive support, because a lot of people do need that, whether that's enzymes or bitters or things like that, and then also just sort of a gut soothing powder, or just to reduce the inflammation a little bit. And what I found when I did that is people already when they came back, the second visit, and wanted to review the breath test result, they were already much better. And we had already two, three weeks of treatment. So then they were ready for anti microbials. Because when you have you know, when you start anti microbials too soon, and then inflamed system, you can actually kind of trigger some bad reaction. So I found that to be more effective. So people then move from phase one diet to a more generous diet that includes more grains and more fruit and more fermentable fibers on purpose, because we want to actually feed the bacteria a little bit while we kill them. So it's a tried and proven method to really help not just symptomatic control, but also, you know, the efficacy of treatment in general. Sure, yeah, I

Dr. Stephanie Gray 23:00

guess that's kind of what where I was going with kind of the first part of treatment is really getting the patient to change their diet, can you expand on you so you reference just in case our patients aren't familiar with what low FODMAP vegetables are, can you mention some of the low FODMAP vegetables that are allowed, and then what some of the high FODMAP more trigger vegetables are.

Dr. Nirala Jacobi 23:19

And you know, just from looking at them, you wouldn't be able to tell right? So they're all part of a wonderful plethora of vegetables. But high FODMAP start with high FODMAP. So high FODMAP or FODMAP stands for let's see if I can still do it, but fermentable, oligo, saccharide, disaccharide, mono, saccharides, and polyols. So these are all substances in these foods, not just vegetables, but foods in general, mostly plant based food that are very fermentable by bacteria, as the name implies. So top of the list of very high FODMAP food will be garlic and onions. Almost everyone will have some sort of bloating reaction to those two foods. But other high FODMAPs would be celery, for example, or green beans. And then in the low category, you have tomatoes and lettuce and kale and bok choy and put up those kinds of greens. So you have very innocent looking vegetable holes actually be the cause of a lot of problems. And so it's always nice to have to have a list of those really spelled out. You know, the whole FODMAP movement was instigated by Monash University here in Australia, where I am, and they have really revolutionized this whole idea of FODMAPs for IBS in general. But the problem with with staying on low FODMAP diets for a long time is that obviously, you are also compromising your normal microbiome that lives in your large intestine, and that's where most of the bacteria are meant to be. And if you stop, well, you're not going to stop feeding them with a low FODMAP diet but you're not optimized I think so I always say that even the biphasic Guide is a temporary solution for this problem.

Dr. Stephanie Gray 25:06

And then can you kind of compare this to the elemental, I don't want to say the word diet elemental Treatment Treatment?

Dr. Nirala Jacobi 25:15

Well, the elemental diet, it is called that. I mean, I was just saying, because so many people are confused, because they think it's also a diet that you do alongside other people treatment. But what we found is that the elemental diet, which is basically a formula, a pre digested formula that has free form amino acids, so not something like hemp, or whey, or pea protein, but free form amino acids that have been manipulated in the lab, so that they're free form very, very easily absorbable. And then it contains glucose, and it contains a certain type of oil. And it's this combination of extremely rapidly absorbing substances that provide nutrients for you the host, but it's so rapidly absorbed that no bacteria or very limited bacteria have access to it before it's absorbed. And the idea is, you're basically starving them to death. And it's actually, you know, gas wise and pre imposed testing wise, it's pretty effective with treatment of SIBO. And what's the duration of that typically, so typically, it's about two weeks. And sometimes practitioners extend that to three weeks, depending on somehow somebody's responding. So but it is a treatment where that is all you're consuming is this powder that you've mixed with water and you have, depending on your size and weight, you get a certain amount of servings per day that your practitioner will tell you. And that's all you consume about that in water. And you do that for two weeks. And this is why it's often the least favorite option for patients. But it is a very effective one. And something I use when other treatments have failed.

Dr. Stephanie Gray 26:52

I was just going to ask how difficult this is to convince patients to do I've had a handful of patients do it, but they were my patients who were just all in wanting to get better. So yeah, we're committed. I don't know what it sounds like you already answered that. In your experience, it is one of the more difficult treatment options. Well,

Dr. Nirala Jacobi 27:07

you know, I think yeah, and I don't know about you, but I see a lot of people that have failed treatment, I get them referred to me or they bind me in that way. And so I see usually people that have multiple food sensitivities and reactions, and in a very inflamed state, and have had a lot of treatments. And so sometimes the elemental diet is also a great supplement for people that have malabsorption, and just are very nutritionally depleted. So So I also use it in that scenario. Sure,

Dr. Stephanie Gray 27:39

let's move on to anti microbials. So as a part of treatment, right, and then I want to get into the different drugs that are available as well. But kind of share with our audience some of your favorite anti microbials. And maybe we could even break down here. I know this was a big take home for me from your course was you helped to differentiate Best Anti microbials for different types of SIBO. Like, like, take home for me, at least what I learned from your course with hydrogen SIBO was to use Berberine. Right, and more or less with methane more the Alisyn or garlic, oregano. So could you again, kind of just mentioned your favorite anti microbials. And then kind of break that down expand on what I just said for different types of SIBO.

Dr. Nirala Jacobi 28:17

Yeah, sure. I mean, you said it just now. But yeah, so I mean, this is tried and proven. But yeah, so provided in terms of anti microbials has a lot of different formula combination formulas available. I'm always really hesitant to name exactly what I'm doing. Because as you know, there's so many people that self treat and I'm always I see them people that have done months and months of antimicrobials, and they didn't have SIBO or, you know, so I'm always a bit hesitant to do the exact dose or tell you exactly what to do without the context of what you need to know. But generally speaking, yes. Berberine is a wonderful herb that we use very often for hydrogen dominant. SIBO is confusing, but Allison, which is an extract of garlic, which I've just told you garlic is a high FODMAP food. But this medicine is actually doesn't contain the fruit tans that are the problem in Whole Foods, garlic. So this is actually medicinal ingredient extracted from garlic, and that's very effective for methane. And so it's oregano oil. Again, be careful with these things because oregano oil, if you do this for months, you will also damage your microbiome. Yeah, healthy microbiome. So those would be my three top favorites. Yes.

Dr. Stephanie Gray 29:33

And what about for hydrogen sulfide?

Dr. Nirala Jacobi 29:35

If someone was tested and found to be positive there, what are your favorites for that? Oregano oil is also very helpful for that and sometimes use something called the Smith as a binder for for hydrogen sulfide, and then also putting a patient on the biphasic diet but no animal products in addition to no FODMAPs so this is because you want to not provide any cysteine and sulfur containing amino acids to the sulfur, hydrogen sulfide producing bacteria. Good to take on.

Dr. Stephanie Gray 30:09

Okay, let's move on to medications. So what antibiotics I don't know how many you actually use in your practice? And I can kind of elaborate here too. But what medications do you use for hydrogen and methane or combined SIBO?

Dr. Nirala Jacobi 30:22

Well, what we usually recommend is if the person doesn't want to do herbs, or if they're if they are sensitive, or they failed herbs, then using typically for hydrogen, it would be Rifaximin or brand names lie facts, and that's a pretty good antibiotic that's also tried and proven has minimal damaging effect on the normal microbiome. But it's very expensive, right? It's very, very expensive. It is super effective for hydrogen, again, you need to understand what caused your SIBO so that you address that alongside treatment, otherwise, you're you are potentially going to relapse. So this is always something I tell my patients as

Dr. Stephanie Gray 31:03

well, yeah. Because with SIBO I just feel like for many patients, and again, this is what you specialize in. I see refractory SIBO all the time, and just keeps coming back at patients come to me after having had refractory SIBO. And so I think yes, getting root cause is just so important. Because you can't take antibiotics the rest of your life. That's not the that's not sustained. Not a good

Dr. Nirala Jacobi 31:22

management strategy. No, it isn't. And then for myth antigens, the recommendation is Rifaximin, and Neomycin. But some practitioners do Neomycin sorry, Rifaximin, and met from that as all or Flagyl, which is more broad spectrum, so more damage to the large intestine. But some people you know, it always depends on how severe the case is. So that's also done. And you know, that would be the primary types of antibiotics. That would be the treatment. And then for you know, pro kinetics is not any such something that everybody needs. As I've mentioned, you've got all sorts of reasons why somebody has developed SIBO. And there's this idea that you just put everyone on pro kinetics, which are medicines that aim to normalize the motility of the small intestine, but yeah, so you have different versions of or different prescriptions that are that are used something like Coachella pride, or Reza lor, brand name, the Reza Lor is very good. Or you can have naturals like you know, ranging from herbs like ginger and artichokes to leaders to Barrow gas. So they start lots of different things that we that we consider. But case by case basis,

Dr. Stephanie Gray 32:40

I want to go back to the various treatment options just for the listener so they can kind of hear also the duration. So you kind of already mentioned that elemental diet is only a few weeks. So although it may be difficult, it sounds like it's you know, a short treatment. Antibiotics are usually you know, 10 to 14 days, and then the herbal anti microbials usually take a lot longer. So four to six. I've even treated patients for eight weeks. Would you agree with that?

Dr. Nirala Jacobi 33:03

Yeah, absolutely. And especially with methane, it's not uncommon to do it for three months or more, you know, but typically with hydrogen, six to eight weeks is a good, good amount of time before you retest, if you're retesting, and I always recommend to retest because it's important to understand if it's totally gone, or, you know, a lot of people still have symptoms remaining. But then you test them, and it's SIBO is actually gone. So that gives you the indication that you've got to look at targeting factors. Yeah,

Dr. Stephanie Gray 33:32

exactly. So it just mentioned some antibiotics. But I want to go back to probiotics, as we've kind of mentioned at the beginning of the episode not tolerating probiotics can be a clue that someone could have SIBO. But yet probiotics are still important. So which probiotics do you use with SIBO?

Dr. Nirala Jacobi 33:48

Probiotics are not often a problem for people with SIBO. That wouldn't be sometimes they are but not not always.

Dr. Stephanie Gray 33:56

Definitely. I've seen it. And I myself, haven't tolerated them in the past. Oh, it's

Dr. Nirala Jacobi 34:01

still for some people. Yeah, for some people, but some people have, like I have tons of patients who can't tolerate probiotics, but don't have SIBO, for example. Yeah, you know, so it's a bit more complicated than that. But prebiotics, which are basically, you know, you can buy them, they're usually sometimes in formulas with probiotics, they're basically the food for the probiotics or the bacteria. So what we now know is that they're really specific strains that have different effects that well, let me just actually preface this whole thing by saying that when you take probiotics, you are not replacing or receding your gut. You know, that's this, this old idea that we need to change in our thinking is that probiotics, you can just replenish the good bacteria you've lost when you've taken antibiotics by just taking a probiotic It doesn't work that way because turns out that that You know, the primary species lactobacillus and Bifidobacterium, that are in probiotics are just a fraction of your normal microbiome. But what they are, are basically metabolic response modifiers. And they somehow in have this growth effect on other key species of your microbiome. And they can affect things like reduce inflammation, or, you know, affect motility, like different bacteria have lactose H N Oh, one nine, I'm always into research strains so that we know that this is actually something that has been shown in research to be effective, rather than just a combination of random strains. So I thought that like the Sillas, Plantarum, 299 v has lots of different research on mitigating inflammation, and I mean, lots and lots of different things that, that probiotics can induce, besides this other sort of fertilizing or growth effect that it has on other key species in the microbiome, but they're transient, you know, they, the effect is only as long as you're taking them.

Dr. Stephanie Gray 36:12

Most companies these days, at least, to my understanding, and I tell patients this, because sometimes they you know, they freak out if they miss a dose of their probiotic, and I say that's okay. But the organisms are only going to last in your system a couple of weeks, and then they're gone. So if you want those effects, you do need to continue to take them

Dr. Nirala Jacobi 36:27

and I usually recommend, you know, also rotating your probiotics. That's like, with most things, I like to rotate substances and, and probiotics. And, you know, I'm not somebody who just put somebody on something for a year and that's it. Sometimes that is required, but most of the time I do rotate, rotate things based on need.

Dr. Stephanie Gray 36:50

agreed on this brought up another question. immunoglobulins I know they really helped me when I had SIBO. Do you use many of the serum derived immunoglobulins? With your SIBO? Patients?

Dr. Nirala Jacobi 37:01

Yeah. Well, yeah, I do. bovine serum immunoglobulins. This is a great level immune booster, but I also do the IG 26, which are the egg based ambulance. Okay.

Dr. Stephanie Gray 37:16

I want to briefly I feel like we have to mention seafile, because we've spent so much time on SIBO, that many patients who have SIBO also could have seafoam. And there's a lot of a lot of overlap with symptoms there. But can you expand kind of on what that is, and what maybe, you know, differentiates that. And then we can talk just briefly about some treatment options for that, too.

Dr. Nirala Jacobi 37:38

Yeah, and I would say C fo is probably way more common. There was one study from Dr. Rao a few years ago that showed that about 25% of patients that he tested, and this was through duodenal aspirates, that he found that they had SIBO alongside SIBO. That was about 25% of people that were comorbid with those two conditions. But I think it's it's really, really common, because when you think about it, Candida is a really normal organism. So what we're talking about C fo stands for small intestine, fungal overgrowth, and fungus is just really, really common when we think about how much we're exposed to antibiotics. And, you know, fungal overgrowth is a natural consequence to overuse of antibiotics, whether that's through oral prescription or just eating a lot of meat that has hormone that has not just hormones, but antibiotics because antibiotics are used in fattening up livestock. So this is something we also consume. And it really has this massive effect on our microbiome that keeps normal fungal colonies in check. And so either that or the immune system is down and fungus can proliferate. And it's mostly Candida species in the in the gut. And they're, you know, they love a warm, moist environment, whether that's behind your refrigerator or in your God, it just is fungus loves us, you know. So it's one of those fungal species that can survive very, very well in our gut. And especially if we feed it, a lot of sugar, a lot of simple carbohydrates, a lot of processed foods. Fungus loves that. And so you can imagine that a lot of people probably even, you know, they might test negative for SIBO, but they have all the classic SIBO symptoms, you might want to consider that they actually have a case of C fault. So that would then mean that you're you don't have to be as correct with your fermentable carbohydrate restriction. But you do want to restrict sugars and alcohol and simple carbohydrates and those kinds of things whilst you treat with antifungals.

Dr. Stephanie Gray 39:43

Yes, and I remember you saying I believe patients who have SIBO can have similar symptoms of SIBO. Right, but they may also have brain fog. They may have this history of rashes or obvious yeast infections, or you know that it may be that patient that can't tolerate the sugar. Those could be I keep coming Back to the word clues or keys into this show. Wow. Yeah, that might be Yeah, that SIBO could be a problem for that patient. Yeah,

Dr. Nirala Jacobi 40:07

I often see people that say, you know, I had, I had, let's say, sinusitis or something, I got all these antibiotics for it. And my guts never been the same since right, that will be a big clue for me. Yeah. And I see a lot

Dr. Stephanie Gray 40:18

of that. And then you already kind of alluded to the treatment options being well, probably natural antifungals, do you typically use botanicals? Or sometimes do you use antifungal medications for these patients?

Dr. Nirala Jacobi 40:30

I do, I do all of that I do different types of antifungals. If they can get a prescription for a nice statin, I stopped and have a great little antifungal that's works really well is very safe, it's not absorbed, that doesn't cause any liver problems. And it can be used long term, I prefer that because it has very minimal impact on the microbiome, for example, then lots of different herbs can have antifungal activity or your things like caprylic acid, you know, Anessa, no ik, acid monolaurin, all of those different things can help. But it's really about reestablishing normal controls in the gut, which means a microbiome restoration type approach.

Dr. Stephanie Gray 41:14

So I'm glad we went overseas. So I want to as we wrap up the show ask you a couple extra questions moving away from SIBO. I know in the opening of the show, you mentioned how important the microbiome is just to inflammation and you know, longevity, I should say reducing inflammation and to longevity. But can you kind of mention that gut brain connection. And so how important gut is gut health is in relationship to mental health just quickly?

Dr. Nirala Jacobi 41:36

Yes, so the gut brain axis has been, you know, I mean, that's another whole long topic. But it is basically how the central nervous system is connected to the digestive tract. Because the digestive tract actually has a nervous system all on its own. That is sort of independent of the central nervous system called the enteric nervous system. But the central nervous system gets constant messages from the gods in terms of microbial metabolites, the microbiome also produces. neurotransmitters, for example, and neuro peptides in the microbiome secrete cytokines to stimulate different inflammatory conditions. So it constantly updates the central nervous system on the state of the digestive tract, and whether or not it should respond to a certain thing, a certain situation, this subject of intense research in an ongoing research, because it turns out that it has a much more central role than previously believed that these microbes really have a very important function for our health and well being that is beyond just digestive health.

Dr. Stephanie Gray 42:47

We mentioned at the beginning of the show that one of the root causes of SIBO could come down to stress. And I know a lot of my listeners, a lot of us are dealing with with stress. So I'd love for you to mention some of your kind of vagal tone exercises, just kind of to help with stress management, could you share some of those with us?

Dr. Nirala Jacobi 43:04

So vagal tone exercises are just one aspect. All right, right, mitigating stress, right. So that is not the one size fits all, for somebody who, you know, I see a lot of people that have had very traumatic events occur to them that have an, you know, a very dysfunctional limbic system response that are stuck in fight or flight and their fear center is just chronically activated, and you cannot do vagal tone exercises alone with them, you know, they're gonna need a little bit more work on and maybe do trauma work. And there's like a whole subset of treatments that are based on either adverse childhood events or ongoing trauma, and that would be like somatic experiencing, or, you know, the EMDR. Those types of therapies are really specific for people with trauma. And oftentimes I refer for that if somebody has had, for example, let's say traumatic brain injury than an accident, then yes, maybe vagal toning is really appropriate for them. And that could be anything from you know, there's whole books and exercises based on eye movement and breathing and toning like that, or different apparatuses. Some people respond really well to get into a parasympathetic nervous system response or rest and digest with hypnotherapy, or tapping or anything like that, that just down regulates the nervous system and helps to reset but if you look at the, you know, the whole polyvagal theory makes a whole nother topic because it's not as simple as vagal toning, you know, and I always tell people about that because something people are frustrated with the gargling and the humming and the this and that, and they're not really having any kind of impact on their digestive health. So it just means that this is a much bigger topic. Don't be discouraged if you've done that and you haven't gotten anywhere. It just means you have to look maybe at different types of modalities that might be more appropriate. for you,

Speaker 3 45:00

and then what role do toxins play in gut health?

Dr. Nirala Jacobi 45:04

This is obviously something that is also a much bigger topic. But basically, we are consuming if you're not eating a very clean and healthy diet and not making an emphasis on organic foods, then it's you know, chances are you are consuming a degree of pesticides and fertilizers and other substances that directly impact your microbiome. And glyphosate would probably be on the top of my list for that, which is the active ingredient of Roundup. So that's, that's one aspect is just getting it in through the food. And then also different types of plasticizers, and solvents and those kinds of toxins that make their way, potentially in our food into our food chain, but also, you know, consuming it through water bottles, and like plastic water bottles, plastic wrap, Styrofoam, that kind of stuff. And those kinds of what we call Xeno. estrogens are chemicals that can act like estrogen and other types of endocrine disruptors can actually affect your microbiome as well. So, you know, those kinds of when you look at anything, everything that impacts the microbiome, it's really no wonder that a lot of us are walking around with a severely compromised microbiome. So it's beyond just SIBO. But it's, you know, this way I always emphasize once you've treated SIBO, once you've treated your underlying cause, the work begins on restoring your microbiome as much as possible.

Dr. Stephanie Gray 46:36

I've totally agreed, I know I was trying to cram a lot into the show. So some of these questions, it's just hard to answer in, you know, two minutes. But I do tell my patients, you know, three major things can impact their gut health, obviously, the foods they're eating, having gut infections, and then toxins as well. So, yeah, we crammed a lot in here. For those who are listening, I do highly recommend that, especially if they're practitioners that they take your SIBO practitioner course, I know, one of our other nurse practitioners here already signed up for it. And it just dives into so much more like all of the elements that on the show where we're you're saying this is a larger topic, right? You dive into that into genomics and libo and SIBO. And I think if I remember right, mast cell activation issues and parasites and whatnot, not just SIBO. So it was just, it was a great course. So maybe your listeners where they can find you and even that course,

Dr. Nirala Jacobi 47:24

yes, so my main website is that SIBO doctor.com. And I have a patient course for SIBO patient course, that's a self guided course where I recommend different products and different treatments and different therapies. And it's a really, I put a lot of effort, same as with a mastery course, and you learn a lot about everything from leaky gut to food sensitivities, to all these different peripheral issues that we see with SIBO. And I have a lot of other practitioner courses on there. And as you mentioned, the SIBO Mastery Course, which is a really popular practitioner course, and then you get listed in the SIBO, treating practitioner database. So there's lots of different courses, as well as pediatrics and liver and gallbladder and lots of different courses that really help the practitioner understand these functional digestive issues a bit more.

Dr. Stephanie Gray 48:16

Yes, I want to take that one too. So the student dr.com for the listeners on social media, are you on social media?

Dr. Nirala Jacobi 48:23

Yes, I have. Basically, yeah, Instagram is it's a long one. Maybe put it in the show notes. But it's Dr. Dot Nirala dot Jacoby underscore the SIBO. Doctor, and then also the SIBO doctor on Facebook.

Dr. Stephanie Gray 48:38

And you have a podcast, I almost forgot to

Dr. Nirala Jacobi 48:41

podcast. Yes, thank you. Yes, I have a podcast called the SIBO. Doctor podcast, and we are in our sixth year of recording. So it's been a long standing great tool to, to, for me to also interview people that have really inspired me and I'm super fascinated with so it's been wonderful to have as a resource as well for practitioners.

Dr. Stephanie Gray 49:02

Yeah, I agree. It's a great resource. All right. So last question, what's your absolute top longevity tip, if you had to pick one, I would say

Dr. Nirala Jacobi 49:09

understand the nervous system in terms of what helps you regulate your own nervous system. So and I can only give myself as an example, I was always a type A sort of personality. And at some point, I had an epiphany that I'm just not meant for the city and I moved, moved to the country and that was a game changer and my whole nervous system was able to relax and it's that it's a simple one for for some people, but you know, some people have a lot of work to do with trauma or they have a lot of other aspects of mental health issues that really affect their digestion. And I think if you can really dive into that and come to a place of serenity and peace that's has such far reaching effects not just on digestive health, but on every aspect of your health.

Unknown Speaker 50:01

What a great way

Dr. Stephanie Gray 50:02

to conclude the show kind of back to how we open, open the show. This was great. Thank you so much for coming on today and really raising awareness of SIBO and helping providers like myself, Miss SIBO and their patients I've learned so much from you. So it was an honor having you on the show today. Thanks so much. My pleasure,

Dr. Nirala Jacobi 50:17

take care.

Dr. Stephanie Gray 50:23

SIBO is common and it isn't something that I want to miss in my patients. If you're struggling with some of the symptoms Dr. Jacoby mentioned today I encourage that you get a breath test and find a practitioner who can help you with appropriate treatment. And lastly, be sure to check out her SIBO Doctor podcast and website. Be sure to check out my book your longevity blueprint. And if you aren't much of a reader, you're in luck. You can now take my course online where I walk you through each chapter in the book. Plus for a limited time the course is 50% off, check this offer out at your longevity blueprint.com and click the core stab. One of the biggest things you can do to support the show and help us reach more listeners is to subscribe to the show. Leave us a rating and review on Apple podcasts or wherever you listen. I do read all the reviews and would truly love to hear your suggestions for show topics guests and for how you're applying what you've learned on the show to create your own longevity blueprint. This podcast is produced by Team podcast thank you so much for listening and remember, wellness is waiting

the information provided in this podcast is educational no information provided should be considered to be or used as a substitute for medical advice, diagnosis or treatment. Always consult with your personal medical authority.