SIBO diet

The Bi-Phasic SIBO Diet with Dr. Nirala Jacobi

In this episode of The Functional Medicine Radio Show, Dr. Carri’s special guest Dr. Nirala Jacobi explains the bi-phasic SIBO diet and its relevance to difficult cases of SIBO.

Dr. Nirala Jacobi is a naturopathic doctor and is considered one of Australia’s leading experts in the treatment of small intestine bacterial overgrowth (SIBO), a common cause of IBS. She lectures nationally and internationally about the assessment and treatment of SIBO and is the host of the popular podcast The SIBO Doctor podcast for practitioners. She is the medical director and senior naturopathic physician at The Biome Clinic, center for functional digestive disorders in New South Wales.

Main Questions Asked about the bi-phasic SIBO diet:

  • What is the bi-phasic SIBO diet?
  • What makes you suspicious that a patient might be in the group with histamine issues?
  • How is the histamine bi-phasic SIBO diet different from the original bi-phasic diet?
  • What about hydrogen sulfide SIBO?
  • What are some of the things you can do to restore the microbiome?

Key Points made by Dr. Nirala Jacobi about the bi-phasic SIBO diet:

  • I put the bi-phasic SIBO diet together for practitioners to really organize their treatment approach for their SIBO cases. So, it’s a diet that’s based on the low fermentable carbohydrate diet know as FODMAP diet. I wanted to offer something to patients and practitioners that made it a bit more streamlined.
  • We get very good feedback with it. Of course, there’s always exceptions and difficult cases as you mentioned, where we may have to make further adjustments to it. But out of that really came also my experience that I mean, the kind of patients that I see now, is not your simple SIBO case anymore.
  • I see pretty advanced and difficult, and failed cases. And so I saw more and more histamine intolerance, which can actually occur with long standing SIBO and for lots of other reasons as well. And so, we I formulated the histamine bi-phasic SIBO diet.
  • Some people just associate histamine with allergies, and you just take an anti-histamine for that. But you actually have about five different receptors for histamine in your body, in every imaginable compartment. In your brain, and in your digestive tract. And in your immune system. So, you have lots of different areas where histamine is actually really important. And serves a special function.
  • When we start to see histamine be a problem, we don’t just see allergies. We see also headaches, we can see gas and bloating. We can see constipation or diarrhea. We see abdominal cramping. We see menstrual cramping. We see insomnia, so you can see how this can be quite confusing.
  • The difference between the original and the histamine SIBO diets is that we the original one has phase one and phase two still within the context of FODMAPs. Or these fermentable carbohydrates. And it’s phase one is basically very restrictive. And then phase two is a bit more generous. The histamine one really focuses on foods that are high in histamine. So, and as well as fermentable carbohydrates. So, it combines the histamine foods as well as the histamine what are known as histamine liberating foods.
  • So, phase one of the histamine bi-phasic SIBO diet eliminates both histamine and histamine liberators. As well as FODMAPs. And then phase two, you’re adding in histamine liberators again. And then when you’re done with that, and you’ve identified, or calmed that whole histamine response, you can transition onto the phase two of the regular bi-phasic SIBO diet.
  • Now, it’s important to mention that you cannot eradicate SIBO with diet alone, we know that. You can manage symptoms with the diet, but you can’t eradicate them. The eradication really comes with antimicrobials. And that’s done usually in phase two.
  • And these SIBO diets are really not meant for longterm treatment, because we know that longterm reduction in fermentable fibers is really starving your micro biome.
  • I think as human beings, our ideal diet is likely to be an 80% plant based diet. And within that 80% plant based, to have a lot of variety there. Not just the same eight to ten vegetables.
  • I actually think the goal of the practitioner is not just to identify SIBO. What I usually tell practitioners is to find the cause of SIBO. What actually happened here. Because we have normal defenses that protect us from bacterial overgrowth. Otherwise all of us would have SIBO, all the time.
  • It’s really up to the practitioner to identify if this patient has SIBO due to some motility defect. The other area of SIBO causes, or underlying causes, is poor digestion. And then lastly, the last category is impaired outflow. Because SIBO is a natural consequence of these underlying causes. And it’s really important to find the cause.
  • Hydrogen as we know is one of the gases that we typically test for in a breath test. And so, we typically use methane and hydrogen to check for SIBO. Methane being more of a constipation relation to SIBO. And hydrogen can be either constipation or diarrhea. So, on the breath test, we can’t really test for hydrogen sulfide yet.
  • So, we have these two opposing ends of the spectrum. And I think what we’ll find is that it needs a different approach. These sulfur reducing bacteria are very resistant to antibiotic use typically. And that we also probably need a different dietary approach to hydrogen sulfide than to other types of SIBO.
  • I tend to adjust the bi-phasic SIBO diet to add more things like soy protein, like soy like tofu to tempeh if they can tolerate it. Of course GMO free, because there is some evidence that soy isolates are also helpful with this. And that a low FODMAP diet might actually be the wrong diet for hydrogen sulfide.
  • Typically when we treat hydrogen sulfide, we have a period, not long, maybe six weeks or so, where we reduce sulfur containing foods, which includes things like red meat.
  • There’s a paucity of herbs that have been shown to be effective for hydrogen sulfide. So, what we do is bismuth in high doses, so bismuth is a binder of hydrogen sulfide. And we use oil of oregano.
  • And what I usually do is in that case is what works really well is just reducing sulfur containing foods for a while. And microbiome restoration which I do with every patient. I really have an intense look at their microbiome. And see what I can do to basically till and fertilize their garden.
  • I’m a big fan of prebiotics once SIBO is cleared. And prebiotics are basically food for beneficial bacteria. But really, what we’ve been teaching patients that to take a probiotic to reseed their digestive tract is really not right. It’s archaic and we shouldn’t talk about it like that anymore. Because probiotics do not replace your own native species.
  • But it does have a regulatory effect on the rest of your garden. And I always tell people it’s either a rainforest, or a garden, whatever analogy you like. But you have to treat it like that. Which means you have to feed and give it nutrients. And that’s usually done with prebiotics. And poly phenolic foods, that means that it’s vegetables and plants that are extremely colorful, they just love that.
  • Again, this is within the context of microbiome restoration which usually comes after SIBO treatment.

Resources Mentioned about the bi-phasic SIBO diet:

Original bi-phasic SIBO diet

Histamine bi-phasic SIBO diet

“What caused my SIBO” handout

Dr. Jacobi’s website

The SIBO Doctor

Nirala’s Instagram tag

Book – Reclaim Your Energy and Feel Normal Again

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