In this episode of the Functional Medicine Research podcast, I interview Dr. Nirala Jacobi in a discussion about the Bi-Phasic SIBO Diet. I have successfully used the Bi-Phasic SIBO Diet with many of my patients so I was excited to cover this topic with Dr. Jacobi. We discussed the specifics of the diet including the various phases, oxalates, salicylates, FODMAPs, vegetarian options, candida, histamine, fermented foods, MCAS (Mast Cell Activation Syndrome), SIFO (Small Intestinal Fungal Overgrowth), DAO, hydrogen sulfide, hypnotherapy, DNRS and much more. If you have SIBO or are a practitioner working with SIBO patients, this is one interview you don't want to miss.
Dr. Hedberg: Well, welcome everyone to Functional Medicine Research. I'm Dr. Hedberg. And I'm really excited today to have Dr. Nirala Jacobi on the show. Dr. Jacobi is a board-certified naturopathic physician. She graduated from Bastyr in 1998 and practiced primary care in Montana for seven years before arriving in Australia. She's one of Australia's leading experts in the treatment of SIBO, which we're gonna be talking about today. And she's also the medical director for SIBOtest. And that's an online testing service for practitioners. She's very passionate about educating practitioners so much so that she founded The SIBO Doctor. This is an online professional education platform for functional digestive disorders. She lectures nationally and internationally about the assessment and treatment of SIBO. And she's the host of the popular podcast which I listened to, it's called The SIBO Doctor podcast. And she's the medical director and senior naturopathic physician at The Biome Clinic. It's center for functional digestive disorders in New South Wales. She's one of the co-founders of the Australian Naturopathic Summit. This is a biennial event that aims to promote and showcase the art and science of naturopathic medicine in Australia. She's also a member of the Gastroenterology Association of Naturopathic Physicians and the Natural Path and Herbalist Association of Australia. So, Dr. Jacobi, thanks for coming on.
Dr. Jacobi: Thanks for having me.
Dr. Hedberg: Great. So, we're gonna be focusing a lot today on treatment and approaches to SIBO and let's go ahead and begin with your bi-phasic SIBO diet. This is something that I've used in practice for years now and it's very, very effective. So why don't you walk us through the bi-phasic diet and why you created this for people at SIBO?
Dr. Jacobi: Well, first of all, thanks for that introduction and to let me know that it's working so well for you because it's always wonderful for me to hear from successful practitioners like yourself that it is indeed a really useful tool that I've created. So, that's really good for me to hear. So, the bi-phasic diet came about, because ultimately, I needed a little bit more... As a practitioner, I wanted to give more structure to a dietary approach rather than just this sort of spectrum of foods, some of which you should avoid and some of which you shouldn't avoid, which is of course, the FODMAP diet. And also what I found is that many people that were on FODMAPs, the Monash FODMAP diet, still had symptoms of SIBO. So, what I wanted to do was structure it and I used the SIBO-specific food guide, which is from Dr. Allison C. Becker, which is based on the FODMAP diet as well as the SIBO-specific... Sorry, the SCD, the Specific Carbohydrate Diet. And so what I wanted to do is take all of that information and put it in a format that allows practitioners to structure their treatment approach.
And so basically, phase one is about six weeks long. It depends on the practitioner, how long they want to extend that diet, but typically four to six weeks. And really, it's about reducing pretty much any fermentable food which includes grains and potatoes and all of the vegetables that we know that are fermentable. And the idea was, we do this before we actually start antimicrobials. So, the aim was to reduce bacterial fermentation so that when we do introduce the antimicrobials, they won't be such a tremendous die off. And then phase two is a little bit more generous where we start to see the reintroduction of certain grains and potatoes and so forth. So, really, it helped me not just structure the diet, but also the treatment in terms of what supplement I wanted to use during which phase so that people weren't leaving with 20 different products per visit. So that really was the inception for me of the bi-phasic diet, and what's come out of that is also now the newly added vegetarian version. And what we wanted to do, I co-authored that with Anne Criner who's a naturopath here as well as a nutritionist and we wanted to not just take the meat out of the bi-phasic diet, we really wanted to offer a lot more to our vegetarians and vegans. So, that's also a good adjunct to the regular bi-phasic diet if people don't want to eat that much meat. And then thirdly, we have the last part of the collection of the bi-phasic diet which is the histamines SIBO bi-phasic diet because I found a lot of people were very histamine intolerance, so that's sort of has now evolved into these three different types of diets.
Dr. Hedberg: Excellent. So, that first four to six weeks, we're removing many foods that are pro-inflammatory that can ferment very easily by the bacteria. And that's going to reduce a lot of their symptoms and inflammation. Is there anything you want to add there as far as why you are removing those foods in that initial period?
Dr. Jacobi: Yeah. And as many practitioners know, when you first see a patient where you don't know if it's SIBO, you don't know if it's LIBO or Large Intestine Bacterial Overgrowth, or SIFO, which is Small Intestinal Fungal Overgrowth, or any of the myriad of other functional issues that we face when we see a patient that ultimately has some form of IBS or dysfunction that's a functional in origin. So, what I did was the first part of the diet, phase one actually has two sub-categories where the first part is the restrictive part and the second part is the semi-restrictive. So, patients sort of self-died themselves through phase one and increase their fermentable foods or slightly more fermentable foods when their symptoms have really improved. And what I found with this approach is really, most people will already have a tremendous improvement in their symptoms not just because of anti-inflammation and less bacterial fermentation, but it's also sort of like a hypo-allergenic part of the diet where we remove dairy, we remove gluten, and many of the things that people are reactive to. So, I find that it's just a wonderful way to calm the gut before we then add in much more sort of caustic agents in some cases like oregano oil or essential oils to kill bacteria and fungi, or in other cases, antibiotics.
So, for me, that really showed me that improving the gut before you even get to the antimicrobial part was really effective in terms of patient outcomes. So, that, I just... You know, because it's such an accessible resource, we've now had it used by thousands and thousands of practitioners worldwide and we get just great feedback from it. And sometimes, you know, and there's always some cases that have either been on super-restrictive diets for a long time already. You and I know those kinds of patients that only eat, like, five foods because they react to everything. And that may not be then appropriate to start them there. So, it's really a basis for individualizing each patient but, it's a good starting point for many practitioners and their patients.
Dr. Hedberg: Yeah. And I've run into a few issues regarding the restricted versus the semi-restricted and that's mainly related to energy especially in women. I've noticed that a lot of my female patients, if we do the full-restricted, their energy just drops too low so we have to add in some rice and possibly some kenoa to try and get their carbs up, their energy up. Have you found that as well?
Dr. Jacobi: So, what I've seen is anything from improved energy for those people that are... You know, there's always some metabolic individualization that we have to consider where if people really are energy depleted and have a low basal metabolic sort of rate as well as just a underweight and things like that, they are going to respond differently than somebody who does not have those sort of roadblocks in metabolism. So, I think that that's one of the reasons I really individualized it and said to practitioners, "Look, you might need to start with rice. That's totally fine." That's up to the practitioner to decide on a case by case basis. But for the most part, I find if I just have somebody, a patient that has never really... Maybe they've reduced gluten or dairy just because they have continued gut symptoms and they're just fresh, you know, they haven't read anything about SIBO, they haven't been diagnosed. I don't really get those patients anymore because I see very complex patients now. But every now and then I get somebody who doesn't know about SIBO and starts the diet and I am re-acquainted with the fact that, "Wow. It is really effective for those that have never really done any other dietary restrictions."
Dr. Hedberg: Right, right. And so after that first phase, and then they go into the second phase, we're just adding some more variety. And I found that some patients we don't even need the herbal antibiotics, just following this diet, they seem to do pretty well without having to take anything. Probably with the more complex cases like you said, you're not seeing that as much, but have you seen that in the past where there was just no need for antimicrobials?
Dr. Jacobi: Well, the way I do it and the way I... The reason I structured it this way is because I imagined a patient arriving in the practitioner's office and, you know,
