The Bi-Phasic SIBO Diet with Dr. Nirala Jacobi

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.

The Bi-Phasic SIBO Diet with Dr. Nirala Jacobi

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, the practitioner suspects SIBO, orders a breath test and gives the bi-phasic diet to the patient to take home and say, “Do this until we have the test result and do phase one.” That was really the impetus for me to do it that way also besides the structure around the product. But really, you know, I always think about once I get the test result back and SIBO is present, just managing it on the diet for me is not… I mean, it can be an answer for some, but what you’re doing is you’re permanently keeping somebody on a low FODMAP diet which also has its negatives, which is you’re not really providing a good amount of fermentable fibers to the large intestine, which of course, as we know, is the home of our microbiome or the majority of our microbiome. So, we don’t really want to keep them on this diet forever. And if we find that SIBO is indeed present, then eliminating these organisms from the upper gut will give them a lot more dietary freedom in the future. So, that’s kind of how I frame it is that… And, you know, really, the other reason why people are… I mean, they’re improving for the reasons you’ve mentioned, which is anti-inflammation and reduction of fermentation. But then as we go to phase two and introducing some of these more slightly fermentable foods, we’re actually wanting for bacteria to wake up a little bit so that they are more killable. Right? So, that was really also the reason to broaden the diet in phase two so that we can actually be more effective with our antimicrobial strategies.

Dr. Hedberg: And when you start phase two when you’re having conversations with patients, obviously, some of them they’re going to add some of these foods back in and they just might not do well with them. So, are you giving any specifics as far as, say, like, beans, for example, where you say, “Just have that by themselves and see how you do,” or do you just tell them to start adding all of these back in or are you a little bit more cautious?

Dr. Jacobi: I’m definitely more cautious. Now beans don’t actually make another entry, really, until you’re done with your SIBO treatments, unless you’re on the vegetarian bi-phasic diet where you can actually ferment or…not ferment, but you can sprout these legumes to make them more digestible. And the sprouting, what we know actually completely eliminates a lot of these fermentable fibers and makes this legume a lot more digestible. So, it’s a great way for people to enjoy more legumes because they are a really good protein source for vegetarians. So, that I think broadens the spectrum of how we can use legumes not just in the vegetarian portion. But yes, you’re right. So, when we do have sensitive patients and, for example… I wouldn’t be too… Well, yes, legumes but more dairy, right? And those kinds of things when they start making an entry, I definitely alert people to that. People typically, when they start with lentils, I usually say, “Look, try a canned lentil,” because canned lentils when you drain them, a lot of the FODMAPs are actually in the liquid. And canned lentils are very well tolerated by even those who say, “I can’t eat beans or lentils because, you know, it’s just too much gas production,” even in those that don’t have SIBO. And that’s because, you know, we have this or the lentils and legumes have this very tough outer cellulose structure that’s really hard to digest even for those without SIBO. And sometimes I tell people to try Beano, which is alpha-galactosidase, an enzyme that breaks down the cellulose. So, sometimes it is just an enzyme and sort of deficiency that by just simple enzyme supplementation can really help them to kind of become accustomed to legumes. But yeah, those would be the heavy hitters.

You know, the number one problem I find with the bi-phasic diet is many people rely too much on eggs, and anybody who does allergy testing sees the reaction to egg come up time and time and time again. So, I often tell people, especially if their energy drops because eggs tend to cause a lot of nausea in those that are very sensitive. Nausea and fatigue, I think, are the primary symptoms I see with egg allergies. So, that’s more what I tell my people is just be aware and if that’s the case, then I might suggest a very low fiber protein smoothie in the morning rather than eggs.

Dr. Hedberg: Let’s just talk about a few specifics that you mentioned in the diet, one being oxalates and, of course, our practitioners will know there’s connections there with kidney stones and a few other issues like joint pain and things like that. Anything you want to say specifically about oxalates and what to look out for?

Dr. Jacobi: So, oxalates are the crystalline structures in plants that some people are susceptible to. But one of the things that happens with SIBO or anybody with a functional digestive disorder, doesn’t have… It’s not really just exclusive to SIBO that we food sensitivities. Certainly not. But with oxalates, what happens is normally, dietary calcium actually binds to oxalate and there’s always trace levels of calcium in many other plants and grains and so forth, like, trace amounts and they actually bind to these oxalates and basically, it gets eliminated. But when people have a lot of diarrhea as is the case in SIBO in many cases, they can’t really bind the calcium to the oxalates. So, it gets eliminated or the calcium actually doesn’t bind to it, and so, you absorb a lot more calcium. Sorry, oxalates. So, in that case, you know, people can become sensitive to these oxalates. Another reason is the loss of oxalobacter formigenes which is a native species of bacteria that helps to break down oxalates. And when that’s gone due to lots of antibiotic use, we do see some problems with oxalates in general. The third reason is Candida. Right? So, Candida has complex mechanisms with which to increase oxalates as well. And anybody who does an organic acids test can see very often fungal markers and oxalate or oxalic acid be elevated. So, those are the three sort of things to look out for and to be aware of, but yes. So, I often find vulva pain and pelvic pain associated as well with bladder pain with oxalates, and so besides joint pain, as you mentioned.

Dr. Hedberg: Right. And then salicylates, these are also found in various foods and they can cause different symptoms. Some of them might be kind of crossover or people might think it’s an allergy because they get things like itching and puffy eyes, sinus congestion, things like that. So, can you talk a little bit about salicylates and what to look out for?

Dr. Jacobi: Yeah. So, salicylates are a way for the plant to defend itself. And most of us can tolerate salicylates. It’s just when they reach a certain threshold, we see a problem with salicylates. And one of the reasons why we see problems especially people that are on carnivore diets or to some extent even SIBO diets or paleo diets is because they become also very acidic. So salicylates typically, once they are ingested, get absorbed and about 80% of the salicylates go to the liver to be detoxified through the gluceoronic pathway. So, if you’ve got any issues, any snips in that way, you can also be sensitive to salicylates. And the 20% that are unbound to albumin don’t go to the liver. They go to the kidney to be excreted and when the kidney or when the urine is too acidic, we actually can’t excrete salicylates very well. So, what they found is that by alkalizing the urine, we see greater than 80% increase of secretion or excretion of salicylates.

So, these are the little tricks of the trades I’ve learned with my extremely sensitive patients. But yeah, it is one of those issues where when food sensitivities are present, there is a lot of overlap with things like histamine and salicylates and to some extent, also, sulfur sensitivities. So, the astute practitioner really has to kind of look into these different sensitivities and see their presentation and look at the different foods. And we’ve created several different add-ons to the bi-phasic diet to help practitioners. Like, we have a high salicylate food. And what I do is I just give that handout to my patient and say, “Look at the high salicylate foods, for example, olive oil, right? Olive oil and coconut can be quite high in salicylates, so you might just…and berries, honey is another one. So, it can be a little bit of a… You’ve just do some sleuthing, but you can tell your patient just remove the really high amount or the high salicylate containing foods. Because, otherwise, if you end up with the bi-phasic diet and several add-ons, you really have not much left to eat, so you have to kind of be aware of that. And what I typically do unless it’s really clear cut salicylates or oxalate, I usually start with a histamine if somebody is super-super sensitive because it makes sense why people are sensitive to histamine or histamine intolerance in cases of SIBO because of the loss of diamine oxidase which is the enzyme that breaks down foodborne histamine and is on the tip of the microvilli. So when we destroy that, we start to see people become more sensitive to histamine in general.

Dr. Hedberg: Now, let’s talk more about that. Let’s bring in fermented foods and histamine since those kinds of overlap in a number of cases. So, you know, you’ll see a patient come in and they’ve been eating a lot of bone broth because they read that it’s really good for the gut, but they have a lot of symptoms of histamine, histamine overload. And we know that bone broth can actually, you know, cause issues with histamine. So, what is your approach with fermented foods? And how does that tie in with histamine?

Dr. Jacobi: Yeah. So, anything fermented or aged has the potential to have a higher histamine content. And mostly, we see that with animal products like cured meats. Tinned or canned fish is very, very high in histamine. And then there are certain foods like spinach and, like you mentioned, fermented foods and there’s a whole slew of other foods that are quite high in histamine, as well as contain histamine liberating foods, which is a different sort of category based on biogenic amines. But basically, yeah, you kind of have to be… The histamine bi-phasic diet is quite restrictive because we have to remove histamine containing foods, histamine liberating food, and FODMAPs. So, it really is a restricted diet for about four weeks and we don’t usually mix that with other diets. It’s a standalone protocol to really see if you’re patient that even with mast cell activation syndrome, you know, a histamine intolerance all the way to mast cell activation syndrome, we found this diet to be really phenomenal in terms of being able to reduce the symptoms of histamine intolerance quite dramatically. And then as you introduce the foods again, you can really see which food is the problem. But for the most part during that time you also want to improve histamine detoxification. You want to start working on fungal issues because we know there’s a big connection between Candida and histamine intolerance because there is a shared detoxification pathway of Candida and histamine through the aldehyde dehydrogenase pathway. So, really, there’s a lot of work that can be done with improving histamine intolerance while still on this quite restrictive diet.

Dr. Hedberg: Yeah, you brought up fungi. I just wanted to bring that up here because I think it’s important for everyone to know about the SIFO, Small Intestinal Fungal Overgrowth. And so if the stool test does not show any fungi, if organic acids is not showing any fungi and any kind of blood antibodies are negative but it’s something that you really suspect. I think I’m only aware of one doctor now who’s a gastroenterologist who’s doing aspirations of the small intestine and actually testing for fungi. Are you aware of any new testing or ways of identifying SIFO?

Dr. Jacobi: Oh, gosh, that’s such a great question, you know, because it is the bane of our existence, isn’t it, as practitioners? Fungal issues are so pervasive and so detrimental to our patients’ health. But I haven’t. That’s a short answer. I really haven’t. And I would say that if all three of those are negative, I would actually look more at mold issues and external issues like mycotoxins and mold spores rather than… I mean, I find that symptoms tend to be much, much worse in people that have an internal mold source like Candida. But you can still have a reaction to all of those mold toxins and not have Candida on board. But if arabinose or the other fungal markers are truly negative, everything is negative, I might actually abandon Candida treatment at the… Unless it’s just there’s no other explanation for somebody’s symptoms. I’d go more into like microbiome restoration, really.

Dr. Hedberg: Right, right. So, with histamine intolerance, you had mentioned DAO earlier and most likely a number of these patients will have DAO enzyme deficiencies in the gut or a genetic predisposition for that. Are there other reasons that everyone should know about as to why histamine intolerance can be so frequent in people with SIBO?

Dr. Jacobi: Well, I think, you know, the other reason is SIFO, which is so common and comorbid with people with SIBO, meaning that about 25… Well, the doctor that you mentioned, Dr. Satish Rao who does the aspirates and did that study on SIFO did demonstrate that up to about 25% of people with SIBO also have fungal overgrowth. I personally think that number, if we did bigger studies, would probably be higher because I see it so often in my clinic, the comorbid with SIBO. So, Candida is a big driver of people having poor detoxification of histamine. Remember that we endogenously make histamine because it’s an important neurotransmitter and an important regulator of things. So, we don’t just get it from our food source, which we normally detoxify quite well through diamine oxidase or metabolized, I should say, through diamine oxidase and histamine and methyltransferase, which was more of a cytosolic enzyme also in the epithelial lining of the digestive tract. So, we have good mechanisms in place to help us take down histamine, but also we have other pathways of detoxification because histamine is made in the body. The other reason why we often see this sort of endogenous rise of histamine is because there are certain cells that contain histamine in there, like, they are sort of the storage vessels called mast cells. And mast cells are really pretty well known in asthma and other sorts of allergic diseases, tend to be migrating into the small intestine in many cases of SIBO. So, in those cases, we will then have a loss of diamine oxidase as well as endogenous histamine release through these mast cells. And that’s what we see in really dysregulated patients.

Dr. Hedberg: Right. So, a patient goes through phase one. They go through phase two of the bi-phasic SIBO diet and they’re doing relatively well. At that point, I assume you’re mainly looking towards microbiome restoration. So, can you talk about how you approach that and some of your strategies?

Dr. Jacobi: Yeah. And that’s, I think, a really, really important aspect. And I’m really a huge fan of the microbiome. I think we all are. I mean, it’s so absolutely fascinating. The research that’s coming out and anything from psycho-biotics which are probiotics that act on the neurotransmitters and the, you know, brain chemistry. I mean, it’s super fascinating. So, what I do in my patients, and I don’t often necessarily wait until the end of SIBO treatment because, again, I see people that actually, for the most part, have failed other treatments. So, I gotta pull out all the guns and look at everything at once. So, I do a stool test that does microbiome assessment on the 16S RNA kind of microbiome markers. And there are a few of them. I don’t like most of them. So, I do usually just use one of those tests that helps me really get an idea of the different phyla. And phylum, for those of you who are not microbiome buffs, is just a group of bacteria that all share similar traits, but they’re very different. A lot of the bacteria, you know, even, let’s say the group proteobacteria that contains your gram-negative bacteria like E. coli, but it also contains the sulfurvibrio, which is a hydrogen sulfide producer.

So, we can have these imbalances in these different phyla and the best way to improve that is not to slash and burn necessarily, but to use very specific prebiotics. I’ve become a really big fan of prebiotics which are really kind of the opposite of what we want to do in SIBO, which is we’re selectively feeding bacteria. So, that’s kind of what I love to do, and I’m also a big fan of strain-specific probiotics. So, using, for example, bifidobacterium lactose, HN019 for constipation type of presentation. It’s really important to also remember that when we use probiotics, we’re not replacing anything, right? We’re not replacing lost native species. We’re just using them as key metabolic or modulators of the environment. Because what we find is when we use different probiotics, they kind of act like a fertilizer. They kind of help to increase your own native species. So, you know, my approach really is to improve and broaden the diet as much as possible and use a lot of plant-based and food sources and polyphenol-rich diets, which polyphenols give the plants and the fruit and the vegetables their color. So, they’re very rich in berries, and green tea is another great one. Green tea is actually a wonderful polyphenol that helps with microbiome restoration. So, there’s a lot… I mean, that’s a whole another, you know, many hours’ conversation, but those would be the basics I think.

Dr. Hedberg: And why don’t we close by talking about the nervous system? I just want to bring up psycho-neuro immunology and the vagus nerve. And some of my listeners might be tired of me bringing up psycho-neuro immunology, but it’s just a point that I just really wanna drive home so that, basically, because I don’t want it to be overlooked. And patients they come in and they have a diagnosis of SIBO and they have gut symptoms and, of course, some symptoms outside of the gut. And so the whole treatment, the whole focus is just on SIBO and the gut and I do worry about that in a lot of people because there’s so many other components to good digestion going back to the brain and psychology, trauma, the vagus nerve and things like that. So, is this something that you’re worried about as well? I know it’s something that you address with your patients, but obviously we’re not psychologists, we’re not psychotherapist. But I found that I’ve had to bring that in quite often to get really good results working on childhood trauma, adult trauma, and all those kinds of things. So, can you speak a little bit about that?

Dr. Jacobi: Yes. I’m sorry. Absolutely. And in fact, I’m really glad you brought that up because it is, as you mentioned, we still compartmentalize that this is the gut and that’s the nervous system and we are starting to make strides with connecting through the gut-brain axis and the vagus nerve. But as you mentioned, adverse childhood events are huge in even setting the stage for a poor microbiome. We do know that. Research has shown that. I have found that it’s absolutely indispensable to work with therapies like hypnotherapy, right? We know that gut-centered hypnotherapy, for example, can be a huge benefit to our patients. I also use or recommend different types of trauma strategies from somatic experiencing. That’s Peter Levine’s work or Annie Hopper’s dynamic neural retraining system. I’ve had some amazing results with that especially with my advanced MCAS patients or Mast Cell Activation Syndrome. So, what… I actually just am in the midst of completing my advanced SIBO Case Management course and one of the module is all about this, about the autonomic nervous system, the vagus nerve and the limbic system and the enteric nervous system and how they all work together and the neurotransmitters they produce.

And so it was a really interesting journey to try to tie this all together, which is somewhat difficult. But I kept coming back to that, you know, especially in these days where there is so much anxiety. I mean, it’s an epidemic of anxiety and overwhelm and despair and all of that as we are seeing not just our natural world be in great peril, but just the sheer survival of what’s happening on this planet. There is just a really heightened sense of anxiety. I don’t know how much you find that, but I certainly see a lot of it in a… They’re not even sort of even aware of it, but old trauma is really coming to the forefront for many of my patients. And to have good referral systems is, I think, key. And this is what I tell all of the practitioners that I teach on functional gut disorders, is find somebody that does gut-centered hypnotherapy. They actually even do this study looking at Skype visits with hypnotherapy and found that they’re slightly less effective than in person, but they’re still really effective. So, you can refer to somebody who’s not necessarily in the same town. So, that’s a good one to have somebody that really knows how to work well with trauma. And I have found that that absolutely expedites people’s healing journey and sometimes is instrumental and a massive game-changer. So, those kinds of therapies that are really deep and profound, I think, we have to consider them in not just our gut people, but really, in most of these chronic illnesses that we’re faced with. So, that would be my recommendation is to have a good referral network.

Dr. Hedberg: I like those recommendations. So, somatic experiencing, I’ve referred out for that with good results. Dynamic neural retraining you brought up, that’s good. Hypnotherapy. I would also add EMDR and acceptance and commitment therapy and cognitive-behavioral therapy. And then meditation is something that can help patients with gut issues as well.

Dr. Jacobi: Absolutely. Yeah, absolutely. I mean, mindfulness, all of that, those are core strategies that in this day and age as, you know, practitioners and functional practitioners we owe it to our patients to really understand them for ourselves and to be able to recommend them so that people can get the most out of their treatment really.

Dr. Hedberg: Excellent. Well, this has been great, Nirala. Why don’t you tell everyone where people can find you online? I think you have three websites. And anything else you mentioned, please do.

Dr. Jacobi: I do. Thank you. Thank you for that. So, my main training platform about SIBO is The SIBO Doctor where you can find the podcast, you can find the bi-phasic diet. I also have a free questionnaire that people can download and practitioners can use called “What Caused My SIBO?” And it’s about really trying to identify, “Is it an adhesion? Is it hypothyroidism?” Those kinds of things. So, that’s useful. And also all the training programs that I do with SIBO Mastery. And then I have a clinic called the Biome Clinic. And we are in lovely northern New South Wales, Australia. And then I also have a breath testing company called SIBOtest. And you can find all of that online and, of course, I’m on Facebook and Instagram.

Dr. Hedberg: Excellent. Well, this has been great. So, to all the listeners, there is a transcript posted of this conversation at Just search for Dr. Jacobi and we’ll have all the links and everything that we mentioned today. So, thanks for tuning in, everyone. Take care and we’ll talk to you next time.

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