Dr Nirala Jacobi

Mastering SIBO and IBS with Dr Nirala Jacobi


Mastering SIBO and IBS

New SIBO Mastery Program Released


Listen up practitioners, this one is definitely for you. Welcome to the SIBO Doctor Podcast. I'm your host, Dr. Nirala Jacobi. And today I want to talk to you about what to do when you're doing all the right things in terms of treating SIBO and IBS, but your patient isn't getting any better. And I think all practitioners and myself included, know what that feels like.

When you've given the correct protocol to your patient and they come back saying, "No, nothing is better. I'm still bloated. I still have brain fog, I still have fatigue, I'm still constipated." And you are just sort of at a loss as to why this may not have worked. You tested them for SIBO, the test came back positive, you recommended the correct protocol for that pattern, and it just didn't work. What's next? That's the question that I'm frequently asked by practitioners.

And I am actually really familiar with this situation because I see such chronically ill patients that it's often not as easy as just treating SIBO. Because if you've learned anything from this podcast over the last six years, I hope you understand by now that SIBO is not just about killing the bacteria because it would be really easy if it was. But SIBO is often a condition within a complex web of contributing factors.

I remember pretty strongly or vividly the mistakes I've made with a particular patient many years ago. This is how we learn as practitioners. We do the best that we think we are doing based on our current knowledge and when something doesn't work, we have to, we're forced to dig deeper until we understand why this didn't work. And so, this was the case with this patient who came in with PMS and headaches and bloating that worsened before her cycle but was pretty chronic and she was bloated all the time, but it did get worse before her period.

She also had diarrhea or very loose stool since a few years. And of course, just like any practitioner, I think, "Oh, this is SIBO and possibly some estrogen dominance issues." I did a breath test. Sure enough, she had SIBO and of course I started with a SIBO treatment protocol, but she never really got on top of her symptoms. She improved a little bit, but the bloating continued. Then I approached it from an estrogen dominance perspective and treated that and it just wasn't, she just wasn't improving.

This just forced me to dig deeper and research and learn about histamine intolerance and she completely fit the picture. Once I realized this and put her on a low histamine diet and gave her some support for histamine clearance, she just completely turned around and improved and has never looked back. So, this is how we learn as practitioners. And I basically had to connect the dots and realize how prevalent histamine issues are among SIBO sufferers and that's why I'm now much better with histamine intolerance. This is just an example of one of the contributing factors that we often see in SIBO.

Really my goal over the past 10 years, not just here with the podcast, but also through my education portal, been my goal has been to educate as many practitioners as possible about the effective treatment and management of SIBO and IBS. So, we know that about 60% of IBS is actually caused by SIBO. That leaves another whopping 40% of other factors or other causes. So, my course that I've created is, and I'm actually relaunching it, I've completely updated and revised it.

It's called the SIBO Mastery Course, and it's for healthcare professionals, whether that you're a naturopathic physician or a nutritionist or an acupuncturist or any of the allied health professions, naturopathic physician, of course, how could I forget you? This course is really something that I have put together in my 25 years of practice, more or less, and just recently have updated it. So fully streamlined this course will teach you not just about SIBO, but also about other causes of IBS.

I thought today because I'm relaunching this course and I'm really excited about it. It's probably the best course I've ever created for practitioners because it is fully updated at this point. But what I thought I'd do today is just kind of cover a little bit about some of the areas of or key areas that I cover in this SIBO Mastery Course that answers the question, what next? Where to look next when a patient doesn't improve? These four key areas are gut wall dynamics, histamine imbalances, gut-brain and brain-gut access, and genomic influences. And I'll talk about each of these key areas a bit more.

With gut wall dynamics, we're really talking about the single cell lining plus the mucus layer and the underlying immune system. So together, I would consider that the gut walls and every layer have a very specific function. And when that gut wall has been damaged, we see a lot of issues around immune activation, food intolerances, food allergies, microbiome imbalances, and this imbalance between mucosal production and degradation.

I go into this in great detail, of course in the SIBO Mastery Course, but especially when it comes to mucus, I think we don't talk about that enough. There's a very important balance of mucosal degradation by bacteria as well as the contractile dynamics of the gut that force mucosal turnover. And when there are imbalances with that, if you think about the importance of mucosal protection, for example, that layer of mucus, that's one layer thick in the small intestine and two layers thicken the large intestine, this prevents mucosal invasion.

Actually, the microbes that are around it, your microbiome and also SIBO bacteria that are not in direct contact with the mucosa, diffuse some of the messengers and communicate with the immune system below the cell layer. So, the mucosa is extremely important for protection and prevention of mucosal invasion, but also as a medium for this diffusing of substances through it. And I see a lot of people that have genomic issues that prevent them from proper mucosal production. And I talk about that also in the course, these genomic issues.

But once I've started to understand that some people, for example, those that are non-secretors with the FUT2 gene, really cannot do this healthy mucosal regeneration process as efficiently. And they also tend to have deficiencies specifically in key bacteria or what we call keystone species such as Akkermansia and Lactobacillus and Bifidobacterium that are really key for immune regulation. So, when you have that kind of deficit of mucosal production and degradation, you're going to have a slower time with healing.

Knowing that as a practitioner will give you the tools to explain this to your patient. To not expect them to feel immediately better after a six week leaky gut protocol, for example, this might take a lot longer to regrow a healthy microbiome as well.

And next, besides the mucosal issues, when we talk about gut wall dynamics, is also this damage to the microvilli. And you already know probably as a practitioner, I hope, that the microvilli are the smallest sort of hair-like structures on top of the enterocytes or the cells that are lining the gut wall and the micro villa are in the small intestine and they effectively increase surface area. But this is where also the brush border enzymes are found. And brush border enzymes offer that last step of digestion and absorption.

So, if they're damaged from the gases of SIBO, you can expect much more digestive deficit and continued bloating, for example, or histamine intolerance if those enzymes are damaged. Also, microbiome dysbiosis of course, contributes to gut wall dynamics because if you have a very aggressive pathobiont profile that can invade the gut wall, you're going to also end up with leaky gut. And once that occurs, we can expect immune activation and increased inflammation.

So really understanding that key area of gut wall dynamics is I think a really important area to consider when your patient is not improving. Next would be really getting very good with histamine imbalances. That is a key area for SIBO and IBS in general. And there are three reasons why histamine can be elevated with SIBO. Number one would be because we know SIBO causes not just leaky gut, but it causes this mast cell migration into the intestinal wall.

Mast cells are parts of the immune system that have granules of histamine. And when they get triggered, whether that's by endotoxins like LPS from the bacteria that cause SIBO or because of food reactions, food allergies, or because of stress because they also have cortisol receptors, then you can experience a lot more histamine reactions because his mast cells are degranulating. But also, we see this in SIBO and also in IBS because of microbial production, potentially. Histamine can be upregulated in production by the microbiome and that's discussed in the histamine intolerance lesson in the mastery program.

The third cause of histamine imbalances in SIBO is because of the damage to the brush border and the loss of diamine oxidase, which is the enzyme that breaks down histamine. So those three are really elaborated in the histamine intolerance lesson in the SIBO Mastery Course. I'm not a big fan, I shouldn't say fan of histamine intolerance, but it was just so revelatory when I understood all of the implications of histamine issues. How high estrogen levels can really trigger and worsen histamine symptoms, for example. This is really important to know if you routinely see women that have PMS, for example. So, it has these far-reaching effects.

The third key area that I think a practitioner should consider when they ask themselves the question, "What is next? I've treated SIBO and the patient isn't any better." Think about the gut-brain and the brain-gut axis. Now, the gut-brain axis is the two-way biochemical signaling that takes place between the gut and the central nervous system. And the brain-gut axis is where is it's basically the effects of the central nervous system on the gut.

So is the metabolome of the microbes in the gut produce these metabolites collectively known as metabolome, and it basically travels up the vagus and sends messages to the central nervous system. But the other way is the effect or the effect that the brain can have on the gut via limbic system activation or chronic trauma and chronic sympathetic nervous system activation. That then leads to the hypothalamic pituitary adrenal access dysfunction and vagal dysfunction, et cetera. So, it's a really dense lesson in the mastery program. And I also talk about microbial neurotransmitter production that influences all of this. So, a very comprehensive lesson there.

And then the fourth key area that I think is really important to consider when you're dealing with chronic gut issues and dealing with chronic SIBO patients and potentially not improving or maybe reacting to some of the substances that you're giving them would be the genomic influences. Getting really good at looking at which areas or which pathways are really affected in your patient. This is specifically true for the FUT2 gene that I mentioned before in gut wall dynamics.

The FUT2 gene is very common, has a gene variant that doesn't allow for not just this mucosal repair but also B12 absorption. This leads then into methylation defects. And methylation is a process, or it occurs pretty much everywhere in the body where there is DNA repair or rapidly dividing tissues require a lot of methylation co-factors for this rapid cell division that occurs in the gut specifically because the gut lining repairs itself pretty much every five days or so. So, it's a very energy intensive process.

But methylation has this effect on everything from neurotransmitter production to detoxification to immune issues. I mean, it's just every process in the body to some extent requires methylation. So, understanding those SNPs or gene variants can be really helpful. And then of course the histamine SNPs as well as the hydrogen sulfide or the sulfur transsulfuration SNPs that aid in the detoxification of not just sulfur, but really the production of glutathione and that then leads into the detoxification pathways.

It’s a really fascinating area of study that helps with understanding also why sometimes we see more reactions to some supplements that we prescribe, for example. All of this together, these four key areas that I look at, of course, require a lot more elaboration. And to some extent, I've talked a lot about all of these topics really in the podcast here with my expert guests over the last six years.

But if you want to access this in a much more concise way then really think about the SIBO Mastery Program. It's now been released, and we have it on sale 20% off until June 30th, 2023. And like I said before, my goal really is to promote as many SIBO practitioners as I can and educate as many practitioners as I can because that means more people are being helped. And that's one of the reasons I also created a Find A SIBO Treating Practitioner database. I've mentioned this before here on the podcast. It's been proven to be an incredible resource and every day we're getting emails from patients asking for SIBO trained practitioners. Only practitioners that have taken this program are eligible to join this database.

It is a really good practice building tool for practitioners that are listening. Because I'm all about empowering you to be better SIBO practitioners, and I want people to find you. So, listing yourself in that database and displaying the SIBO Doctor Approved button can all be incredible tools that aid in increasing your exposure. There are people that have taken the course previously that have written some really beautiful thank you notes and testimonials that I want to share with you because it's been so powerful.

That SIBO database, Find A SIBO Practitioner database has been really a game changer for some practitioners. Louise, who's a nutritionist in New York says, "I want to thank Nirala for creating a way for people to find a SIBO literate practitioner who has taken the comprehensive SIBO Mastery Program. I would say that at least half of my clients find me via the SIBO doctor database. I also love the support of or support materials such as What Caused My SIBO questionnaire and the beautifully revised SIBO Bi-phasic Diet eBook. This is invaluable." Thank you, Louise, for that testimonial.

So, somebody who's getting half their patients through just being on the database, I think is pretty powerful as a practice builder. I don't really need to say much more other than understand that it's a really comprehensive field of knowledge and going really deeply into not just understanding the pathophysiology of SIBO, but all of these other contributing factors, I think makes you a much better practitioner. Also, I will go into what you can do about many of these contributing factors.

I add a lot of naturopathic therapies and hydro therapies and a lot of treatment suggestions that will just expand your knowledge of not just functional digestive disorders, but really also how to supplement and when to wait. Sometimes when somebody comes in and says they're not any better, you may actually just need to wait a little longer. Specifically, around IMO as an example, IMO or intestinal methanogen overgrowth. We often do a breath test, and if the breath test is quite high throughout the test, this is known as methanogen overgrowth.

If you have somebody that has a gas level of methane of let’s, say 50 or 60 throughout the test, this can take months to really effectively treat to the point where they have regular bowel movements by themselves or on their own. So, you may have to supplement with something that keeps them more regular until then. These are the little tips I want to share with you in the mastery course. I hope you take this action and invest in your education, and I wish you all the best until the next episode of the SIBO Doctor Podcast.

I can share with you now that it will be all around sulfur sensitivity. I get a lot of questions to get more information about hydrogen sulfide, and I have a great podcast coming up for you in June about not just sulfur sensitivity, but the whole issue around sulfur and its role in the body in general. It's absolutely fascinating conversation with Dr. Stephanie Seneff.


Mastering SIBO and IBS with Dr Nirala Jacobi is available now


Scroll to Top