Welcome to another episode of the SIBO Doctor Podcast. I'm your host, Dr. Nirala Jacobi, and I hope you're all having a wonderful start to 2022. Today is a really beautiful rainy day here in my little corner of the world, so you may be hearing that in the background. Yeah, very nice and green everywhere I look.

Today's topic has been requested numerous times from our listeners, life after SIBO. And many of you have asked, "I've been treated for SIBO, now what do I do? How do I prevent it from coming back?" And it's a really worthy topic to unpack. And I'll talk about it in four bullet points or topics. One is, we'll start with retesting, the dos and don'ts of retesting. Number two will be preventing relapse by identifying what caused your SIBO to begin with, because it's different for many people. There's different categories of what causes SIBO. So really knowing how to identify it is your best weapon against relapse. We'll discuss that a little bit and then I'll move into food introduction on the biphasic diet.

Many of you listeners have heard about the biphasic diet, have probably been prescribed it by your practitioner, or have downloaded it from thesibodoctor.com. It's a free resource, and we've had thousands of people on that diet. We'll talk about how to actually reintroduce the foods on the biphasic diet. And then we'll conclude with some tips about microbiome restoration, because we all need to feed our good bacteria and they often use the very foods that you've avoided as fuel. We need to talk about how do we bring these good bacteria back in balance. And this also I'll discuss a little bit about the differences between the small intestine and the large intestine in terms of microbiome, but really, let's start with the retesting issue as to, if should you retest after having been treated for SIBO, or should you just go by your symptoms if you completely recovered from all of your digestive symptoms.

The way I do it in my practice is when I treat for SIBO and the person is telling me that they're completely symptom free, I may actually just wait and see if they have a relapse in a month, two months, three months, or however long it takes. If they're completely recovered from all of their symptoms, no bloating, no abdominal pain, no diarrhea or alternating bowel patterns, or the host of other symptoms that are associated with SIBO, even systemic symptoms like fatigue or food reactions or acne rosacea, or restless leg syndrome. If those symptoms have all resolved, we may just wait. But if a patient says, "I still have remaining symptoms," that could be SIBO, could be something else, but it's a remaining symptom that they've had all throughout. For example, food reactions, we know that SIBO can cause leaky gut, which can cause food reactions.

The SIBO may be gone, but the leaky gut may still be there. In those cases, I may retest to understand if SIBO is still an issue, or if we're dealing with other peripheral or other issues that may have been caused by SIBO, but are not yet resolved. I always find retesting very helpful in general, because it really tells us whether or not your treatment has been really effective.

That's what I often recommend, is just to start with a clear slate and say, "All right, we know it's totally gone. So the symptoms that are remaining are definitely not do to SIBO," so we can concentrate on treating, like I said, potential leaky gut, or even SIFO, small intestine, fungal overgrowth, which very much mimics the symptoms of SIBO, but will be negative on a breath test. It's really helpful.

If you fall into that category of still having remaining symptoms after you've been treated for SIBO, I really recommend that you repeat the breath test and use the substrate that you use before. If you started off with a lactulose breath test, don't switch over to a glucose, a fructose, just go with what tested positive before so that you can actually compare apples to apples and not apples to oranges. That covers retesting.

Retesting is very helpful, especially for those that have remaining symptoms after a round of SIBO treatment. And just as a final word, I often see patients that self-referred to me or have been referred and they've been on months and months and months of herbal or conventional treatment for SIBO and I retest them and low and behold, they don't have SIBO. So it's a really important point to consider retesting in your journey of clearing SIBO.

Next, let's move on to, how do we prevent a relapse of SIBO? Well, preventing relapse has everything to do with identifying the underlying cause of SIBO. What caused you to have SIBO to begin with? And many of you who are frequent listeners of my podcast may remember an episode I did a couple years ago. I think it is now called the underlying causes of SIBO. And I really went into detail of what the underlying and causes are. I grouped them into four different categories. The motility category, something happened with the motility of your small intestine, the digestive deficit category, where you are just lacking some of the digestive juices that help to normally keep SIBO at bay like hydrochloric acid or enzymes or bio. Something is not quite right with how you're producing these juices. That's a category.

Another category is some obstruction or pseudo obstruction or adhesion or some mechanical situation where you have some scar tissue from other conditions like endometriosis or other types of potential previous surgery in your abdomen, like removing your gallbladder or cesarean section or having had your appendix out. Very frequently when you've had, or just even a routine abdominal surgery, you can form scar tissue within the abdominal cavity that can adhere to the structures of digestion. And then they can create a kink in the garden hose situation where it just doesn't flow very easily through these sections. And so it's more of a situation where you don't have anything wrong per se with your digestive tract, it's just the outside structures maybe affected because of these scar tissues. That's another category of more structural problems.

Then the final category of underlying causes to SIBO is medication that you may be on that may be slowing the transit through your digestive tract. And that can also predispose you to SIBO or bacterial overgrowth. These four categories are what I address in that other podcast, but basically in the motility category, you have numerous conditions that affect motility in the small and intestine.

Number one is if you've created antibodies to the migrating motor complex, which is a section in the small intestine that's responsible for clearing the upper gut of bacteria between meals. If that's not functioning correctly, it's pretty normal for bacteria to just remain and overgrow. This is commonly seen after about a food poisoning. It's estimated that about one in nine, so about 11% of people that have had a case of food poisoning can develop IBS and SIBO symptom because of this condition.

And that's something that you can check. You can get a blood test called the IBS-smart. If you're in America, you can get this from Gemelli labs. And it tests for these two antibodies to see if you have this damage to the migrating motor complex. If you're in Australia, here at sibotest.com, we offer this test, and that's a good way of standing if you have developed SIBO after a case of food poisoning, and that's really important because it's a very common reason why people relapse after SIBO treatment. That's the primary cause of SIBO relapse in the motility category.

The other conditions in the category or issues that cause disc motility or problems with motility in the upper gut are things like or conditions like hypothyroidism, where your thyroid... We know that hypothyroidism does affect gut motility, as well as mold exposure. Mold in your environment, secrets microtoxins or toxins that are very specific to molds, and they can affect all manner of digestion and are very, very toxic to all digestive organs and other...

You can have a lot of other systemic symptoms, but mold toxins can absolutely affect motility. Understanding if that's the cause of your SIBO has a lot of repercussions, because you may need to do a lot more to get rid of mold and refer to the podcast episode with Dr. Jill Crista, where we talk about this phenomenon of mold exposure and development of SIBO. Other issues include traumatic brain injury or chronic viral diseases or viral infections and autoimmune conditions like scleroderma. They all affect some aspect of motility in the small intestines. If you have a problem with upper gut motility, bacteria are just allowed to remain and proliferate. So it's pretty common. Understanding if that's your cause of SIBO, you are a good candidate to be considered for prokinetic use, and prokinetics are a type of, or a category of medicines, both herbal or conventional that reset or aim to reset the normal motility of the upper gut.

And if you address that, then you are keeping on top of bacterial overgrowth in the upper gut. It's important to note that upper gut problems with motility don't really translate into having or frequency of bowel movements. They're very separate. Frequency of bowel movements is usually more of a peristaltic issue related to large intestines. If you say, "Oh, I have a bowel movement every day," that doesn't mean you don't have a problem with motility in the upper gut. Just remember that. The other cause or the other category of underlying causes is more the poor digestion where bacteria are not killed by the digestive juices, such as hydrochloric acid, bio, and enzymes that may be missing due to various issues. For example, if you've had H. pylori Before, the bacteria in the stomach, that can cause reflux and causes a lot of upper gut problems, you may actually have some issue with the production of stomach acid because H. pylori can damage hydrochloric acid or stomach acid production.

So this may be your issue, is that you're just not secreting enough stomach acid to not only digest your food, but to kill bacteria and/or prevent them from overgrowing in the upper gut. That may be your issue. What I forgot to mention is we do have a questionnaire, a free questionnaire that you can download from the sibodoctor.com, and it's called What's Caused My SIBO. And you can fill this in and you can give this to your practitioner. And it's really helpful for them to sort out what type of underlying cause you may have. And that can really help with creating a treatment strategy for you to prevent this relapse from happening. The scar tissue issue or the adhesion issue from endometriosis or abdominal surgeries, et cetera, or even having something going on with your IIO CCAL valve, this is all in this obstruction or adhesion category.

And this is where you may want to investigate working with a visceral manipulation therapist. I think I have also covered that on previous podcast episodes, but you can find a visceral manipulation therapist @barrallinstitute.com. So B-A-R-R-A-L-L institute.com. And visceral manipulation therapists are very specific with what they do. It's not just abdominal massage. It's very specific with how they address scar tissue. Or if you're in America, there is a place in Colorado, I believe called Clear Passage. Adhesions is a big issue for some people and not at all for others. You wouldn't want to give a prokinetic for example, to somebody that has a problem with adhesions, because it may actually make them worse. It's really important point to understand these underlying causes because it helps guide treatment to prevent relapse.

Okay. You've retested or haven't retested, we've talked about preventing relapse by identifying underlying causes. Now, let's talk about food reintroduction. You're SIBO clear, you've addressed the underlying cause. Now it's time to reintroduce foods. And so if you're on the biphasic diet, again, many of you have known my three different versions of the biphasic diet. I have a vegetarian and a regular one and a histamine biphasic diet. It's basically a diet that splits the treatment into two phases. And the first phase is quite strict in terms of food restrictions to really minimize bacterial feeding in the upper gut. It really prevents the feeding of bacteria. And then the second phase is you implement this when you're actually in active treatment. And I use the second phase of the biphasic diet also as a maintenance diet just to see if a patient will relapse.

This is typically done for about... If the treatment is about six weeks, six to 10 weeks, you might want to do another four to eight weeks of maintenance on the phase two to really see if anything is happening in terms of relapse. But if people are doing generally well and no symptoms, the first thing you'll do is you'll increase the amounts in the limited foods category. These are foods that have higher concentrations of fermentable carbohydrates. You can reintroduce these foods. Now, an important note is if you've been really on a very, very low FODMAP diet or fermentable carbohydrate diet, and you're reintroducing foods that have a higher FODMAP content, don't be surprised if initially you may have some bloating or some minor symptoms, but just start with very small amounts and increase steadily. And typically people will adjust.

It's just often bacteria that have been not fed for a long time usually in the large intestine that are starting to be active again, and that's not necessarily abnormal. You want to persist with small amounts and increase steadily. So you wouldn't eat perhaps a whole bowl of black beans soup. You might want to start with a small amount and increase over days. That's a good tip. I often tell my patients that. Then the next thing you'll do is after increasing foods in the limited category, you want to start reintroduction of some high FODMAP foods like garlic and onions. And again, just start with very small amounts and increase. And once you've done that, you can proceed with increasing all foods in the higher FODMAP category. And why would you want to do that? It's because they're typically very healthy foods.

They're very high in fiber. We know that fiber is very, very important for microbiome health. And this is a good segue where we talk about microbiome restoration, the fourth point that I wanted to make today. And just as a reminder, I've done a podcast, and I can't remember now when, but it's been perhaps... I think I did it last year, perhaps about the differences of microbiomes in the small and in the large intestine. They're very, very different in the small intestine. You are meant to have bacteria, but because it's a place of absorption and very high degree of immune activity in the small intestine, you're typically not going to see normally very high concentrations of bacteria in contrast to the colon where we do expect high levels of bacteria, because that's where they're meant to be. And so we do want to promote the growth of these healthy bacteria in the large bowel because they do so many incredible things for us.

They provide all sorts of metabolites that are very important for human function. We can't really stay, or it's not advisable to stay on a low FODMAP diet long term because we essentially are preventing bacteria from using these fibers to increase that production of short chain, fatty acids, and other really important metabolites. So can't stress enough the importance of microbiome restoration. Sometimes this is a real important point for some more than others. And especially for those that have been on numerous rounds of antibiotics, not just for SIBO treatment, but also for perhaps other conditions throughout their life. If they've had a lot of bladder infection, sinusitis, bronchitis, et cetera, or have been on it for acne treatment, Lyme treatment, et cetera, this can be quite devastating to the normal microbiome. And often I see a mixed situation with these people where they have SIBO, but they also have what I call LIBO or large intestine bacterial overgrowth.

And so sometimes you still need to address the LIBO or the bacterial imbalances in the large bowel, even when SIBO is gone. So microbiome restoration is a really, really great completion of a gut rehab. There is a great course on the sibodoctor.com website taught by [Dr Jason Hololak 00:22:40]. And many of you will have heard of his name. He's been on lots of podcasts in the functional community because he is such an expert on this topic.

And microbiome restoration course is really fabulous. If you want a deeper look into the key players of your microbiome and how to really bring them back. Another great resource is a podcast I did with Dr. Will Bulsiewicz who wrote Fiber Fueled. And he's a gastroenterologist who wrote this wonderful book. Half of it is recipes. And it's really about how to regrow your microbiome using whole foods. He's big time into plant-based diets. And plant-based diets really are the backbone of microbiomes restoration because our gut bugs really, really love plants because many plants and vegetables and fruit, et cetera, contain not just fiber, but many phytonutrients that the microbiome uses to do its thing and provide diversity in the microbiome. So very important.

The way I look at microbiome restoration is in three steps. And step one is, again, increasing fiber content on the biphasic diet, so just starting slowly. Step two can be using prebiotics. Prebiotics are smaller molecules often found in foods that are more digestible for bacteria. And these are fuel for bacteria. And typically, what's available is PHGG or partially hydrolyzed guar gum often used in methane dominant SIBO because there's some research that suggests that it can lower methane, albeit quite amounts. We can't count on just PHGG on doing the job. Another one is galactooligosaccharide. And that is often quite tolerable, especially if it's a human galactooligosaccharide like bimuno, for example, which is great for boosting bifidobacterium in the colon. And inulin is another one, acacia fiber is another prebiotic. Another one is fructooligosaccharide.

Fructooligosaccharide and inulin can be quite reactive, so I'd probably start with the other ones. I think in other podcasts, I address the prebiotics, but this is sometimes a great way. If you're somebody who's very sensitive to FODMAPS, you might want to start with prebiotics in teeny tiny amounts and increase over time and just let that microbiome regrow and become more tolerant of fibers and FODMAPS. And third point is then overall increasing your plant-based foods. Of course, as I mentioned, Fiber Fuel is a great resource because half the book is recipes and lots of foods that you may never have thought of. And really am a big fan of plant-based diets because they are throughout research. We know that plant-based diets offer a lot of health benefits. Then let's briefly talk about probiotics.

I'm not saying everyone needs a probiotic, but one great thing to start, perhaps reintroducing histamine. Well, I should say fermented foods. Some people are sensitive to the histamine content of fermented foods like sour crowds, especially fermented vegetables or miso, et cetera. Miso is actually quite tolerable by many. So maybe start with that before you move to fermented vegetables, but that's a great way to start to reintroduce specific species. A lot of fermented vegetables contain lactiplantbacillus plantarum. And that's a great bacterial species that has many benefits in the gut. Start with slow reintroduction of fermented foods. In terms of other probiotics, I usually base my recommendations on what symptoms a patient may have. If they're pretty symptom free, at that point, we may not use a probiotic at all. We may just use prebiotics.

I may do a test to look at the health of their microbiome. There's different labs that offer these. So, if you're working with a practitioner, you may want to consider that because it's really helpful to understand. A stool test will give you a good understanding of what's happening in your large intestine. Again, not necessarily what's happening in your small intestine because we can't culture that. Just getting a stool test is not indicative at all of what's happening in the small intestines. A very, very important point. You can't elaborate on what you're finding on a stool test to anything what's happening in the upper gut. That's often misinformation that's been told to some patients that I've seen. They've been told they have SIBO based on the stool test. That's not accurate. Also in terms of probiotics, I think that I wanted to mention something.

Oh yeah. The other important point about probiotics is that you can't really repopulate what you've lost through antibiotic use or herbal antimicrobial use with just giving you probiotics. It just is not efficacious. Usually we give probiotics as a... It tends to help boost Keystone species in your gut, and it helps to mitigate symptoms. But just using probiotics if you have a very denuded or a very poor microbiome profile in your large intestine, isn't good enough. You're going to have to do other things to rebuild your microbiome.

I hope that was helpful to you for considering what to do after you have been treated for SIBO and have cleared SIBO. Yeah, stay tuned. This year will be interesting with lots of other topics. And also a relaunch of the biphasic diet is coming very soon, as well as a new course and a course aimed at people that are not close to any SIBO practitioners and really need treat themselves. I have a whole new course in store for you coming very soon. So stay tuned for that. And I wish you a wonderful spring if you are in north America and wonderful fall if you are in Australia. And see you next time. Take care.

Thank you for listening to the SIBO doctor podcast. We hope you find the information in this episode useful in the treatment of your SIBO patients. Thanks to our sponsors, sibotest.com, a breath testing service with easy online ordering. Thanks again for listening.