When working with someone who has SIBO and HPA-D, I had understood from the SIBO point of view, in order to help the MMC, it’s a good thing to have four to five hours minimum between meals and 12 hours of no eating overnight, but then the HPA-D may need to support more frequent eating. How do you approach this, and what would be your advice as the SIBO is also likely contributing to the HPA-D? So is it just important to focus on getting rid of that first?

Chris Kresser:  I don’t know how important either of those strategies is on an absolute level. I think it really depends on the person. There are lots of people who successfully treated SIBO without going five hours minimum between meals or 12 hours of eating overnight, although I think many people just naturally do go 12 hours without eating overnight without much difficulty. So that should be fairly easy. Certainly I would aim for that, four hours between meals, but if that makes totally spin somebody out and then makes them unable to cope with life, that’s not going to be beneficial or valuable. I would say shoot for that, and if the HPA axis is functioning relatively well, they should be able to tolerate that, but if they’re really, like they get super jittery, anxious, and feel horrible if they do that, then that’s probably not a good idea to recommend that.

We’re always having to modify our plans based on who’s in the room in front of us—the individual characteristics of our patients. Everything that we talk about here, we can always just think of it as a starting place in the general guideline, and then we have to tweak it based on individual circumstances.