Transcript of Episode 233: Practical Solutions for SIBO
With Dr. Daniel Pompa and Dr. Michael Ruscio
Ashley:
Hello, everyone. Welcome to Cellular Healing TV. I’m Ashley Smith, and today we welcome special guest, Dr. Michael Ruscio. We have a really popular topic for you today. Dr. Pompa and Dr. Ruscio will be talking all about gut health and, more specifically, small intestinal bacterial overgrowth otherwise known as SIBO.
From daily bloating to constant fatigue and unexplained weight gain, we’ll hear about how gut health relates to just about everything else in the body, how changes in gut health can manifest as disease, and what we can do to fix the problem, and start living a healthy, enjoyable life again no matter how long you’ve been suffering for. If you have ever struggled with your digestion, you will want to check this episode out.
Before we get started, let me tell you a little bit more about Dr. Ruscio. Dr. Michael Ruscio is a doctor, clinical researcher, and best-selling author whose practical ideas on healing chronic illness has made him an influential voice in functional and alternative medicine. Dr. Ruscio specializes in digestive, autoimmune, and thyroid disorders, and he consults out of his Bay Area clinic. His simple and affordable approaches to healing chronic illness could be exactly what you’ve been looking for. Dr. Ruscio’s book, Healthy Gut, Healthy You, is a game changer in teaching you strategies to transform your gut health. Let’s welcome Dr. Pompa and Dr. Ruscio and get right into it. This is Cellular Healing TV.
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Dr. Pompa:
Let’s jump right in, Michael. I have to ask the obvious question. You’re known for the gut work that you do. How did you get into this? Typically, people have a story. What’s yours?
Dr. Ruscio:
I had a story. It’s not necessarily the coolest story of the stories you hear out there. I was in college, and I was actually quite intent on going into conventional medicine. That was really kind of the path that I was on. I was your typical kind of Type A, and had good grades, and was very driven. That just seemed like a laudable goal given all my drive, but also, perhaps, a lack of direction.
They say, “Life is the teacher,” and in my case, the teacher was an intestinal parasite that then brought me to a point of extreme insomnia. If anyone’s ever suffered with insomnia, you know how just debilitating that can be, and bouts of brain fog, which also can be debilitating. When you feel like it’s hard to carry out an intelligible conversation with someone, it’s very, very much a unpleasant impairment.
In addition to some fatigue, and some bouts of depression, and feeling cold, and given I was, months before that, feeling nearly invincible as a college athlete. Nothing here really added up. I was doing what I loved. I was getting adequate sleep. I was eating all organic. I was studying health and nutrition in addition to—
Dr. Pompa:
Oh, my God. It’ll all sound like my story.
Dr. Ruscio:
In addition to my formal academic training, I was also studying those areas. I was dialing all those knobs into optimal, yet I fairly suddenly started feeling quite ill. I went to see three conventional doctors, figuring, well, this is what they do. None of them could find anything with the different assays that they ran.
Dr. Pompa:
I ran down that same road, by the way.
Dr. Ruscio:
Right, and many people do. They commented that, “Well, you have a healthy body composition. Your triglycerides, and cholesterol, and blood sugar all look good. All the major boxes check, and there’s not really anything we can do for you.” I found my way to a alternative medicine provider who focused on digestive health. He told me that, “I think you may have a parasite.” I remember thinking to myself, this guy is off his rocker. This guy must be crazy.
I didn’t do anything, actually, at that point in time. I was kind of thinking about it, but I went out, and I did some research on the internet. I said, “Oh, it sounds like I have adrenal fatigue. Oh, it sounds like I have hypothyroid, or it sounds like I have heavy metal toxicity.”
Dr. Pompa:
I went down the same road, man.
Dr. Ruscio:
Right, and so I did the herbs for thyroid conversion and didn’t really feel much better. I did the adrenal support herbs; got a little boost that later faded. I peed in a cup for my testing of heavy metals, and I came back high in lead and—I believe it was lead and mercury. I did detox work and didn’t feel any better after doing that.
I was kind of brought to my knees by this whole process. I said, “Geez, even though I’m a college student and $350 feels like a million dollars to pay for this stool test that the doctor wanted me to do”—I figured, at this point, I don’t feel like I have much left to lose, so did the stool test. It came back with an amoeba. Treating that amoeba was the only thing that led to lasting improvement in all these symptoms that were not digestive, ironically. That’s actually an important tenet for us to establish here early in the conversation is that you can have things like brain fog, and fatigue, and even skin problems, or joint pain as a byproduct of a silent digestive problem. I learned that the hard way.
I diverted my path into alternative medicine. I loved the field, but there were also some aspects of the field that I didn’t love. I felt there were some aspects that were overzealous and some treatment plans that were totally not guided by science or even reason, but rather dogma and, really, overzealousness. I started challenging some of the things that I’d learned, and trying to find what really worked, and what may have been well intentioned, but misguided. That’s led me to form one retrospective chart review that we’re now drawing up a publication.
We have IRB approval for a placebo-controlled trial we’ll be performing starting, hopefully, in January, looking at a herbal remedy that can help prevent SIBO recurrence, or at least we think it can. We’re trying to see if that actually will be able to perform or live up to its proclaimed ability to aid. I’m trying to strike that balance of giving people well thought out, conservative, but progressive information.
The double edge of the sword here is yes, we want to help people, but if we’re not tempered in our recommendations, then we can lead people into thinking that they’re more ill than they are, that their life has to be more difficult with supplement popping and dietary restrictions than it needed to be. That creates harm in and of itself. Sometimes in attempts to help people, if we’re not careful, we actually harm them. I’m trying to now strike a reasonable and well informed, cautious balance of all those factors.
Dr. Pompa:
I love it. Healthy Gut, Healthy You is the title of your book. Matter of fact, where can you find it just right off the bat?
Dr. Ruscio:
Healthy Gut, Healthy You you can find on Amazon. It’s available both in print and as a Kindle or a NOOK version. You can get it mainly through Amazon, but also through Barnes & Noble.
Dr. Pompa:
People watching this, don’t tune out because if you have a thyroid condition—we both had thought, no doubt, my thyroid’s playing a role, and mine was, but I went down that road like you did. Addressed my adrenals, the whole thing, but there was definitely something more upstream. Today we know the microbiome—the gut plays a role in how our brain works, our immune system. Really, it can tie into our hormones, everything.
Dr. Ruscio:
True.
Dr. Pompa:
I think most of our viewers and listeners get that fact, but many of them right now listening and watching this are still saying, “Okay, but I have done it all. I’m still trying to fix my gut.” Yours was a parasite, and I do want to talk a little bit about that. I, too, when I was sick had parasites. I killed my parasite, but yet, I still had symptoms. I still had insomnia. Things got better a little bit, but it wasn’t until I got the mercury out of my brain that I actually was able to even get rid of a lot of my Candida and parasites permanently because my giardia and other things kept coming back.
All right, so let’s talk about some of these conditions. We talked about SIBO at the top of the show, and I loved what you said. People struggle with this. Maybe it’s not SIBO. How do they know? Maybe it is. How do they fix it? Give us some advice. It sounds like you’re really versed in this because you’re developing a product even to knock SIBO back. Let’s start at the top right there.
Dr. Ruscio:
I actually clarify, we’re not actually developing a product. We’re studying a product that’s often used in the SIBO community as a preventative measure, but there hasn’t been any study done to know if that actually works for the measure it’s purporting to help with.
Dr. Pompa:
What is it? Can you talk about it?
Dr. Ruscio:
It’s just a natural prokinetic agent. There’s a handful of them out there, but prokinetics help to essentially ensure adequate movement of food through the intestines. When there’s inadequate or slowed movement of food through the intestines, that’s one of the underlying causes of SIBO. However, we don’t have any studies on the natural treatments. We do have one drug model study using tegaserod, which is no longer available in the US, and also low-dosage erythromycin, which have shown benefit. They haven’t shown the ability to prevent SIBO from coming back ever, but they delay the time in remission, so that’s nice.
The counterpoint, natural agents claim to do the same thing and support the same underlying mechanism, but there hasn’t been any data showing it can actually help with that. I have some suspicions that the importance of motility in SIBO is clearly there, yes, but I think it’s been overstated. Sometimes people end up pursuing motility at the expense of perhaps not just making a dietary modification or using the appropriate probiotics.
That kind of ties in with your earlier point, which I had to do some additional steps also. I think if I had my book now, I would have gotten healthier so much faster. Yes, I probably got about 70, 80 percent better right after treating the parasite or in the course of a few months, but I had some histamine sensitivity that lingered. Sometimes, for people on the diet, that can be a major problem because as people gravitate toward healthier foods, they’re oftentimes gravitating toward more histamine-rich foods. This also accompanies, and this histamine intolerance can be a byproduct of a damaged intestinal lining.
For some people, that can be game-changing, cathartic, improving experience when they reduce dietary histamine, even though they are these foods that are harped on as being so health promoting, kombucha, sauerkraut, kimchi, any other fermented food, really, and things like spinach and avocado can all be problematic if consumed too frequently for people with histamine sensitivity.
I did have some lingering brain fog, and the real missing piece that needed to slide into place was not eliminating completely—again, not going to these dichotomist extremes of being unreasonable about my level of histamine avoidance, but just realizing that I can’t have, or I shouldn’t have a high histamine food with every meal for days and weeks on end.
Dr. Pompa:
It’s virtually impossible to eliminate them completely, right? It’s like a contamination -inaudible-. There are histamines in so many things. The reduction of it allowed you to get a whole—to make other treatments more effective, or at least work. I liked your point. You don’t eliminate histamines as the solution to your problem. You have a histamine reaction because you have an inflamed gut. It’s this balance.
Let’s back up, though, because you made so many great points. Let’s back all the way up and explain what SIBO is, what symptoms. Many people, they’re struggling with gut. At some time during their gut issue, they deal with SIBO. I dealt with it. I didn’t even know what it was when I was dealing with it. I look back, I’m like, “Oh, I had SIBO.” I fixed it without even knowing what it was. What is it, and let’s talk about some of the symptoms. Then we’ll talk about some of the fixes that will lead us into the whole gut conversation.
Dr. Ruscio:
Sure, so SIBO stands for small intestinal bacterial overgrowth. This is essentially where you have too much bacteria in the small intestine. Now, you should have bacteria—
Dr. Pompa:
It could be good or bad, right? The good guys -inaudible-
Dr. Ruscio:
Right, yeah, exactly. You should have bacteria in your small intestine. It’s not necessarily an issue of them being bad bacteria. There are different theories and observations showing that sometimes it’s bacteria that comes from further down the intestinal tract, grows up. Sometimes it’s bacteria that comes from up the line and makes its way down. There’s debate there. I don’t think it makes a huge difference in terms of—in most cases in terms of how you have to treat this. Essentially, you end up with too much bacteria in your small intestine.
We also know a similar phenomenon can happen with fungus or yeast known as small intestinal fungal overgrowth. You can see this general trend of overgrowth in the small intestine. Why that is so important for a multitude of reasons is because the small intestine is responsible for 90% of caloric absorption, it represents over 56% of your digestive tract, and it is where you have the largest density of immune cells in your entire body. There’s a profound inflammation/immune system connection hinged into the small intestines.
Some of the healthy gut advice, which is centered around feeding gut bacteria with fiber, and prebiotics, and vegetables, and fruits, which can be health-promoting, but in the context of those with SIBO and also with IBS, these may actually be the maneuvers that are worse—the worst possible maneuvers for one’s gut health, which comes back to your earlier point of people being confused and really not knowing what to do.
Oftentimes, people think they’ve done everything, but they really have not. They’ve done everything that they know about, which is great, but it’s me saying I had a legal issue. I went in there as a self-defendant, and I went with every defense I could think of. I’m not a lawyer, so it’s everything that I can see, but it’s not everything that’s available out there.
Just real quick, and I think this is important to establish, your gut—anyone’s gut—is really an ecosystem. It’s not about just what’s the one thing, the SIBO, and just killing the SIBO, or combating the SIBO, or the Candida, or the yeast, or the yeast pylori, or whatever, or the inflammation. It’s really a garden, and we want to find the combination of factors that will create the healthiest soil.
When you have healthy soil or a healthy host, you harbor the growth, and you encourage the growth of healthy bacteria, and fungus, and other like life. Sometimes you get caught in this mono-therapeutic focus. Even in someone who has a fairly high level of specialty in SIBO, I always remember to look at the gut broadly in the context of the whole individual just so we make sure that we’re addressing it as holistically as we really should.
Dr. Pompa:
Let’s talk about it now. Bloating is one of the number one symptoms that people get. Two hours, even six hours after a meal, boom. It feels like you’re pregnant. It feels like you just ate, frankly. Okay, so that’s the number one. Gas both ways, this way and that way, constipation, diarrhea, all of it—what do we do? What’s the first step? How would you walk someone through this?
Dr. Ruscio:
-inaudible- build upon that, that those are your most classically defined SIBO symptoms. We’re now seeing an association with SIBO to hypothyroidism as one, and even thyroid autoimmunity according to a recent Polish study that showed that those with SIBO had a higher level of thyroid antibodies than those healthy controls. Even to skin, we’re seeing SIBO correlated with rosacea and metabolism. We see some evidence showing a—I should mention that the SIBO data there also shows that after treatment of the SIBO, the rosacea, the skin condition, improved. It’s good to have both observational and also treatment outcome data.
Also, we see that metabolism can improve by measure of cholesterol and blood sugar after treatment of SIBO. Just coming back to—I’m trying to reinforce that principle that you often have non-digestive symptoms as a byproduct of a digestive problem. I’m sorry. Was your question where do we start with SIBO?
Dr. Pompa:
Yeah, where do we start? That was a great point because, again, we’re talking beyond the gut here. Your health is your gut here, or your gut is your health. What do we do? What’s the first step?
Dr. Ruscio:
This is all outlined in Healthy Gut, Healthy You. In case people feel a little bit like this is all coming at them kind of fast during this conversation, -inaudible- and we go through it one step at a time just to make it easy. We want to start with diet and lifestyle. That is really the foundation. Now, you’ll hear disparate things about what the best diet for SIBO is. What happens sometimes is people believe X, and so they find research that reinforces X, and they ignore all the research showing that that is not the case for everyone.
What I’ve tried to do is look at what the entire body of literature shows. When you do that, you don’t have to worry about defending a certain diet. You can just say, “Well, there’s a certain population for which this diet works, and it does not work for others.” Let’s look to what the key indicators are—
Dr. Pompa:
By the way, clinically I have found that it is a little bit different for everybody.
Dr. Ruscio:
Right, exactly.
Dr. Pompa:
-inaudible- to your point. Go ahead.
Dr. Ruscio:
If we look at the body of literature on diets, you see that different diets can work well for different people and fail for others. We get into these arguments about what diet is the best, vegetarian, paleo, Mediterranean—
Dr. Pompa:
By the way, I have a whole principle I talk about called diet variation. I believe the magic is in switching diets, and I believe one of the greatest mistakes we make as a modern-day population is staying on the same diet. It typically worked for us at one point, but I believe humans are genetically—DNA is set up to change diet, force adaptation. Therein lies the actual—the key. That’s why everybody’s technically right. With SIBO, I do find, though, that some people, if they take certain products and killers while they’re on things that beat SIBO, that can work, but other people have to get rid of them. It is very different.
Dr. Ruscio:
Exactly, and I completely agree. Now, with SIBO, there’s a couple places that are logical to start, meaning they seem to work for at least a majority of people. Now, a paleo-type diet is one great place to start. A paleo diet does not mean you have to be high protein, high fat, high meat. It can be a lower protein and fat, and higher carbohydrate type of diet. I’ll come back to that in more detail in just a moment.
Essentially, the main tenet is a non-processed, whole foods-based diet where you focus on meat, fish, eggs, vegetables, fruits, nuts, and seeds. It’s a very unprocessed diet, and you can skew the -inaudible- balance of carbs, proteins, and fats to your individual desires. That can be a very good starting point. There is data showing that the paleo diet can help with IBS.
Now, I choose my words very carefully because I try not to conflate different things together. That, I think, only propagates confusion. Now, IBS studies, we have much more of those. We know that anywhere from 4 to 84 percent of IBS may have the underlying cause of SIBO. IBS is just essentially the same symptoms that often manifest as SIBO. They’re definitely kind of a proxy for one another.
We see great research showing—or I shouldn’t say great research. We see some research showing that the paleo diet can help with IBS amongst a litany of other conditions. You can start there. Here’s one of the nice things. You don’t need to be on that diet for months and months to evaluate if that is a appropriate or inappropriate maneuver for yourself. Two to three weeks is ample time to at least be able to say, “Yes, I’m feeling better.” Will you be 100% healed? No, but you’ll be able to clearly say, “Yes, I’m feeling better,” or, “Eh, I don’t really notice anything,” or, “I may even feel a little bit worse.” For those people, they can progress to another two- to three-week dietary trial. I’m happy to expand upon that one if you’d like.
Dr. Pompa:
Yep, absolutely.
Dr. Ruscio:
The next one would be a low FODMAP diet. People have probably heard about low FODMAP diets. Essentially, one of the main principles of a low FODMAP diet is it restricts foods that are rich in prebiotics, which feed bacteria. Some of these foods are stereotyped as being very healthy. Again, it’s not to say that they’re always healthy or always unhealthy, but it’s learning, to your earlier point, what person will benefit from what maneuver dietarily.
In people with IBS and with SIBO, some evidence is showing that—definitely those with SIBO have too much bacteria, and so eating foods that are very rich at feeding bacteria would logically not be a good idea. Other people who don’t have abnormally high levels of bacteria may be abnormally sensitive to the gas pressure that’s caused when bacteria essentially eat and then release gasses.
Even for those without SIBO, a low FODMAP diet can be helpful due to some people being hypersensitive to gas pressure. We do have a number—over 10 randomized clinical trials showing quite impressive effectiveness of a low FODMAP diet. I should also mention that the low FODMAP diet, in addition to helping to starve some of these bacterial overgrowths—and I say this in the context of sometimes the low FODMAP diet is depicted as being unhealthy for your gut because it starves bacteria, but that is a—it’s a very narrow way of looking at this issue, again, coming back to some of our earlier points.
We know that a low FODMAP diet can reduce leaky gut, inflammation, immune activation in the gut by decreasing histamine and may actually enable the increased growth of serotonin and PYY cells in the intestines to make, essentially, the cells in the intestines more like that of healthy controls. It’s important not to take one observation that people who go on a low FODMAP diet see a decrease of Bifidobacterium populations, which is true, but if that occurs in a healthier host and looked at along with all these other contextual factors, then I am hard pressed to make a argument that a low FODMAP diet is an untenable recommendation.
Dr. Pompa:
Again, we’re not saying to stay on that diet forever. I believe, again, it’s the variation. Periods of diet change are actually good regardless of the temporary changes it does in the microbiome. Explain to people because that may be the first time they’ve ever heard of FODMAP, and they’re going, “What? What is this? What is it?” Give a little bit more explanation of what—paleo, I think, people understand. You’re right. You can change how much protein. Explain this.
Dr. Ruscio:
Sure, and I should just mention that I absolutely agree with your point in terms of broadening the diet or changing the diet. As people become healthier, they will be able to thrive on a broader array of foods. It’s very important that we establish that. Then regarding the low FODMAP diet, this is a diet low in mainly carbohydrates, fruits and vegetables, specifically, that feed or are rich in prebiotics and are powerful at feeding bacteria.
The foods are—they don’t seem to have a huge rhyme or reason. There are many stereotypically healthy vegetables, many in the Brassica family, that are actually high in FODMAPS and to be avoided on a low FODMAP diet. It’s fairly easy to find a good food list on the internet. Not every food list agrees, so don’t let that freak you out. It’s not about looking at the small amount of disagreement that you want to focus on. It’s the large amount of foods that are agreed upon. The book also gives you a well-researched low FODMAP diet food list.
Things like broccoli, cauliflower, asparagus, avocado are all high FODMAP. Some people go paleo, and they cut out—maybe they were eating some grains, and they cut out some of those grains and eat a lot more vegetables. All of a sudden, they feel worse. That does happen to some people. I know it’s very defeating when you’re taking actions to improve your health, yet you’re feeling worse, but for these people, it may be a simple adjustment of going to a lower FODMAP diet. Then they may feel better within, again, two to three weeks.
Dr. Pompa:
There’s truth to that, as well. Okay, let’s go on. Let’s call it step three, if you will.
Dr. Ruscio:
Within that diet and lifestyle—I’m sorry. It’s lifestyle, and I think you’ve probably addressed that fairly amply up until now, so I think people understand sleep, exercise, manage stress, pursue purpose, what have you, but worth, at least, just ticking those very briefly. The next step would then be some non-dietary interventions. This is what some people get stuck in sometimes. They get stuck in the quicksand of diets, and they don’t know when it’s time to leave the dietary trial camp and then go into some non-dietary interventions.
This is important because some people will try to force a dietary solution to a non-dietary problem. We want to make sure we don’t keep beating them over the head with the dietary stick. Now, one of the next things that someone can do that can be very helpful is a course of probiotics. There’s quite a bit of confusion regarding probiotics because there are hundreds, if not more, products out there.
What I did in the book was help the reader realize that there are really three to four categories that almost any probiotic product can be organized into. Now, category one of probiotics consists of a mainly Lactobacillus- and Bifidobacterium-predominated blend. When you look on the label, you’ll see Lactobacillus acidophilus, Bifidobacterium infantis, and you’ll see mostly—those probiotics will be either a Lactobacillus or a Bifidobacterium species probiotic. That’s category one. You want to definitely try one of those because they’re—that is the most well-studied category, and they have been shown to have the ability to combat SIBO, fungus, parasites, and to improve IBS. I’m talking very high-level scientific data.
Now, category two is a Saccharomyces probiotic—a Saccharomyces boulardii-containing probiotic. This is actually a healthy fungus. When you look on the label there, you will see Saccharomyces boulardii. Then category three is your spore-forming, also sometimes described as a soil-based probiotic. Here you will see predominately Bacillus strains, Bacillus licheniformus, Bacillus subtilis, Bacillus clausii. These strains have also been shown, up along with the Saccharomyces boulardii, to have a multitude of benefit for someone’s gut.
There’s another important aspect to this, which is most people—by far, the majority of people will either be neutral or benefit from the use of probiotics. However, there’s a smaller subset that may notice some kind of negative reaction. Why the category system can be helpful, amongst other things, is if you try product after product after product and you don’t understand, and you keep having this bloating reaction because you keep taking a Lactobacillus/Bifidobacterium category one blend, the answer there will allude you for a very long time.
If you can understand that, okay, I’m going to try each one of these categories of probiotics, see how each one feels relative to my gut health, and then use what works, and discard what doesn’t, now you can, in a very short period of time, personalize a probiotic protocol for your individual gut. One of the next most powerful steps can be a high-quality probiotic, taking into consideration the different categories to help personalize the mixture to an individual.
Dr. Pompa:
I want to make people aware of this potential pitfall, as well. You find one that works, and then stay on it for many months, a year, and then you end up monoculturing. One of the things I love to teach is rotate these bacteria—very important—or even go on and off of them. I find that the soil organisms, people with severe SIBO, it’s a very safe place to start. They seem not to react, the people especially who react to probiotics. That seems like the place to start. I don’t know what you’ve found there, but—
Dr. Ruscio:
I’ve heard that. I haven’t found that, clinically. I was swept into that thinking—I think I was maybe placeboing myself for just—because it’s very hard when you hear many people saying one thing, not to create that placebo effect in your own head. I mean, it’s difficult. We know that in IBS trials that are placebo controlled, meaning that all of the placebo effect is attempted to be designed out of the study, the average placebo effect is 45%. Placebo, even for the most brilliant mind, is a powerful fact to guard against.
There are some people who clearly do better on soil-based, but there—I’ve also noticed there are clearly some people who do better on the Lactobacillus and Bifidobacterium blend. Then some people do well on neither, and only well on the Saccharomyces boulardii. I think they all have a case that can be made for them.
I do think that in the general scientific literature, the utility or just the recognition and identification of the soil-based organisms is not where it should be. There should be more data on those. We only have, I believe, about 14 clinical trials with soil-based probiotics whereas we have maybe a few hundred with the Lactobacillus, Bifidobacterium blend. Unfortunately, the category one does kind of predominate the conversation right now, but I do think that’s shifting in a positive way.
Dr. Pompa:
Then what? What’s step four for—do we go killers at this point?
Dr. Ruscio:
One of the next—and there’s some nuance in here, also. Of course, we can’t go through every aspect of the steps in detail. Along with that second step, there’s also the consideration of adrenal support and enzymes. Especially with enzymes, even more so with hydrochloric acid, I think there’s a lot of confusion about that, and I tried to really dispel some of that confusion in the book. I’ve seen some cases where their non-responsive GI symptoms were a byproduct of taking acid when they didn’t need to or taking bile when they didn’t need to. Those can both be helpful, but we want to make sure that we’re not having someone go on something just because, oh, I heard it was good for your gut health. We want to make sure to qualify that per individual.
After we get through that confection of different treatment options, then we can escalate to antimicrobial herbal therapy, so things like oregano, and [Allicillin], and berbamine. People have probably heard of many of these. If someone is not able to resolve dysbiosis or imbalances—dysbiosis is a umbrella term for SIBO, and H. pylori, and Candida. It kind of encompasses everything. Then herbal antimicrobial agents can be one of the next things to consider to administer. We do have data showing that these herbs can work well for a number of conditions.
The nice thing about these is many of these herbs have broad action where they will act against bacteria, fungus, and parasites all at the same time. This is nice because as helpful as testing can be, there are probably more things that we cannot test for or cannot routinely test for. Another mistake people make is they want to try to test their way to better gut health. I can tell you that, yes, testing does have a time and a place, but I am doing far less testing now than I was several years ago. The book protocol is—
Dr. Pompa:
-inaudible-
Dr. Ruscio:
Yeah, and the book protocol can be done without any testing because, again, it’s not about knowing what the one thing is. We’re trying to create a healthier milieu in the gut soil globally. We can perform some pushes and pulls to the gut milieu and read someone’s response to figure out what’s working well for them. The herbals are nice because instead of having to worry about is it SIBO and Candida, or is it one or the other, the herbs can help to give a gentle push to the microbiota and thus, hopefully, if it works, after that push, the microbiota will rebalance to a healthier equilibrium.
Dr. Pompa:
Most of the herbs, they don’t wipe out the good bacteria. They kind of bring things in control. It’s definitely a better way to go. Is there another step? I do have a question about hydrogen-producing bacteria. People are going to ask—you and I just mentioned testing. Can I test for SIBO? Of course, there’s breath tests, but talk a little bit about that if there’s not a step five.
Dr. Ruscio:
Yeah, there are more steps. There’s actually a -inaudible-
Dr. Pompa:
That’s why I didn’t want to cut you off, but I had to -inaudible-
Dr. Ruscio:
I get it. We’ll help keep each other in check here because there’s a lot of different ways we can go. We’re going to have to anchor each other. There’s the ability within the book protocol to escalate the antimicrobial therapy. People may have performed the antimicrobial therapy in the past and seen a small response or only a short-lived response. There is definitely something that can be done to help make that response greater or more long lasting.
Sometimes it’s a simple adjustment to the dose and the duration. Sometimes we have to add in the addition of anti-biofilm agents to help with the stubborn colonies and/or along with that, anti-inflammatory and specific antiprotozoal agents. The nice thing here is you have one agent that can act as both of those. Then the furthest or the highest escalation of antimicrobial therapy can be a liquid-only meal replacement known as an elemental diet.
This is where we do have one formula that I think is a bit novel that I mention in the book, which is a palatable version of an elemental diet. Just in brief here, an elemental diet is essentially if you were to picture a meal replacement shake, that devoid of any artificial sweeteners, bad colorings, fillers, excipients, super hypoallergenic and gut friendly, and devoid of really any prebiotics and—that’s been researched in a number of studies to help reduce both SIBO and gut inflammation.
We use a formula known as Elemental Heal, which is a semi-elemental diet, which is palatable. That’s the big thing. The older generation of elemental formulas were very, very hard to stomach. They just tasted horrid. There’s a newer generation coming out that are palatable. For people who have not responded to anything else, sometimes knowing how to use and using a good elemental diet formula can be a real game changer. Those are a few of the things—a few of the maneuvers that we can perform within the antimicrobial therapy. Then you were also asking—sorry. Remind me what the other question was.
Dr. Pompa:
I know there’s different ways of testing for SIBO, the breath test, which, again, I went down that road. I stopped doing it. What’s your thoughts on it? That’s the breath test.
Dr. Ruscio:
There’s a breath test that can be performed for SIBO, and that’s likely the most validated. There is a gold standard, which is essentially with an endoscopy tube, taking a sample out of the small intestine, and culturing that sample. Some of the validity of that measure has actually been questioned, and it’s obviously not able to be done in routine clinical practice.
Now, that can be helpful, but—and you will see disparate recommendations. Some people will vehemently recommend testing every time they go in to treat SIBO and perform serial retests. I think that that contingent is slowly becoming a bit less testing prone as we’re learning more about this. You will see others who recommend no testing at all. I think the truth lies somewhere in the middle, probably a little bit closer to the no testing at all.
The North American Expert Consensus concluded fairly liberal use of SIBO breath testing. The [Rome] Consensus, which is probably the most highly regarded body in gastroenterology in the entire world recommended reserving it for select cases where you had evidence of malabsorption. One systematic review suggested treat to get a base line to see if that’s one of the chess pieces on the board, and then from there, treat empirically, which is what we do in the book. Treat empirically, meaning treat someone, observe the response, and then use their response to adjust the treatment. That’s essentially what I do in the clinic, and that’s what I recommend in the book, also.
There are also other tests that can be done. There are other breath tests that can be done for H. pylori. There are stool tests, of course, that can be done for other types of dysbiosis. There are even blood tests that can be performed and other urine tests. It’s tempting. I understand. In theory, it’s tempting to say, “Well, I want to test to know what’s there.” Some people say, “If we’re not assessing, we’re guessing.”
There’s another aspect of this, which is very important, which is if you’re only able to assess 30% of what we know could be a problem, then how helpful is your testing, especially if you stop listening or your don’t listen as closely to the patient’s changes because you’re only looking at what the labs show? This is one of the ultimate travesties of a testing-heavy method of practice is you don’t get those absolutely valuable pearls from the patient’s response to steer how you’re moving things forward.
Dr. Pompa:
I agree 100%. Then you have your certain bacteria that are hydrogen producers, certain bacteria that are methane producers. I interviewed Dr. Brown on—he has -inaudible- product called Atrantil, which, by the way, my doctors absolutely get fantastic results. It has a tendency to treat both. People argue, well, if you test, you could then target the hydrogen producers, which are different to kill than the methane producers. What’s your thoughts on that?
Dr. Ruscio:
I think that question brings us to what I think is another incredibly important fundamental pillar for us to establish, which is—how do I say this most diplomatically here? If you’re looking to make practice more difficult, you will certainly be able to make that a reality, but if you’re looking to make practice more simplified, then you will be able to make that a reality. The challenge is that some people—
Dr. Pompa:
-inaudible- well.
Dr. Ruscio:
Some people really enjoy the complexity, which is all fine and good, but you must always look for how do we bring this back to the simplest core set of recommendations, or treatments, or tests?
Dr. Pompa:
By the way, Doc, I train doctors, so that, what you just said, is very, very true. I have a group that absolutely loves to make it more complicated, and that’s the way they’re going to function. Then I have a group that absolutely wants it simple. You’re right about that.
Dr. Ruscio:
It’s not to say that what you do would be any less effective or any less scientific. In fact, I would argue—and I believe it was Einstein that first said, “If you cannot explain something simply, then you do not understand the problem well enough.” We should not conflate being remedial with being simple. A good clinical algorithm is one that—
Dr. Pompa:
I’ve been doing this for many years. I’ve been teaching for well over 15 years going on 20. The longer I go into it, the more I’m making things more simple. It’s like you said, the less I test, the more that I—you just really end up at a more simple view the more you learn.
Dr. Ruscio:
Precisely, right. The more we learn—and this is happening as a field—the less we have to do. A cell phone now can do 10 times, arbitrarily, what it used to be able to do five years ago, and it’s half the size. As we get better, we should be able to do more with less. I can say, for some patients and certainly for some doctors, the piece that eludes them is they’re making things unnecessarily complicated.
Here’s a great point. By the way, there’s a lot that we know works. Sometimes what I find happens is people are chasing down the exotic, and the new, and the complicated, but they haven’t even mastered the therapies that we know work. If that’s happening to you, then you are doing your patients a disservice. It’s not intentional. Obviously, we’re all trying to help people as much as we can. It’s just important to realize that sometimes these new and novel things, if they’re distracting you from having a mastery of what we already know works, then you’re really committing a dice roll.
To your point, I see the validity in testing to identify what type of organisms, hydrogen or methane, if you’re using pharmaceuticals because then you would want the one certain pharmaceutical, or potentially two different pharmaceuticals if it was methane, or a different pharmaceutical altogether if it was a fungus. Again, with the herbal medicines, it appears that most of these herbal medicines have broad-acting effect.
Again, do we need to make it more complicated like that? I really don’t think so. I would rather have someone undergo antimicrobial therapy, look at their response, and then we can say that either cause a reaction, so we have to change to a different formula because it was likely some kind of allergic or intolerance reaction—they improved somewhat, meaning we can either go longer, or a higher dose, or use biofilms, or they didn’t respond at all, meaning maybe the stimulus that the microbiome needs is not antimicrobial stimulus. If you get so caught up in all the details of these tests, you may miss some of those simple directing cues at the expense of trying to analyze all of this complicated lab data that you’re pouring over.
Dr. Pompa:
I agree. Without pulling you into a new topic, a new direction, which I tend to do, what are—what’s the next steps with this that are absolutely imperative that people listening need to hear?
Dr. Ruscio:
After someone performs antimicrobial therapy, I do recommend they use a prokinetic, but again, my recommendation there may change in light of the placebo-controlled trial that—it’s been actually a few years long to actually run this trial.
Dr. Pompa:
Back up. Prokinetic, people aren’t going to understand.
Dr. Ruscio:
I’m sorry. Prokinetic is an agent that helps to keep food moving through the intestines at an appropriate pace. That is one of the recommendations I make at the moment. That may change in light of new findings depending on some of the research that we’re going to be performing. To take a broad spectrum natural prokinetic—many of the ingredients in these are very novel and, arguably, maybe even health promoting like ginger. We don’t have to make, necessarily, a hard case for safety. It’s cost that I also try to be very sensitive to, and that’s why I try to minimize the amount of things that people take so that they’re not incurring more cost than they need to.
A prokinetic may be helpful. The other thing that I think is probably more important and maybe something that’s more of a tripping point for people is we wait until this point until the experiment with either increasing the prebiotic and fiber content of the diet or utilizing a fiber and/or prebiotic supplement in their supplement regimen.
There’s a very important directing principle that—if you look at all the literature, you can kind of tease it out. People who are the most symptomatic have the highest chance of negatively reacting to prebiotic and/or fiber supplements. There are data showing that they can be helpful. They have shown the ability to reduce blood sugar, and leaky gut, and help with essentially healing the gut, and feeding bacteria that feed short-chain fatty acids. There have been some mechanistic and held outcome data points showing that the prebiotics and the fiber can help, but they can also flare people. How do you know which way someone’s going to go?
It seems that the more symptomatic someone is, the higher the probability that they’ll have a negative reaction to fiber or prebiotic supplementation or high levels in the diet. We wait until we’ve gotten a little bit down the road of the gut-healing protocol to then cautiously introduce these to see if someone will benefit or if they will have a negative reaction. Then if they do, we go into that with our eyes wide open, and we pull them out of that very quickly in case they’re reacting negatively.
Dr. Pompa:
Every fiber’s not created equal, you know. You have more soluble fibers, which the bacteria love to eat, and then you have the more insoluble fibers like psyllium, which is more of a prokinetic. It moves through. Talk about some of the prokinetics that you’re studying. Talk about what they are, the things that our viewers can be like, “Oh, okay. I could try this to help speed things through the gut a little bit better.”
Dr. Ruscio:
Again, I would only recommend someone uses those after they’ve gone through all the other steps in the protocol because you want to make sure you use this at the appropriate point in the sequence. Iberogast is probably the most well-studied compound. That was what we were going to study originally, and we had approval to study that.
Then Iberogast changed hands in terms of who owned the formula, and they took that product off the market in the US. You can still buy it—for no safety reasons to my knowledge. It’s probably just a business decision that dictated that maneuver. You can buy it still through some online outlets if you live in the US. It’s just we couldn’t study it if it wasn’t allowed for distribution in the US.
MotilPro is another good agent that can be helpful, which has some similar but different ingredients, ginger as one, and then there’s a few other compounds. The challenge that we get into here is we have predominately mechanism studies and very few outcome studies with these natural prokinetics. Why that’s detrimental—and this is another, I think, fundamental point I talk about in the book. If you look at mechanisms, and then from the mechanism and for what the treatment should be, there’s a fairly high probability that you could be wrong.
To your earlier point about soluble and insoluble fiber, one would think because soluble fiber feeds bacteria, for the people with IBS, the soluble fiber would be the most prone to causing reactions. It’s actually the complete opposite. The people who have IBS do the best with soluble fiber and have the highest incidence of adverse reactions with insoluble fiber, which it totally doesn’t make sense.
Dr. Pompa:
Oh, yeah. -inaudible- more irritable. The bile is irritable, and it tends to make them—drive them nuts.
Dr. Ruscio:
Right, or even as another example, we would think that people with gut inflammation or leaky gut would do better on a high FODMAP diet because prebiotics and FODMAPS feed bacteria; bacteria secretes short-chain fatty acids; short-chain fatty acids -inaudible- inflammatory and repairative to the gut lining, yet we see, for some reason, for those people, when they do that, they actually can feel worse.
The point I’m driving at is with the prokinetics, theoretically, they should work, but until we really can substantiate that, I do recommend using them, but I don’t put all my eggs in that basket in terms of prevention. Those are probably the two better-known prokinetics that are on the market. There are some different ones in Canada that are essentially some of the—some similar ingredients, but that’s an area where I still think we have a decent amount to learn.
There are medications that can useful. Low-dose naltrexone is one, and that may have other -inaudible- amino modulatory benefits. Low-dose erythromycin is another in addition to a third compound known as Resolor. These drugs, you’ll have side effects. It’s not to say that they have severe side effect profiles, but I think people like -inaudible- starting with the natural compound, and so that’s where we recommend people start in the book.
Dr. Pompa:
Real quick on the drug thing, the [Xican], what about the one that they advertise on TV? Am I saying that right?
Dr. Ruscio:
Xifaxan?
Dr. Pompa:
Xifaxan, thank you. That seems to help with the—it helps more with the methanes and not the hydrogens, so it only works for about half the people. What’s your thoughts on it?
Dr. Ruscio:
The Xifaxan, or rifaximin as it’s also called, that helps with—I think you inverted those—with the hydrogen—yeah—
Dr. Pompa:
-inaudible- I invert everything.
Dr. Ruscio:
Yeah, I do this. It’s hard sometimes to keep all the details straight. That helps with the hydrogen SIBO. It likely needs to be combined with neomycin, which probably has a little bit more—not probably, appears to have a higher side effect profile than the rifaximin. There’s two different pharmaceutical antibiotics that be used, and they can be helpful.
Now, especially the rifaximin is criticized sometimes, and I actually think that we should defend the antibiotic in this case. I really do try to be objective. Even though I like the natural medicines, there are—we want to be fair. With rifaximin or Xifaxan, the studies that are criticized are studies that are only using one intervention of an antibiotic. They’re not combining the intervention with diet, lifestyle, probiotics, preventative treatments.
Would we expect to see a remarkable level of improvement with just one mono-therapeutic approach? No, but those studies showing benefit, even though some of those studies are short-term benefit with rifaximin, do substantiate the idea that antibacterial therapy can be helpful in IBS and SIBO. I think as natural providers, we have a nice, robust toolkit of other therapies that can work along with the antimicrobial treatments to extend and hopefully prolong indefinitely the improvement that can be garnered -inaudible-
Dr. Pompa:
Listen, I’ve had people helped by it, honestly, and again, whether it’s—I’m making up a number—50% of them, it still was helpful in some of the cases, for sure. Oh, gosh, where were we going with that, though? We had something else. We were going down—I knew me asking that question was going to throw me off because we were really going down a road there.
Oh, I know what it was. People utilize, gosh, even Vitamin C flushes to just push out bacteria. Sometimes it works. People utilize—we kind of talked about fiber. Sometimes that can help move things along. Magnesium is another. These are basic things that people use that sometimes help. Is it in that same category that we were discussing?
Dr. Ruscio:
Great question. Technically, these are not known as prokinetics. They’re known more as laxatives. There’s a difference there. It doesn’t make a huge difference for our audience.
Dr. Pompa:
They -inaudible- peristalsis, but they have a flushing effect.
Dr. Ruscio:
Right, now for constipation, yes, magnesium, Vitamin C can both work very well as can a predominantly soluble fiber. Now, the constipation can also be a byproduct of bacterial overgrowth or a food choice. We also have data showing that probiotics can be an effective treatment for constipation.
Now, one nuance here—and we also talk about this in the book—is that when people go on a low FODMAP diet, sometimes they’ll become less bloated but more constipated because the low FODMAP diet is reducing some of these fibers and prebiotics. If you know that going in and if you tell people that going in, they have a better ability to kind of wrestle with that mentally, and they understand, okay, this is helping with the bloating, some of the gas, maybe some of the abdominal pain, but I’m a little bit more backed up, so now I’m going to do one serving of magnesium citrate at night, and my bowels are now moving fine.
Dr. Pompa:
Yeah, right, then it’s helping.
Dr. Ruscio:
For the majority of cases, by optimizing their diet, finding the right probiotics, using a little bit of natural laxation support, which for some people, it’s totally normal if they need that. A little bit of fiber, or magnesium, or Vitamin C, or a mixture of those, totally reasonable. There’s a small subset of people who may have constipation induced via non-IBS mechanisms, so to speak. If someone has all their other digestive symptoms ameliorate, go away, yet they’re still left with constipation, then that may be a different type of constipation.
In some of these cases, it could be known as dyssynergic constipation where there may be tightness in the muscles, especially in the pelvic floor. We’ve interviewed a gastroenterologist motility specialist who has pioneered something known as biofeedback therapy, which can retrain some of those muscles, and so essentially the colon to contract and the anus should open up to expel feces. In some people, that signal gets skewed, and they have to retrain those muscles. The solution is essentially this retraining.
Then in other people, they may have slow transit constipation of which there are a number of treatments. We have discussed this with gastroenterologists on our podcast, and we’ve referred for some patients to use these. A small number of patients seem to like them, but I’ve found that many patients would rather be on fiber, and high-dose magnesium, and maybe even an occasional enema than use some of the medications like linaclotide, or Linzess, or what have you. I do think there’s a time and a place for those. It’s just a very small subset. For some people, they do help. We should remain open, but try to really utilize the most noninvasive therapies first for a specific condition.
Dr. Pompa:
I’ve seen this little food for thought here that PEMF devices can help that, what you’re talking about and even get the peristalsis moving because part of it’s neurological. I’ve seen people with laser devices and light therapy actually help, as well. There’s some other thoughts. Here’s a big one: We both have seen this where something as simple as the ileocecal valve can be open. Now, we can argue how did it get open in the first place? You have to go upstream even further. Closing it makes a significant change in people. Talk a little bit about that.
Dr. Ruscio:
I wish there was more data looking at some of these ileocecal valve therapies. Manual therapies are often used, and the—
Dr. Pompa:
Pretty much going in and finding the tender point, and basically massaging it. That’s pretty much as simple as it gets.
Dr. Ruscio:
I think the group that’s really done the best to advance visceral massage or visceral manual therapy has really been Gary and Belinda Wurn who are at Clear Passage and have pioneered a therapy known as Wurn therapy, where they’ve documented reduced infertility, reduced SIBO relapse after doing an assessment and then breaking down, with fairly intensive manual therapy, these scar tissues and these adhesions.
I think if there’s a structural component to this, it may not be as specific as the ileocecal valve, per se, but maybe there’s points at which there’s adhesions or scar tissue that need to be manually broken down. By doing that, definitely, there have been some—again, a small percentage of cases, but certainly some cases that have seen very, very impressive results from some type of visceral therapy to the abdomen.
Especially if someone has any history of abdominal trauma or surgery, that indicates that you may be someone who wants to consider this. Then if you also have a history of any kind of inflammatory issue in the gut or the bowel, inflammatory bowel disease, endometriosis, or any kind of tubal obstruction, or ligation, or issue—and I’m regarding some of the female parts—then you may want to consider this.
It’d be something at end phase, and I do recommend some of these therapies as considerations at the end of the book for a section—what do you do if you’ve done everything in the book and you still haven’t optimally responded? That will really only be the minority of people because the book protocol is quite robust. There are some things, like this visceral therapy, you’re going to have to go see someone in person to really have that sorted out.
Dr. Pompa:
Folks listening and watching, if you take your belly button and the prominent place on your hip, there’s a diagonal line—I don’t know—six inches, maybe less, five inches. Go about halfway, push in. If you find a tender spot, maybe you need some of this work. Again, to Dr. Michael’s point, it could be even more complicated than that, but at least it’s a place to start. I’ve watched enough people make a significant difference just finding that tender spot and having someone or even yourself work that spot out.
Okay, let me give you the final word here as we come to a conclusion. Great stuff, Dr. Michael, and again, find the book, absolutely. I think this book will be a really good seller. It sounds like you’re really well researched, which I appreciate. Healthy Gut, Healthy You, Amazon, find it. I’ll give you the last word, Michael, on this topic that—something that these people need to hear.
Dr. Ruscio:
I think there’s really two things in one that are the most important for people to keep in mind. One is to be careful with where you get your information. I say that because I’ve seen enough patients read on the internet why they should avoid low FODMAP, or carbs, or lectins, or oxalates, or fiber, or gluten, and they’re not given the context and the carefulness with the crafting of the message. They end up making themselves sick or making their lives more difficult because they have this fearful relationship with food.
If that’s happening to you, it’s really detracting from your health rather than contributing to your health. I tried to write into the book a very hopeful and a very empowering message regarding diet and not one that’s doom, and gloom, and fearful. That, I think, is the one because it’s very important that people don’t make themselves sick because they feel they have to encumber themselves with this daunting level of dietary avoidance. It’s very, very important.
Then kind of along with that in terms of mindset is—and I always share this Nietzsche quote, which is “He who has a why to live can overcome almost any how.” It’s important that you maintain a foot in what you want to do with your life. What happens sometimes is these come together, and people start withdrawing from their work, or from their purpose, or from even their social interactions because they’re trying to diet harder, and harder, and harder. It’s very important to have a healthy outlook on your diet and good educators to help you achieve that healthy outlook.
Then make sure, if you want to be the best mom in the word or if you’re trying to lead a non-profit, or whatever you’re trying to do, keep that purpose in your life because that purpose will help pull you through some of the challenging times we all go through.
Dr. Pompa:
Well said, Doc. Love it. Well said. Great job. Great interview, and thank you for being on Cellular Healing TV.
Dr. Ruscio:
My pleasure. Thank you for having me.
Dr. Pompa:
-inaudible- the book. Thank you.
Dr. Ruscio:
Thank you.
Ashley:
We hope you enjoyed today’s episode of CHTV. We’ll be back next week and every Friday at 10 AM Eastern. You may also subscribe to us on iTunes or find us at Podcast.DrPompa.com. Thanks for listening.
