This episode is a replay of a popular show from 2018 with gut expert, Dr. Michael Ruscio.
Dr. Ruscio joined me to discuss the complex topic of Small Intestinal Bacterial Overgrowth, otherwise known as SIBO.
You’ll learn how your gut health relates to just about everything else in the body, how imbalances in the gut can manifest as disease, and you'll hear tips about we can do to address the problems in your gut, no matter how long you’ve been struggling. I hope you’ll enjoy this episode!
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.
- CytoDetox: total detoxification support where it matters most – at the cellular level.
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Transcript:
Ashley:
Hello, everyone. Welcome to Cellular Healing TV. I’m Ashley Smith, and this episode is a replay of a popular show from 2018 with gut expert Dr. Michael Ruscio. Dr. Ruscio joined Dr. Pompa to discuss the complex topic of small intestinal bacterial overgrowth, otherwise known as SIBO. You’ll learn how your gut health relates to just about everything else in the body, how imbalances in the gut can manifest as disease, and you’ll also hear tips about what we can do to address the problem in your gut no matter how long you’ve been struggling. I hope you’ll enjoy this episode.
Dr. Pompa:
SIBO, which we’re going to jump deeper into because I love what you said. I made the comment that, “Gosh, people really have trouble with SIBO.” You said, “Man, it’s very simple. Let’s talk about that.” I love that. I can’t wait to hear it. People do; they ask a lot of questions about SIBO, small intestinal bacterial overgrowth, which has so many causes to it that people get very confused. You’re going to bust through that today. Also, your new book, I really want to promote that for you because it’s going to break into these conversations as well.
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 the path that I was on. I was just your typical Type A and had good grades and was very driven, and that just seemed like a laudable goal given all my drive but also perhaps a lack of direction. They say life is a 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—yeah, how 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 an 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 my…
Dr. Pompa:
Sounds like me. It really sounds like my story.
Dr. Ruscio:
Right, in addition to my formal academic training, I was also studying those areas, so 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, and 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 an alternative medicine provider who focused on digestive health, and he told me that I think you may have a parasite. I remember thinking to myself this guy’s off his rocker. This guy must be crazy.
I didn’t do anything actually at that point in time. I was thinking about it. 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 got 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. I believe it was lead and mercury. I did detox work and didn’t feel any better after doing that.
I was 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 to lose so did the stool test. It came back with an ameba, and 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, and 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 learned and trying to find what really worked and what may have been well-intentioned but misguided. That’s led me to perform one retrospective chart review that we’re now drawing up for publication, and we have RIB approval for a placebo-controlled trial we’ll performing starting hopefully in January looking at an 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 needs to be, and that creates harm in and of itself. Sometimes in attempts to help people, if we’re not careful, we actually harm them, so I’m trying to now strike a reasonable and well-informed cautious balance of all those factors.
Dr. Pompa:
Yeah, no, I love it. Healthy Gut, Healthy You is the title of your book. Matter of fact, where you can 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, and you can get it mainly through Amazon but also through Barnes & Noble.
Dr. Pompa:
Obviously, people watching this, don’t tune out. If you have a thyroid condition—we both had thought, no doubt, my thyroid’s playing a role. Mine was, but I went down that road like you did, addressed my adrenals, the whole thing. There was definitely something more upstream. Today we now 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. I do want to talk a little bit about that because 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.
Dr. Ruscio:
Me too, yeah.
Dr. Pompa:
It wasn’t until I got the mercury out 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 because 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, so let’s start at the top right there.
Dr. Ruscio:
I should 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 it actually works for the measures 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-dose 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. 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 they 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 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’ve gotten healthier so much faster. Yes, I probably got about 70, 80% better right after treating the parasite in a course of a few months. I had some histamine sensitivity that lingered, and sometimes, for people in the diet, that can be a major problem. As people gravitate toward healthier foods, they’re often times gravitating toward more histamine rich foods. This also accompanies and is a—and this histamine intolerance can be a byproduct of a damaged intestinal lining.
For some people, it can be a 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. 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 dichotomous 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:
I mean, it’s virtually impossible to eliminate them completely, right? I mean, it’s like a contamination, worse. The histamines are in so many things, but the reduction of it allowed you to get a hold—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, right? You have a histamine reaction because you have an inflamed gut. It’s this balance.
Okay, 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. It’s sometime 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, right? I look back, and I’m like, oh, I had SIBO. I fixed it without even knowing what it was. Okay, so what is it? Let’s talk about some of the symptoms, and 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, and this is essentially where you have too much bacteria in the small intestine. Now, you should have bacteria.
Dr. Pompa:
Good or bad, it could be good or bad, right? The good guys [00:12:36].
Dr. Ruscio:
Right, yeah, exactly. You should have bacteria in your small intestine, and 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, and sometimes it’s bacteria that comes from up the line and makes its way down. There’s a 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, but 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, so you can see this general trend of overgrowth in the small intestine.
Why that is so important for a multitude of reasons is because a 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 intestine. Some of the healthy gut advice which is centered around feeding gut bacteria with fiber and prebiotics and vegetables and fruits…
Dr. Pompa:
Makes it worse.
Dr. Ruscio:
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 worst, 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. Often times, people think they’ve done everything, but they really have not. They’ve done everything that they know about, which is great. 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, right? It’s everything I can see, but it’s not everything that’s available out there.
Just real quick, 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 H. 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, and then when you have healthy soil or a healthy host, you harbor the growth and encourage the growth of healthy bacteria and fungus and other like life. Sometimes you get caught in this monotherapeutic focus, and 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:
Yeah, so let’s talk about it now. Bloating is one of the number one symptoms that people get, right? Two hours, even six hours after a meal, boom, it feels like you’re pregnant. Feels like you just ate, frankly. Okay, so that’s the number one; gas, both ways, this way and that way; constipation; diarrhea; I mean, all of it, right? All right, what do we do? What’s the first step? How would you walk someone through this?
Dr. Ruscio:
I should also just build upon that that those are your most classically defined SIBO symptoms. We’re now seeing an association with SIBO to hypothyroidism. That’s 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—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, so just coming back to and trying to reinforce that principle that you can have nondigestive 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. 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 fast during this conversation…
Dr. Pompa:
[00:17:03].
Dr. Ruscio:
We go through it one step at a time just to make it easy, but we want to start with diet and lifestyle. That is really the foundation. Now, you’ll hear desperate things about what the best diet for SIBO is. What happens sometimes is people believe X, and so they find research that reinforces X. They ignore all the research that that is not the case for everyone. What I have tried to do is look at what the entire body of literature shows, and 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:
To your point. Go ahead.
Dr. Ruscio:
Yeah, and if you 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 that typically worked for us at one point. I believe humans are genetically—DNA is set up to change diet, force adaptation. Therein lies the actual—the key, and 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 feed SIBO, that can work, but other people have to get rid of them. It is very different.
Dr. Ruscio:
Right, 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. The 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, but essentially, the main tenet is 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 macros, the balance of carbs, proteins, and fats to your individual desires. That can be a very good starting point, and 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, and we know that anywhere from 4 to 84% of IBS may have the underlying cause of SIBO. IBS is just essentially the same symptoms that off manifest as SIBO. They’re definitely 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, and here’s one of the nice things is that you don’t need to be on that diet for months and months to evaluate if that is an 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:
Yeah, absolutely.
Dr. Ruscio:
Okay, so 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, and 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, well, 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 gases. 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 ten 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. That is 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 in 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 an argument that a low FODMAP diet is unattainable 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. They’re going what? What is this? What is it? Give a little bit more explanation of what—the paleo I think people understand. You’re right; you can change how much protein, but 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, and as people become healthier, they will be able to thrive on a broader array of foods. It’s very important that we, yes, 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, and the foods are—they don’t seem to have a huge rhyme or reason, but 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, and 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. Maybe they were eating some grains, and they cut out some of those grains and eat a lot more vegetables. All of sudden, they feel worse. That’s does happen to some people, and it’s inadvertent. I know it’s very defeating when you’re taking actions to improve your health, yet you’re feeling worse. For these people, it may be a simple adjustment of going to a lower FODMAP diet, and then they may feel better within, again, two to three weeks.
Dr. Pompa:
Yeah, no, there’s truth to that as well. Okay, let’s go on. Let’s call it Step 3, if you will.
Dr. Ruscio:
Sure, so within that diet and lifestyle—I’m sorry, is lifestyle. I think you’ve probably addressed that fairly amply up until now. I think people understand sleep, exercise, manage stress, pursue purpose, what have you but worth at least just taking those very briefly. The next step would then be some non-dietary interventions, and this is what some people get stuck in sometimes. They get stuck in the quicksand of diets. 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, and so we want to make sure we don’t keep beating them over the head with a 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 1 of probiotics consist of a mainly Lactobacillus and Bifidobacterium [prenominated] 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 1, and you want to definitely try one of those. 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 2 is a Saccharomyces probiotic, Saccharomyces boulardii containing probiotic, and this is actually a healthy fungus. When you look on the label there, you will see Saccharomyces boulardii. Then Category 3 is your spore forming, also sometimes described as a soil-based probiotic. Here you will see predominantly Bacillus strains: Bacillus licheniformis, Bacillus subtilis, Bacillus clausii. These strains have also been shown along with the Saccharomyces boulardii to have a multitude of benefit for someone’s gut, but 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 that you keep having this bloating reaction because you keep taking a Lactobacillus/Bifidobacterium Category 1 blend, the answer there will elude 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:
Yeah, and I want to make people aware of this potential pitfall as well. You find one that works, and then you stay on it for many months, a year, and then you end up [mono-culturing]. It’s 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 found there.
Dr. Ruscio:
I’ve heard that. I haven’t found that clinically. I was swept into that thinking. I think I was placeboing myself or just—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 intended 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 base. I’ve also noticed there are clearly some people who do better on the Lactobacillus and Bifidobacterium blend, and 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 in identification of the soil-based organisms is not where it should be. There should be more data on there 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 1 does predominate the conversation right now, but I do think that’s shifting in a positive way.
Dr. Pompa:
Okay, then what? What’s Step 4? 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 and 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 sense some cases where their nonresponsive 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 that through that confection of different treatment options, then we can escalate to antimicrobial herbal therapy so things like oregano and Allicinin and berberine. People have probably heard of many of these. If someone is not able to resolve dysbiosis or imbalances—so dysbiosis is an umbrella term for SIBO and H. pylori and Candida. It 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, and the nice thing about these is many of these herbs have brought 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.
Dr. Pompa:
Me too, doing far less.
Dr. Ruscio:
Yeah, and the book protocol can be done without any testing. Again, it’s not about knowing what the one thing is. We’re trying to create a healthier milieu in the gut soil globally, and so 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. 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 hopefully, if it works, after that push, the microbiota will rebalance to a healthier equilibrium.
Dr. Pompa:
Yeah, most of the herbs, they don’t wipe out the good bacteria. They bring things in control. It’s definitely a better way to go. Okay, 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 5.
Dr. Ruscio:
Yeah, there are more steps.
Dr. Pompa:
Yeah, I didn’t want to cut you off, but I had [00:33:35].
Dr. Ruscio:
Sure, I get it. I get it. We’ll help keep each other in check here because there’s a lot of different ways that we can go, so we’re going to have to anchor each other. There’s the ability within the book protocol to escalate the antimicrobial therapy. People have may have performed the antimicrobial therapy in the past and seen a small response or only a short-lived response, and 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 iteration. Sometimes we have to add in the addition of anti-biofilm agents to help with the stubborn colonies and/or along with the anti-inflammatory and specific antiprotozoal agents. The nice thing here is you have one agent that can act as both 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…
Dr. Pompa:
Yeah, [00:35:03].
Dr. Ruscio:
Yeah, both SIBO and both gut inflammation. We use a formula know 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, and for people who have not responded to anything else, sometimes knowing how to use and using the 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 are also asking—sorry, remind me what the other question was.
Dr. Pompa:
Yeah, I mean, I know there’s different ways of testing for SIBO.
Dr. Ruscio:
Oh, sorry, testing.
Dr. Pompa:
The breath test, which, again, I mean, 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. 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, and you will see desperate recommendations. Some people will vehemently recommend testing every time you go in to treat SIBO and perform serial retests, and 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 mostly 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 baseline to see if that’s one of the chest pieces on the board. Then from there treat empirically, which is what we do in the book. Treat empirically meaning treat someone, observe their 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 that in theory it’s tempting to say, well, I want to test to know what’s there. Some people would 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 you 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 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—and he has a 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 can then target the hydrogen producers which are different to kill than the methane producers. What’s your thoughts on that?
Dr. Ruscio:
Yeah, 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 is that some people really enjoy the complexity, which is all fine and good. We must always be looking 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. 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 who 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…
Dr. Pompa:
I’ve been doing this for this 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. I mean, it’s like the—like you said, the less I test, the more that I—it’s like you just really end up in amore 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 cellphone now can do ten times arbitrarily what it used to be able to do five years ago, and it’s half of 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 is 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.
Dr. Pompa:
So true.
Dr. Ruscio:
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, but to your point, I see the validity in testing to identify what type of organisms, hydrogen or methane, if you’re using pharmaceuticals. Then you would want 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. Then we can say that either caused 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 what—maybe the stimulus that the microbiota 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 this complicated lab data that you’re pouring over.
Dr. Pompa:
Yeah, I agree. I agree, okay, without pulling you into a new topic, a new direction which I tend to do. 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. Again, my recommendation there may change in light of the placebo-controlled trial that—it’s been actually a few—there’s a long backstory on this trial.
Dr. Pompa:
Back up, prokinetic, people aren’t going to understand.
Dr. Ruscio:
Yeah, sorry. 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. You wouldn’t have to make necessarily a hard case for safety. It’s cost that I also try to be very sensitive to. 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, so 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 we experiment with either increasing the prebiotic and fiber content of the diet or utilizing a fiber and/or prebiotic supplement in their supplement regiment. There’s a very important directing principle that, if you look at all the literature here, you can 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 health outcome data or data points showing that they—the prebiotics and the fiber can help.
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. 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:
I mean, every fiber’s not created equal. You have more soluble fibers, which the bacteria love to eat. 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:
Sure, so 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 a few other compounds.
The challenge that we get into here is we have predominantly 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, 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 instance of reverse—of adverse reactions with insoluble fiber, which was totally—yeah, which it totally doesn’t make sense.
Dr. Pompa:
Oh, yeah, [00:47:19] irritable. I mean, the bile is irritable, right? It tends to make them—drive them nuts.
Dr. Ruscio:
Right, or even as another example, we would think that people with gut inflammation and leaky gut would do better on a high FODMAP diet because prebiotics and FODMAPs feed bacteria. Bacteria secretes short-chain fatty acid. Short-chain fatty acids [00:47:39] inflammatory and repair 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 natural prokinetics, theoretically they should work, but until we really can substantiate that, I do recommend using them. I don’t put all my eggs in that basket in terms of prevention. Those are probably the two better known prokinetics that are in 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 be useful, low-dose naltrexone is one, and that may have other positive amino modulatory benefits. Low-dose erythromycin is another, in addition to a third compound known as Resolor. These drugs do have side effects. It’s not to say that they have severe side effect profiles, but I think people like at least starting with the natural compound. That’s where we recommend people start in the book.
Dr. Pompa:
Real quick on the drug thing, Zypan, what about—the one that they advertise on TV, am I saying that right?
Dr. Ruscio:
Xifaxan?
Dr. Pompa:
Xifaxan, thank you. In fact, that seems to help with the—it helps more with the methane and not the hydrogen, 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—I think you inverted those, with the hydrogen…
Dr. Pompa:
Yeah, [00:49:04 ]. I invert everything.
Dr. Ruscio:
Yeah, no, I do it. 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 can 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 monotherapeutic 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 in 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 [00:50:27].
Dr. Pompa:
Listen, I’ve had people helped by it, honestly, and again, whether it’s 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.
We talked about fiber. Sometimes that can help move things along. Magnesium is another. I mean, these are basic things that people use that sometimes help. Is it in the same category that we were discussing?
Dr. Ruscio:
Sure, 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 [00:51:29] for 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, and 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. The low FODMAP diet is reducing some of these fibers in prebiotics. If you know that going in and if you tell people that going in, they have a better ability to wrestle with that mentally, and they understand, okay, this is helping with the bloating, some of the gas, maybe some of the abdominal pain. I’m a little bit more backed up, so now I’m going to do one serving of magnesium citrate at night. My bowels are now moving fine.
Dr. Pompa:
Yeah, right, that is 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 normally 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 mechanism, so to speak. If someone has all of 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, whether it 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. Essentially, the colon should 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 found that many patients would rather be on fiber and high-dose magnesium and maybe even occasional enema than use some of the medications like linaclotide or Linzess, or what have you. I do think there’s a time and place for those. It’s just a very small subset, and 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, so 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 could argue how did it get open in the first place? You have to go upstream even further, but 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.
Dr. Pompa:
Yeah, 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 it may be that 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 case 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 had 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 regarding some of the female parts, then you may want to consider this.
It’d be something end phase. 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. The book protocol is quite robust, but there are some things like this visceral therapy that you’re going to have to go see someone in person to really have that sorted out.
Dr. Pompa:
Yeah, and folks listening and watching, I mean, if you take your bellybutton 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. They’re not given the context and the carefulness with the crafting of the message, and so 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 try 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. 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, very, very important.
Then 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 the healthy outlook. Then make sure, if you want to be the best mom in the world, or if you’re trying to lead a nonprofit, or whatever you’re trying to do, keep that purpose in your life. 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:
[00:59:49] your book. Thank you.
Dr. Ruscio:
Thank you.
Dr. Pompa:
All right, cool, she’ll cut that out, yeah, great information, great job, man. You’ll sell some books. That’s for sure.
Dr. Ruscio:
Thank you. I appreciate it. I’m very passionate about it as you can probably tell. I’m trying to help give a good guide through the tumultuous landscape of gut information on the internet.
Dr. Pompa:
Yeah, that’s great. We branched out, but I think we pulled them in from an area that everyone’s clamoring about. It’ll be great. It’s going to be a great interview.
Dr. Ruscio:
Good, awesome.
Dr. Pompa:
Thanks, Michael, all right, man.
Dr. Ruscio:
My pleasure. Thank you. Thanks, guys.
Ashley:
Bye.
Dr. Ruscio:
Bye-bye.
Ashley:
Have a good one.
Dr. Ruscio:
Thanks, you too. Bye-bye.
Ashley:
That’s it for this week. We hope you enjoyed today’s episode. This episode was brought to you by CytoDetox. Please check it out at buycytonow.com. We’ll be back next week and every Friday at 10 a.m. Eastern. We truly appreciate your support. You can always find us at cellularhealing.tv, and please remember to spread the love by liking, subscribing, giving an iTunes review, and sharing the show with anyone you think may benefit from the information heard here. As always, thanks for listening.