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Episode Intro

Dr. Michael Ruscio: Hey, everyone! Welcome to Dr. Ruscio Radio. This is Dr. Ruscio.  Today’s podcast is going to be a little different. I went down to hang out with the guys from Mind Pump Radio a few weeks ago and did a podcast recording in their live studio in San Jose. A lot of fun, really interesting group of guys, and we decided to share the interview on our show because I thought there were some good points that were brought up.

We talked about some of my career early in the fitness industry and how I learned a lot of what’s helped me in the health and medical industry, which is people over-complicate things. And you can get swept into teachers and gurus who over-complicate things, perhaps even though they’re well intentioned because they maybe have a personality type that makes things more complicated than they have to be, or they don’t spend a lot of time in clinical practice. So they can allow themselves to be overly indulged by interesting academic details, but never really feeling the pressure of needing to be more efficient and cost effective.

And I talk about how I really figured that out in my exercise career, got totally swept up to that when I was early in college and doing personal training and rehab and learned my way out of that and was able to much more quickly identify those things in health and medicine.

We also talked about the gut quite a bit, and thyroid issues, controversies where we have good data where we have some data that’s off the mark. Really fun show. I just want to make one important qualifier. They are an explicit podcast, meaning there’s profanities and there’s some pretty candid discussion. I have had any profanity use muted out of the conversation, so you may notice that, of course, because we don’t use any profanities or typically don’t use any profanities on our show. So I’ve made sure to make this filter to be non-explicit in terms of the profanities, but you still get the candid commentary. And I hope you will enjoy this show. And we will get right to it. Okay, thanks!

Mind Pump Introductions

Sal Di Stefano: What part of Italy is your family from, Mike?

DrMR: Calabria.

Sal: Oh. I’m Sicilian.

DrMR: Yeah, yeah. Cool.

Sal: Yeah.

DrMR: So not too far.

Sal: We’re close.

DrMR: Tan skin, down south.

Sal: You guys have hard heads. That’s what I remember about you.

DrMR: What Italian doesn’t, though, I guess?

Sal: That’s the point. That’s true right there.

You came highly recommended by Robb Wolf, whom we respect greatly. We met with him. How many months ago was that now? A few months?

Adam Schafer: It’s been like two.

Sal: Two months.

Justin Andrews: Yeah probably about two. That was a huge compliment.

Sal: We had a great time with him. And after we were done, he’s like, “You’ve got to talk to Dr. Ruscio. He’s like my dude when it comes to gut health and stuff.”

DrMR: Yeah, I pay him for that endorsement. It’s expensive but worth it.

Sal: I was just going to ask about that.

Justin: He has that title, “My dude.”

Your Interest in Health

Sal: How did you get into gut health? Now, I’m looking at you. You obviously work out. So you’re in fitness. Have you always been into—

Justin: He sizes everybody up as they come in.

Sal: Yeah.

DrMR: When I was young, I was tired of getting picked on and my lunch money getting stolen. So I decided to start working out. [Laughs] No. I was always an athlete and always really into health. Actually, there’s a circuitous but interesting story that leads up to this that I think showcases some of the stuff that needs to be updated in the fitness industry. So at first, coming back to the hard headed Italian-ness, I wanted to go into law only because I really liked arguing.

Sal: Yeah, we’re going to hit it off.

DrMR: And talk with my hands.

Adam: Excellent.

DrMR: So I went into pre-law. And I thought I was pretty good at it. But I saw the negative aspects of my personality getting pulled out. And I was like, “Ew. This is not a path that I want to go down because I didn’t like where I was going.”

So I then went into biology because I figured, “Well, why not just go into science?” So I was working as a personal trainer at Bally’s and also getting my degree in biology.

And I remember—I’ll never forget this—I was at a meeting with the regional head of personal training. And he was going around giving everybody feedback, reviewing their files, their sales, whatever.

And he said, “This client of yours, Melanie, you’re doing a really great job with her.” Melanie was, I think, 31, obese, sweet as a peach, just the nicest girl. And she was losing weight. She was doing great.

And he said, “She’s really been progressing nicely, but why don’t you slow things down with her a little bit because we could have here for a year instead of six months.”

Sal: Wow.

Adam: What?

Sal: Wow!

DrMR: And I was just like, “What the F is this guy talking about?” So I started really to see the ugly side of the fitness industry. And I was complaining about this to my cousin, who was actually a former WCW wrestler. And he said, “Why don’t you just go into the medical end of things? If you don’t like the whole fitness, why not go into the really scientific side of it and go into medicine?”

I had never thought about it. But it clicked because I was always the guy who was making workout routines for my friends or dietary plans just through my own reading of Poliquin or Check or whatever. So that was a big thing that put me down the path.

Your Health Past

Adam: How old are you right here?

DrMR: Right now?

Adam: No, no, no. At this time in your life.

DrMR: God, I was a freshman in college. So what’s that?

Justin: Were you 21, 22?

DrMR: I think you’re a little younger than that.

Justin: Maybe even younger.

DrMR: I’d say like 19 maybe.

Justin: 19, 20.

DrMR: 19, 20. So I was pretty young. But that was a pretty big cathartic moment just figuring that I could go into this. I never had thought about trying to become a doctor or do anything with medicine. But as soon as he said that, I was like, “You know what? This is what I’ve been interested in.”

And from there, I was telling you guys some of the other story, which was I was in college, and I thought I wanted to go into orthopedic medicine at first because I knew I wanted to go into medicine. But I didn’t know just what I wanted to do. So everyone would say, “Well, you’re kind of a burly guy. You should be an orthopedic surgeon because those are usually burly guys.”

Sal: That’s the stereotype.

DrMR: So I was like, “Sure. That sounds good.”

Sal: There’s a joke in the medical world. How do you hide something from an orthopedic surgeon?

DrMR: How?

Sal: Hide it in a book.

DrMR: Fair enough.

Sal: Other doctors have told me this joke because they’re apparently the jocks of the medical world.

DrMR: Right. Right, yeah. So I got lumped into that, and rightfully so. So I’m trucking along. And super type A, trying to keep my GPA up, trying to do all that stuff.

And all of a sudden, I start having insomnia, fatigue, depression, feeling cold, feeling tired. And I’m saying to myself, “What the hell is wrong with me?” Because at this point, I’m 23. And I’m used to feeling invincible. I played lacrosse in college. I was the guy who could get laid out, pop right back up, and almost feel like I had more energy because of it. You know how you’re young and just a nut.

Justin: Oh yeah.

DrMR: And then all of a sudden, I can’t sleep, and I’m feeling tired and I’m feeling cold. And I’m saying, “What the hell is going on?”

So I went to see three conventional doctors. And they all said, “Yeah, you’re super healthy. You’ve got low body fat. All the standard stuff checks out.”

And I’m saying, “Well, okay. But do you remember what I said before. I was feeling great three months ago. And now, I’m feeling kind of—.”

And they said, “Well, maybe it’s too much stress or whatever.” And none of that was salient because I was leaving enough time for sleep even though I wasn’t sleeping well. I was eating really well. I loved what I did. I wasn’t overstressed. It wasn’t anything way out of sorts.

So long story short, I ended up finding a functional medicine provider. He said, “I think you have an intestinal parasite.”

I remember thinking, “This guy is full of—. I don’t have diarrhea. I never went to a foreign country and got food poisoning, anything like that. That can’t be.”

But it turns out that when I did a stool test, I had amoeba histolytica, which is one of the more pathogenic amoebas that you can have. And it wasn’t causing any digestive symptoms, but only causing non-digestive symptoms like fatigue, depression, insomnia, what have you.

Sal: Wow.

DrMR: And that was a huge cathartic for me, and it changed the direction I wanted to go. And I went into alternative medicine in light of that experience. And now, it’s that sort of thing I help my patients with. And it’s been a great shift ever since.

Personal Training History

Sal: How long did you stick around with the Bally’s thing? How long were you a trainer there for?

DrMR: A few more months, I think. And I was learning some of the trainers that were the busiest were just the best salesmen. And some of the best trainers were the ones that weren’t as busy. And I remember listening to some of these guys just, “Now, Samantha, blah, blah, blah.” These total salesman lines.

Sal: Yes.

DrMR: And these people are just eating it up. And I’m like, “I know that this guy who is making the sales pitch doesn’t know anything scientifically or from a fitness perspective,” but he had a full book of business.

And so I said, “You know what? This is just not the environment that I want to be in. If I’m the best person at misleading and selling people, I’m going to be ‘the best trainer.’” So I just departed from that.

Sal: It’s hilarious because we literally—this is what—

Adam: This was us in our 20s. This is a lot of what inspired Mind Pump. All three of us worked for 24 Hour Fitness. I did for ten years.

Sal: We grand opened clubs and ran some huge teams. And what you’re saying is 100% true.

Adam: And we talk about that’s part of—I was that guy. I was the top in sales. I was a terrible trainer. If I’m being completely honest with myself. And I’ve shared this on our podcast. And this is what bothers me. But in the defense of trainers that are in their early 20s that are doing this, they’re being fed the information for the company.

DrMR: Sure.

Adam: So all the information that I was getting was the meetings and the education that they were providing for me which was all things to help them sell supplements, sell more personal training, keep clients longer.

DrMR: Right.

Adam: It wasn’t necessarily what’s in the best interest of my clients.

DrMR: Right.

Adam: And so through my 20s, I was focused on the dollar and focused on making more money and doing that. And in those types of companies, that’s what people attribute to being a good trainer, which is the complete opposite.

So later on when we started learning and reaching beyond our small, little world inside the fitness community at 24 Hour Fitness or Bally’s, gyms like that. And it’s why we speak so passionately. Man, so many people have no idea that there’s so much more information out there. And the stuff that they’re being fed is to poke at their insecurities, to sell them or get them to buy something. It’s really, really unfortunate. So you put that together a lot earlier than we did.

Opinion on Medical ‘Salesmen’

Sal: Mike, would you say a lot of the information that people read about their own health, the information that’s put out there to the public—would you say a lot of it’s false?

DrMR: Well, we’re really opening a huge can of worms on this one.

Sal: True.

DrMR: But as a preface to my answer on that, the same thing happens in health and medicine in my opinion. And I think this is what has helped me, I think, do a pretty decent job in my space now, which is alternative and functional medicine, because I put those things together early in the fitness industry, went into the health industry, and I saw the same stuff repeating.

Adam: Same thing.

DrMR: And so it really helped me pierce through the BS pretty quickly. But yes, I do think that a lot of the same stuff happens. And I think it may not be as Machiavellian or this conspiracy theory as sometimes people put it out to be.

I think there are well-intentioned people that don’t know how to use science to update their opinion. But rather they have an opinion and they use cherry-picked data to reinforce a preexisting belief.

Justin: Yes.

DrMR: And that by definition is dogma. And one of the things that has been very freeing for me is to, learning from these experiences, approach things objectively and almost assuming anything that I think going into an analysis could be wrong, because I’ve been wrong before. I used to be that guy, totally sold on whatever it was back in the fitness industry, only to learn that that was totally wrong.

So when you do that, you can try to look at all the data on an issue and look for a trend in the data. And so then you can use data to update your opinion and craft your opinion rather than just say, “Well, I believe everyone should be low carb. Let me find every low-carb study out there and use that to reinforce.”

But it’s so freeing if you can just say, “Let me look at what studies have shown a high carb diet can be beneficial.” There are a ton of studies showing that there can be some benefit here. So how can I be that dogmatic in my views? Or how can I be that strong in my views?

And it reminds me of a quote that I love, which is, “Dogmatism can only exist in the presence of ignorance.” I don’t mean ignorance in an insulting way. The true definition of ignorance is just not knowing about something.

So in my opinion, people can only be hard driving on an opinion of they’re ignorant to the contradictory information on that opinion.

And so I think what ends up happening is in the field you have people that have one position and there’s this wealth of science that can support that position. But the problem is, they’re not looking at the wealth of science that refutes that position and trying to craft a well-informed opinion from all the data. So yes, it’s pretty common, I think. Yeah.

Practice Methods

Sal: You work—you say alternative health. But you also work in more traditional Western health as well. Do you look at all those? When people hear alternative health, they think of Chinese medicine, ayurvedic medicine, that kind of stuff. Do you work with all of that? Or how would you explain or define the methods that you use?

DrMR: Sure. Well, the most official description, I guess, is functional medicine. But if you’re not familiar with functional medicine, another proximal term could be naturopathic medicine, which is very similar.

But to put it really simply, what I try to do is have a very science-based, efficient, and practical application of natural medicine that also borders in some areas on conventional medicine.

And it’s not about saying, “Your conventional doctor is wrong, and we’re right.” It’s really about looking at the evidence in natural medicine, conventional medicine kind of on that line.

And then usually the frontline therapies we’re going to use are going to be more from the natural camp because that’s people’s preference. I’d rather cure my IBS with a probiotic than a laxative.

Sal: Right.

DrMR: Okay, understandable. So we’re going to look at the evidence on both sides and try to best understand what the best way to apply the natural medicines are, but also when we want to integrate in with the conventional system and not turn a blind eye to some of those things that can be very helpful.

And maybe using thyroid autoimmunity as an example (another area that I work in), when people have thyroid autoimmunity like Hashimoto’s—and thyroid autoimmunity is a primary driver of hypothyroidism in Westernized countries—those people are also at elevated risk, not a high elevation, but they’re at a small elevated risk for thyroid cancer. So we want to make sure they’re continuing with their follow-ups with their endocrinologist to keep tabs on the thyroid tissue to make sure that there’s no cancerous or pre-cancerous lesions forming so that they can be detected early.

So it’s not to say, “I like natural medicine and I think it can cure everything under the sun. And I’m going to turn a blind eye to the fact that, hey, no matter how good I am, you may get thyroid cancer.” And I’d be an absolute idiot if I delayed the diagnosis of that by five years because of my philosophical beliefs.

Thyroid Testing

Sal: So you want to take all those views. It’s interesting you talk about thyroid autoimmunity. It wasn’t that long ago that if you went to the doctor and got tested and they tested your thyroid hormone and looked okay but you had all these symptoms of thyroid issues that they’d be like, “You’re fine. You’re absolutely fine.”

Is it more accepted now to test for things like antibodies and to find if somebody has autoimmune issues with their thyroid?

DrMR: I think it is becoming accepted. There are a few important things to understand with thyroid autoimmunity. Conventional medicine doesn’t see a strong treatment for thyroid autoimmunity itself.

So rightfully so, they’re not overly concerned about tracking thyroid autoimmunity in a lot of cases because there’s not a direct treatment for that. But rather they want to check thyroid function to determine if you need thyroid hormone replacement therapy and also keep tabs on the thyroid structure to make sure you don’t have nodules—

Sal: Goiter.

DrMR: Or others aspects that could become a more serious medical issue that requires an intervention there.

But there is some data that is showing that certain shifts potentially in diet or certain gut health interventions or certain vitamins can help with thyroid autoimmunity.

But to be honest, the data there isn’t incredibly strong. So looking at selenium as an example, probably the most common nutrients you’ll hear recommended for thyroid autoimmunity are selenium and vitamin D. So let’s look at selenium.

When you look at the high level science, you do not see agreement in terms of what the data shows for selenium. And the most notable is a recent Cochran database systematic review with meta-analysis.

So the Cochran database essentially analyzes studies for bias to make sure there’s not bias in the study. And then a systematic review with meta-analysis—it sounds complicated, but it’s actually quite simple.

It’s like surveying a bunch of people who went to a restaurant. Let’s say there’s a new restaurant down the street. We want to figure out should we go there, should we not go there. So we find out that there have been 100 people that went to the restaurant. So we’re going to survey each one of them.

And that’s like a systematic review. It’s surveying all the people that went to the restaurant or all the studies that have been done on an issue. And then the meta-analysis is just calculating a numeric score in terms of what the rating was, so a 70/100.

So a systematic review with meta-analysis is really just doing something that we all do all the time, which is let’s see if we can get a bunch of data in terms of what people think on the restaurant and give that a score. It might be 4/5 stars or 70/100, whatever.

So this is really helpful because when you look at this higher level science, you get a summary of what most of the clinical data says.

Sal: So it’s basically a study on the studies.

DrMR: It’s a summary of the studies.

Sal: Summary of the studies.

DrMR: Exactly. Exactly.

Sal: Okay. So you get a consensus.

DrMR: Exactly.

Sal: Okay.

DrMR: Which is important because one study can be misleading.

So with selenium, there are some studies showing benefit. There are some studies showing no benefit. When we put them all together, we show no consistent or overly favorable benefit with selenium supplementation, which may sound odd to some people listening.

However, if you read this study more closely, you see that most of the benefit with selenium was achieved at three months of supplementation, less so at six months, and after six months, the benefit completely drops off.

So what that probably tells you or what that should tell us if we draw an inference here is that there is probably an aspect of short term selenium repletion that’s helpful for thyroid autoimmunity. But outside of that window, there’s no more benefit.

And why that’s relevant is because people may read about selenium being good for thyroid health and take it every day for the rest of their lives when they really don’t need to.

So it’s coming back to that theme of trying to be progressive but conservative. Let’s not just fall off the deep end with selenium and give everyone selenium high doses for the rest of their lives, but realize that there’s this reasonable window of maybe three to six months that it has its primary utility for.

Sal: So I’ve had a few clients in the past who’ve had symptoms of thyroid autoimmunity, have gone to traditional doctors, gotten tested, and found that their thyroid hormone was fine.

Adam: What are some of those symptoms? Explain that.

Sal: Yeah, that’s what I was going to ask. What are some things that people can look for, because obviously if you go get tested and you’re like, “Hey, your thyroid hormone is fine, but you’ve got all these symptoms that could point to an autoimmunity there,” what do they look like?

DrMR: Well, that’s the challenge with symptoms. In some cases, especially with thyroid, they’re very nonspecific.

Justin: Right.

DrMR: So there could be fatigue, weight gain, constipation, dry skin, feeling cold, thinning hair, depression. Those are probably some of the most common. And symptoms can be suggestive. But really, there are many other things that can look like a problem with thyroid.

So here’s the general way I would approach thyroid, generally speaking. Have a standard evaluation to see if you have frank hypothyroidism, because that’s easy to detect. And that’s easy to treat. So if someone has frank hypothyroidism, that means that they’ll have—according to the conventional range—high TSH, low T4.

If that’s the case, they want to go on a medication. There’s debate as to whether or not a straight T4 medication or a T4/T3 combination medication is better. The consensus does seem to show that most patients prefer a T4/T3 combination, so that may be something for people to try first.

If their doctor doesn’t want to do that, say, “Okay, I’ll start with the T4. Give it a few months. But if I’m not feeling totally well, I’d appreciate it if you would humor me and add T3 into the mix.” I think that’s totally reasonable.

So check off that box. Am I frankly hypothyroid and require medication or not?

If you’re not hypothyroid, meaning if your thyroid levels are normal according to the conventional ranges, I would then look to another cause of the symptoms. And oftentimes and as I found myself, I had hypothyroid-like symptoms but were being driven by a problem in the gut.

So if you’re not frankly hypothyroid, the next thing I would do would be to investigate your gut health, because that may be where—and I should preface. I’m assuming your diet and lifestyle are already dialed in.

Sal: Okay.

DrMR: That’s always the first step.

Justin: Right.

Sal: Sure. I’m so tired. I only sleep two hours every night. Well…

DrMR: Exactly. Assuming you’re getting sleep, getting some time outside, getting some exercise, managing your stress—assuming those basics are in place and your still not feeling well and you’ve checked the box, meaning you’re not hypothyroid, I would then recommend looking into your gut health.

Not to say that gut health is a panacea, but gut problems are very common. And they can cause many of the symptoms that look like hypothyroidism.

Sal: Excellent.

T3/T4 Supplements

Adam: What are your thoughts—when I hear you talking about T3, T4, right away it pops into my head a lot of the supplements that are out there to manipulate these things.

What are your thoughts on that? What are your thoughts on supplements like T3, T4? Are there risks to taking that? Are they any value whatsoever? Does it really benefit anything? I know a lot of people use that to try to lose body fat.

DrMR: I think that argument is most salient when people are trying to use thyroid hormone—so prescription thyroid hormone—to get their levels back into the normal range. And there is some data that shows that if people are in the upper half for T4 and T3, they may feel a little bit better.

But the supplements that help with conversion of T4 to T3, they may be mildly beneficial. But usually what I’ve found is there’s a cause of that problem. There’s a cause for the non-optimal conversion or the symptoms that you think are because of the non-optimal conversion.

Sal: So in other words, it’s not treating the root.

DrMR: Right.

Sal: You’re just putting a band-aid on it.

DrMR: Exactly. So these natural agents that help with conversion of T4 to T3 or help to boost T4 or T3, I tried them. I had a lot of patients that come to me after trying them. They may garner some benefit, but I think those things are more an end-of-the-line therapy.

And it’s better to start off with diet and lifestyle and then gut health because that can actually, in itself, cause problems with the levels of T4 and T3, especially of T4 to T3.

Justin: That’s what I was wondering.

DrMR: Yeah.

Autoimmunity Rise

Sal: So autoimmune disorders and diseases in particular seem to be on an explosive rise over the last maybe 20, 30 years. Is that because we’re diagnosing them more accurately? And I’ll throw all autoimmune issues including food allergies which—I have kids. And when I was a kid, I remember I think one kid who had a peanut allergy. And now, you’ve got entire classrooms that are peanut and egg free and all these different things.

Justin: Yeah.

Sal: Are they really on a rise? Or is it just because we’re diagnosing them?

Justin: We’re just becoming aware of them.

DrMR: There’s probably a component of it that has to do with increased diagnostic capability. But clearly, autoimmune conditions are on the rise. And it’s likely because of the environment that we live.

And said simply, the hygienic environment that we live in now also combined with the use of antibiotics, which can be lifesaving in certain applications—the unintended side effect of that is partially impairing the development of the immune system, which then opens the door for the increased prevalence of autoimmunity.

So it’s like this inverse biological scale where, if you go to a hunter-gatherer population, they’re going to have a shorter life expectancy and higher infant mortality, but no autoimmunity. You come here, and it all flips—longer life expectancy, lower infant mortality, more autoimmunity.

So I think it’s just important to keep that in mind, because sometimes people, when they have an autoimmune condition, they beat themselves up like it’s something that they did. And oftentimes, it’s a genetic hand that you’ve been dealt. And that combined with the environment that we’re in today.

Sal: Yeah.

Justin: Getting into the epigenetics that help express.

Sal: Well, classic studies have demonstrated that kids that grow up on farms—far lower rates of autoimmune disorders. Why? Probably because they were exposed to animals and more bacteria and dirt and that kind of stuff. And the other side of that is they tend to take fewer antibiotics.

In our generation, we grew up—antibiotics were given out like candy.

DrMR: Right.

Emulsifiers (Artificial Sweeteners)

Sal: For everything single thing that we had. How about some of the stuff that we eat? They’re finding now artificial sweeteners alter gut flora. And glyphosates, which are found in genetically modified foods, alter gut flora and stuff like that. Do you think those play a role?

DrMR: There’s been some published evidence showing that emulsifiers, which are oftentimes found in processed foods, do have a correlation to autoimmunity. But I think it’s hard to parse out, is that because Western societies are eating more processed foods? Or is the processed food consumption directly in and of itself?

I do think there’s some plausibility to that argument that emulsifiers in processed foods are driving autoimmunity, because the emulsifiers can partially irritate and break down the lining of the gut. So I do think that that’s plausible. And it comes back to a simple principle, which is avoid processed food as much as you can.

The artificial sweeteners piece is interesting. And gosh! There’s so much to say about so many of these things. There’s so much to say about thyroid autoimmunity. There’s so much to say about artificial sweeteners. But a few broad strokes with artificial sweeteners.

Do they affect our microbiota? Yes, they do. And there’s been one very interesting study where they found people to be either artificial sweetener responders or non-responders.

And what they did was they gave two groups of people artificial sweeteners. And they noticed that one group had negative changes in their blood glucose. And the other group didn’t. So the people that had the negative changes were labeled as artificial sweetener responders, meaning they had this negative response. And the others were non-responders.

So the researchers then looked at their microbiotas and found there was a change pre- and post-artificial sweeteners in their microbiota. So the people that had the negative glucose changes—your insulin resistance, your fasting blood glucose—they had a change in the microbiota that correlated with those negative metabolic changes.

Then they took the microbiotas from each group, transplanted them into mice. And it was only the mice from the negative responding group that saw also negative responses in their blood glucoses, whereas the other group did not.

So it’s something to do with certain groups of people have this predisposition to have their microbiota negatively affected. And that seems to be causal in causing problems with glucose.

Now, that’s just one study. So coming back to my earlier point of not just looking at one study, what does the larger body of evidence show regarding artificial sweeteners?

The body of evidence shows there does not seem to be any benefit to artificial sweeteners in terms of preventing weight gain or aiding in weight loss. So there’s no clear benefit. And some data, not conclusively, but some data suggests there may actually be a detriment.

So when you look at the fact that there’s no clear benefit and a potential detriment, I think the conclusion to draw there is fairly clear, which is conservative use of artificial sweeteners.

And there was one study in particular that really looked at this. It was called the “San Antonio Longitudinal Study on Aging.” And they prospectively broke people into two groups, meaning they said, “This half will have artificial sweeteners. This half won’t.” And then they tracked them over time.

That partitioning is important, because part of the reason why we may see some of the data showing that artificial sweeteners correlates with weight gain is because people who are overweight are drinking more of them.

Sal: Sure.

DrMR: So they factored out for that. And they had equal allocation of this group. They showed that the people who consumed artificial sweeteners over the course of, I believe it was nine years, saw a 3.1 inch circumference gain in their waist compared to the other group, which saw a 0.8 who were not using.

Sal: Wow!

Adam: Oh, wow!

Sal: So artificial sweeteners make you fatter.

DrMR: Yeah.

Sal: Based on that study.

DrMR: And they actually also found a dose-dependent relationship. So the more that the people in the use-of-artificial-sweetener group were drinking, the higher their waist circumference became.

Adam: Oh, wow.

Sal: See, this is huge for a lot of our listeners, because a lot of our listeners are gym rats. They work out. They want to build muscle, burn body fat. And a lot of the products that they use—all the products that they use are sweetened with artificial—

Adam: Well, they just want the low-calorie option. That’s usually where they get that.

Sal: That’s right. “I want to take a protein powder. But I don’t want anything but protein in it.” Or, “I’m going to take this pre-workout. And I want to have zero calories.”

DrMR: Right.

Sal: And they’re all artificial sweetened. And if you work out five, six days a week and you take a pre-workout supplement, you take one or two protein shakes a day and a protein bar a day—

DrMR: Adds up.

Sal: It’s a lot of artificial sweetener that you’re taking for a long time over the course of, some of these people, decades.

DrMR: Yeah.

Sal: Is that one of the things you recommend your patients eliminate when they’re coming with gut issues?

DrMR: Yeah, I don’t make that direct recommendation, but we put them on diet plans where that’s implicit in the diet. So yes. Yeah, certainly constant use of artificial sweeteners is not doing you any favors and potentially harming you. So why would you do them?

Justin: Yeah.

DrMR: And they even showed in that same study, the other group was drinking regular, sugar-sweetened sodas. And they gained a lot less weight.

Sal: Wow.

DrMR: So clearly the benefit from artificial sweeteners has been overstated.

Adam: Which I think that’s a big point, because I think the argument that most people use to justify that is the calorie thing. “Oh, well, it’s saving me 200 calories-plus a day by me having these sugar-free drinks or these foods that are sweetened with artificial sweeteners.” And in reality, they were better off probably having something that has real cane sugar in it versus trying to avoid a couple hundred calories to save them.

DrMR: And that’s the conclusion you see made in many of the research papers. When you have to use a sweetener, use a natural sweetener like juice or agave or sugar. Try to use it minimally, but that is probably better than the artificial sweeteners.

Gut Health & Microbiota

Sal: What’s interesting when we talk about gut health, it’s kind of becoming a big thing now. There are lots of, now, conventional—

Justin: It’s very hot right now.

Sal: Studies and science that are showing just how important your gut health is and your microbiome is to everything almost. They’re connecting it to people’s emotions and state of mind even.

I remember reading a study where they had women go in and get an FMRI, which is functional MRI machine ,where they can see actual function of the brain. And they had them take a probiotic. And they could see changes in the way that the brain actually worked after taking a probiotic. So there’s obviously an influence there even in the mind.

So it’s this big thing now. And one thing that a lot of people don’t realize is when we’ve tested food additives and sweeteners, especially those of the past three, four decades, we didn’t even know to test them against the microbiome because we didn’t even know that that was important.

So is there anything else people should look out for, like dyes and preservatives? Do we see any changes in microbiome from those things?

DrMR: Yeah, maybe the easiest way to paint this would be just to make what sounds like a simple recommendation but is probably the most profound, which is eat a diet as devoid as you can of processed foods or artificial sweeteners or anything synthetic or chemical. And just focus on whole, fresh foods.

You can get into some nuance in terms of diet from there—low carb, moderate carb, high carb, low FODMAP, paleo, what have you. And we can talk about some of those if you want. But that’s really probably all people have to be worried about.

You can get so sucked into the rabbit hole with all these details only to eventually detail your way back to that simple recommendation. So I would say that’s a hugely important thing.

And the other thing that I would throw out there is remembering that it’s not that the microbiota is driving every disease. You create an environment with the stuff that you do in your day to day. And that environment is the environment that houses the microbiota.

So the better you create your internal environment, the healthier your microbiota will be. They’ve shown, for example, that exercise improves the health of your microbiota irrespective of diet.

Sal: Wow.

DrMR: Sunshine can help improve your microbiota irrespective of diet. Even things like type 1 diabetics who don’t make insulin but need it, when they start insulin therapy, that improves their microbiota.

Stress can either have a negative or positive impact on your microbiota. Sleep can have a negative or positive impact. If you wash your dishes with a sponge or use a dishwasher, that can have an impact.

So there’s a little bit of an overzealousness forming about the microbiota driving every disease. But you really have to take a big step back and remember that it’s not to say that the cause of every disease is the microbiota. There’s an equal input and output from the microbiota. So keep your diet generally healthy, and keep your lifestyle generally healthy. That’s going to be the foundation.

From there, then we can get into some more clinical interventions for improving your gut health. But you have to be careful going down that rabbit hole, because you can get so deep in it.

And I read most of these abstracts. And they all come back to the same core group of fundamentals—healthy diet, healthy lifestyle, and then if things are still awry, look into working with a clinician who can help you sort out where the imbalance is in your microbiota, because an imbalance can create this self-fulfilling imbalance where if you have an overgrowth of one thing, that overgrowth poisons the other good guys. And until that bad guy is knocked out, the good guys can’t flourish.

So start with the foundation. And then get clinical from there is what I’d say.

Sal: It’s truly a symbiotic relationship. It goes both ways.

DrMR: Yeah.

Sal: 100%.

Diet Culprits Affecting Gut

Justin: When I’m coaching a client, I’m always trying to help them connect the dots and be more aware of what they’re intaking, consuming. So I make them track. And I say, “Don’t change the way you’re eating. Just eat how you normally eat. And we’re going to track it. And together, we’re going to look at it.”

And for me, one of the biggest culprits I see is this overconsumption of just sugar in general. Do you see a common theme in people when you look at their diet as far as culprits that could be affecting their gut negatively that tend to help them in general? Like, “Hey, most people tend to do this. And this is probably not ideal for our gut.” Do you see something like that?

DrMR: Yeah, a lot of this depends on where you’re coming into the conversation. If you haven’t even really changed your diet much, then just shifting to some type of healthy diet plan, you’re going to see a lot of benefit.

So that could be Mediterranean. It could be paleo. It could even be vegetarian, even though I’m not a huge advocate of vegetarian diets.

If you’re coming from the standard American diet, shifting to a healthy diet plan that avoids added sugar, to your point, and processed foods, you’re going to see a lot of benefit.

We can talk in a second, if you want, about the comparative studies looking at these different diets to see what diet actually has the edge to be the healthiest.

But there’s something else that may be salient for athletes or exercise enthusiasts. This has to do with how exercise impacts the microbiota. And I’m being a little bit speculative here, but I think this is somewhat well reinforced of an argument.

We see in athletes that are overtraining or training excessively increased risk for infection. I’m sure you guys have heard of that. Part of this—well, let me take a step back and say—

Too much exercise can increase your risk of infection. But some exercise can actually increase the diversity of healthy bacteria in your gut. And why this probably is, is because exercise can be a little bit immunosuppressive.

And so in the right dose, it can prevent your immune system from killing the good bacteria in your gut, having too overzealous of an immune system. So a little bit of immunosuppression, good. Too much—now you’re so immunosuppressed, you have an increased risk of infection.

But the problem can be too much exercise may downregulate the immune system in the gut to a point where it allows small intestinal bacterial overgrowth to occur or other like imbalances. I use the example of SIBO (or small intestinal bacterial overgrowth) because it’s pretty in vogue right now.

And so some athletes are really noticing that their digestion is not great probably because of over exercising, also maybe because of some of the garbage in the powders and the pills and whatever.

And then they’re finding benefit in diets that restrict foods that feed bacteria. And this is known as a low FODMAP diet most typically. And what’s interesting or maybe counterintuitive about these diets is at face value they seem healthy. These foods that are restricted by the low FODMAP diet seem healthy—asparagus, cauliflower. Aren’t those healthy foods?

Well, it depends. If you have bacterial overgrowth, those foods have a lot of prebiotic in them that feed bacteria, and they may actually make you feel worse. And increased inflammation in the gut increases bacterial overgrowth. So some athletes are finding benefit from going to these low FODMAP diets to help rebalance this altered gut flora.

So that may be something a little outside of the typical healthy diet recommendations that could be salient to your audience. A low FODMAP diet for those with IBS-like symptoms (gas, bloating, constipation, loose stools, abdominal pain, reflux) may be helpful because of an underlying imbalance that’s been driven by that kind of exercise/athlete lifestyle—lots of exercise, potential gut immunosuppression, and then some of the other garbage that is in the supplements.

Adam: Now, is this why you’re not a huge fan of a vegan diet? Is that why?

DrMR: Yeah, that’s part of the reason. I think the vegan diet may be a little bit extreme, where if you look at our evolutionary history, there’s not a strong argument for a vegan diet. And this is as someone who—I really appreciate looking at evolution.

And if you look at our evolution, there are actually a few pivotal points in time that have steered us away from a vegetarian-type diet and a vegetarian-type gut.

And I’ll bore you with some details about early hominid history. But there were two competing ancestors, hominids, at the same time. And one of them would become us. And the other one would go extinct.

You had Paranthropus boisei, which was like a gorilla, a really big hominid that lived predominantly on the ground, had very strong jaw structure, and could just eat nuts and roots and this very tough vegetative matter like a cow almost. And he had a very long intestinal tract to help break that down. So he was a specialist in the stuff that was just right there on the ground.

He was competing with Homo habilis, who was more like us. He was omnivorous. He could climb up in a tree and eat honey. He could scavenge off a kill and eat some meat. He could eat some fruits or berries. But he was omnivorous. And the other was more of a vegetarian specialist.

Now, at some point—and we believe it’s when the Himalayan Mountains formed—that changed the global climate to where Africa, where these hominids were, became much more arid. And so a lot of the vegetation died. And so with that, Paranthropus boisei, who only ate vegetation, became extinct.

But the clever, crafty, adaptive, omnivorous Homo habilis lived on. And part of his diet was a diet that allowed him to survive on things like, yes, honey and ripe fruits, but also a heavy amount of scavenging off carcasses that involved a lot of meat consumption.

And that actually changed the anatomy of our intestines where we became more dependent upon the small intestine and less dependent upon the fermentative large intestine, which is more a vegetarian-diet-centered intestinal tract. So there’s a lot of evolution suggesting that we shouldn’t be strictly vegetarian.

But when you look at the comparative studies, coming modern day and trying to filter this through clinical trials, we have had studies done that look at a low carb diet next to a vegetarian diet for numerous conditions.

And to put it simply, studies generally compare low carb, vegetarian, and paleo in some of these set ups. And compared to no diet at all, all the diets show benefit. It’s important to establish that, because your vegetarian friend may say, “Well, what about this study?” Yes, they’re out there.

But the comparative studies that have compared one to the other to see if one has a slight edge show general favorability of either a low carb diet or a paleo diet. Again, they all work. But there seems to be a favorability toward a lower carb diet or a paleo diet according to the best evidence that we have right now.

Sal: Yeah, I think in modern times you can eat vegan and be perfectly fine. But it takes a lot more planning. It’s very difficult to get certain nutrients. It’s just a fact. You’re not going to get as bio-available forms of iron. You’re not going to get certain B vitamins.

When you give creatinine to vegans, it’s new tropic. It actually boosts their IQ a little bit. And you give it to an omnivore. And it doesn’t really do that. And that suggests that there’s a little bit of a deficiency in creatinine, which you get from meat products.

DrMR: Interesting. I didn’t know that. Yeah.

Sal: And again, I respect people’s moral reasons for eating vegan. But when someone says, “It’s the healthiest way to eat,” I shake my head, roll my eyes a little bit.

DrMR: If you’re objective, it’s not supported to say it’s the healthiest. It’s a healthy way to eat compared to no diet at all.

Justin: Right.

DrMR: But if you’re going to be objective, if not’s the healthiest.

Adam: Oh, we tend to tell people, “Pay attention to what you were doing before you switched over to that because—”

Sal: It might be more about what you’re not eating any more than what you’re eating more of now.

DrMR: Right. Right. Right. What you’re including now.

Adam: Exactly. Most people that go vegan after not doing anything whatsoever were grossly under eating vegetables. It’s amazing when you all of a sudden start introducing four, five servings of vegetables in a day, how great you feel.

DrMR: And that’s probably why people feel better on virtually any diet plan when they’re coming from no diet at all.

A to Z Weight-Loss Trial Study

But there’s one other point that I think is interesting here that may help satisfy some of the debate in terms of carb intake. So Christopher Gardner is a Ph.D. researcher over at Stanford. And he did a great study called “A to Z Weight Loss Trial.” He compared Atkins, Pritikin, Ornish, and Zone—so low carb all the way up through high carb. And what he found is that all the groups saw a weight reduction and an improvement in their blood lipid profiles. But there was a slight edge for the Atkins diet.

So he said to himself, “Why is it that everyone’s responding, but the Atkins has a slight edge?” So he did a sub analysis. And in the sub analysis, he was able to figure out that while some people can respond to any diet, there are some people that only respond to a low carb diet.

And it’s the people that have the worst insulin sensitivity who will only respond to low carb. People with good insulin sensitivity will respond to any diet. That’s important to factor into our conversation here, because it cuts through the “This diet is better because it worked for Suzy Smith, but it didn’t work for me.”

It’s just because not every diet is going to work for everyone. People with good baseline insulin sensitivity can go on any of these plans and have success. People with compromised insulin sensitivity will probably only find success on a lower carb diet.

Sal: Just for the layman, you take 1000 average Americans. And a good chunk of them, a large chunk of them, are going to have insulin issues, which is why low carb seems to work best for most people—not for everybody, but for most people because a lot of people have—

DrMR: And that’s reflected in the studies like we just talked about. Exactly, yeah.

Sal: Yeah, so you’ve got a little bit of that—what is that called? They call it self-selection or that selection bias or whatever because of the sample size.

Leaky Gut Syndrome

I wanted to ask you a little bit about leaky gut syndrome. It is not accepted yet—I say ‘yet’ because I think it will be eventually. I’d like to know your opinion on it—by Western medicine. I hear people laugh at it sometimes when I talk about it. What is leaky gut syndrome? And what is your opinion on it? And what are some of the symptoms?

DrMR: Well, I partially see where more conventional medicine is coming from with chastising leaky gut syndrome, because in some circles it’s almost used as a term like adrenal fatigue, where people just use this as a descriptor.

Sal: Just a blanket—

DrMR: “Oh, my adrenal fatigue today.” That’s not really—first of all, the whole concept of adrenal fatigue is being seriously questioned right now. And the method of testing that is being seriously called on the carpet. So it’s one of those things that’s like this self-feeding prophecy where people just blame, “Oh, my leaky gut today is—gosh—really.” So I understand where they’re coming from.

There are a couple different ways to assess it. There’s the lactulose mannitol test, which can produce a false negative or false positive if someone does or does not have SIBO, so I don’t like that test.

And then there are antibodies against things like zonulin and occludin. And to tell you the truth, I don’t really do any leaky gut testing because, to the degree to which someone is ill, especially if they have digestive symptoms, I’m assuming they have a degree of leaky gut.

Now, to your question, “What is leaky gut?” It’s essentially when your gut is letting too much stuff through, to put it really simply. Your gut is a selectively permeable membrane that wants to absorb things like nutrients and wants to keep out things like parasites and toxins and what have you.

So it’s a selectively permeable membrane. And when there’s damage in the gut or inflammation in the gut, you can let too much stuff through. That can cause an over activation of the immune system. And this has been correlated with autoimmune conditions.

But then the question is, what do you do about that? And that’s really where I jump in. I’m assuming if you have autoimmunity, if you’re ill, if you have IBS, if you have IBD, if you have depression, if you have insomnia, fatigue, I’m assuming your gut health is probably not great.

So I don’t necessarily need to quantify that. What I do need to quantify are the things that we can treat that will improve the leaky gut.

So I just make that recommendation, because a lot of patients coming in reading about leaky gut and thinking that there’s some leaky gut test that then has this corresponding leaky gut treatment. And what it really has is a bunch of supplements that may help with leaky gut but don’t fix the underlying problem of the leaky gut.

And so a lot of people come in spinning their wheels, not realizing that you don’t have holes in the bow of a ship just because. You’re sailing in rough waters. Or your wood is rotting. You have termite infection.

So leaky gut doesn’t happen just because. So I circumvent and I go right to what the cause of leaky gut could be. So it’s definitely something that I think has validity to it and has been correlated in some of the research literature with different conditions. It’s just—in my opinion—it’s just an intermediary between disease and an underlying deeper cause and effect.

Adam: Hearing you say that makes me have to ask you then, how frustrating, or how often do you get this where something comes out, like leaky gut, and it becomes popular and before you know it, there’s a supplement to treat this symptom?

Sal: Yeah.

DrMR: Yeah.

Adam: Versus is this something you see a lot of? Is it something that just came up recently that frustrates you? How often does this piss you off?

DrMR: Stuff like this happens all the time. And admittedly, I may come off a little bit jaded or passionate about this sort of issue because I see so many patients that come into my clinic, and they’ve taken so many supplements, and they’ve done so many self-tests, and they’ve just wasted so much time and so much money.

Leaky gut is a shining example of that. Adrenal fatigue is a shining example of that. Many of the thyroid conversion supplements are other shining examples of that. And these are all things that I did. I’m not criticizing. These are things I did myself when I was in college, not feeling well. I did the same thing.

Went on the internet, took the thyroid symptom quiz, thought I had hypothyroid. So I went to Whole Foods and I bought the iodine kelp supplement plus a Guggulu thyroid conversion compound with selenium. I get it. It makes a lot of sense cognitively.

But there’s this simple analogy where if your car broke down and we let you into the machine shop, could you fix your car? You have access to all the tools. Do you know how to use them? No, you don’t know how to use them. Chances are, you’re going to waste a lot of time and money in the machine shop trying to fiddle around and fix your car if you don’t know how to use the tools.

So I would say I spend probably 30% of my time talking people out of a disease they think they have or from doing a test they think they need to do or from taking a supplement they think they need to take, because in clinical practice these things tend to be pretty simple. It’s a lot of complexity in terms of analysis, but then what you do ends up being simple.

So yes, things like this irritate me all the time in terms of people doing these self-tests and self-treatments. And I’m all for self-education, but if you’ve done a little bit of tinkering and you haven’t gotten anywhere, it’s really going to be in your interest, in my opinion, to turn things over to a clinician, because in the long run, they’ll save you time and money.

Sal: And what kind of tests do you run to figure these things out for people? Are they stool sample tests?

DrMR: For gut workups specifically?

Sal: Yeah.

DrMR: So for a gut workup, what I like to do in most cases—there is some nuance here, but I almost always will perform a SIBO breath test.

Now, let me just preface by saying most of the people who come into my clinic have already done some dietary tinkering. Their lifestyle is in somewhat decent order. And so we’re not going to start there. We’re going to go to level two.

If someone comes in, which occasionally someone comes in—

Sal: Because you’re not usually the first person they see.

DrMR: Exactly. Exactly. Or they’ve done a little bit of research. And they said, “Oh, the paleo diet. Let me try this. Or let me try a probiotic.” So if someone comes in like that and they haven’t even gone on the paleo diet, I’ll say, “Fred, take this book home with you on the paleo diet. I’ll see you back in 30 days. And we’ll check in.” And oftentimes, 70-80% of improvement is yielded just by that.

But for the people that have done some dietary tinkering, I’ll almost always do a SIBO breath test. And it’s a three-hour lactulose hydrogen methane assessment via a breath test.

And then I’ll usually do a stool sample. Depending on their insurance, if we can go through LabCorp or Quest, that’s great. Then we’ll do a combination of stool, blood, breath, and urine.

And all those markers are looking for different things in the gut. You can look for antigens in the stool, antibodies in the blood, certain organic acids in the urine, and then an H. pylori assessment via the breath. And so I’ll usually do that kind of workup.

Now, if I’m suspicious of inflammatory bowel disease, then we’ll add in some inflammatory markers that are consistent with inflammatory bowel disease. But that’s generally the workup.

And then in conjunction with that, we’ll do a general core wellness panel, where we’ll do a preliminary thyroid screening for overt hypothyroidism, look at vitamin D, screen for anemia, look at liver and kidney function.

But the initial assessment, while thorough, it’s not excessive. And that’s, I think, an important thing for the healthcare consumer to be cognizant of.

I think, with only good intentions, sometimes functional providers or even your conventional doctor who is trying to get into more alternative medicine maybe is getting information that’s a little bit biased by lab company or supplement company educational materials. And so you end up with a testing or supplement model that’s a bit excessive.

Sal: So you mean someone goes home with 15 different bottles of—

DrMR: 15 bottles of supplements or thousands of dollars’ worth of lab testing. Now, if you have no health insurance, your initial lab bill being between $900 and $1500 isn’t unreasonable, if you have no insurance at all.

But if you’re using insurance in maybe a hybrid model where you can get some tests covered and some tests not, you should be looking at maybe a few hundred dollars. So somewhere between a few hundred and maybe $1500 is, in my opinion, the max for what a reasonable initial lab bill should be.

But it’s fairly common for people to be spending in excess of $3000, $4000, $5000 on their initial lab testing evaluation. And I know that there can be a time and a place for that.

But I think that’s a very excessive model that needs to be reexamined, because it can end up doing more harm for the patient than good because it creates financial stress. Also on the clinical end of things, if you have too much information, it’s very hard to analyze that data and know what’s helping and what’s not helping.

So it’s better, I think, to use what’s termed as a vertical differential diagnosis rather than a horizontal. Horizontal means you’re going to attack everything at once. Vertical means you’re going to organize a hierarchy based on the person’s presentation and say, “We’re going to start with items 1 and 2. We’re going to see those through to fruition and then reevaluate. If everything’s improved after 1 and 2, we’re done. If not, we move on to 3 and 4 or 5 and 6.”

So when you go through these things in a vertical, hierarchy fashion, you make the treatment much simpler, much more cost effective, and much less excessive. So those are some of the tests that I do initially. And I’m always looking at the person in this vertical model, because if those things don’t work, there are these secondary and tertiary and quaternary fallbacks that we look into.

Recommended Reading

Adam: Now, when you came in here, you were—what was it called? The Sony—

DrMR: Oh, Sony digital paper.

Justin: Okay, the Sony digital paper. You were reading some studies. And by the way, that’s really cool. We’ll make sure to put that in the show notes.

Sal: Yeah, super cool.

Adam: But I love to ask someone like you who’s got a specialty like this. What are you reading right now that has got you excited or very intrigued in this world as far as the gut? And what are you diving into right now or learning?

DrMR: Well, the gut histamine piece is interesting. Let me pin a pin there for one second because there’s something non-gut related that I think is really important, which is thyroid autoimmunity.

So this autoimmunity epidemic, I think many people have heard about it. And there are just a few important things for thyroid autoimmunity that I think it’s important for people to understand because it could potentially save them heartache, fear, what have you.

So if you’re reading up on this, you figure out that Hashimoto’s is an autoimmune process that causes hypothyroid and that Hashimoto’s is important to treat and to monitor and what have you, which, yes, it is. But there’s some nuance.

So the main lab marker that’s used to track Hashimoto’s is an antibody called TPO (thyroid peroxidase). You can get it at LabCorp, Quest. Any doctor can do it for you.

Now, anything above usually 35 is considered positive. So oftentimes, people will have this test done. And they’ll see that, yes, they have Hashimoto’s. Their antibodies are elevated.

But the level of elevation dictates risk. Why this is important is because if people are above 500, then they are increased risk. But if people are below 500, they’re at minimal risk.

So why is this important? Because when people come in initially, they may be at 800, 1200, 1400, 1500—very high. But then they make some healthy diet and lifestyle changes, maybe use some vitamin D, maybe use some selenium, maybe investigate a problem in the gut, treat that problem. And they’re feeling, at the end of all that, much better.

We retest their antibodies, and their antibodies are now 225. Now, depending on the type of clinician that you are and how you’re trained, you can take that and manage that conversation one of two ways.

One way, the way I would not recommend, “You still have autoimmunity. There is still a problem. We still have to treat you. We still have to do stuff. And you still need to be afraid of this chronic internal inflammatory burden.”

And people get really fearful about that. And they walk around every day thinking that there’s this smoldering fire of autoimmunity in their body that’s going to be problematic.

However, if you look at some of the contemporary studies with a critical and conservative eye, you see that when people are between 100 and 300, really below that 500 mark, they are at minimal risk for any kind of progression of the disease. And it’s what I would term a clinical win.

So why that’s important is because there are a lot of people walking around with positive TPO antibodies, but in the lower end of the range that don’t have to be fearful anymore about their autoimmunity and can just focus on living their life.

I think that’s something that’s really important, because I see a lot of patients that come in and they think there’s still something wrong with them when there’s probably not. So that would be one important thing that I’ve been reading up on and seeing this trend in the literature that it’s not like a light switch, on or off.

And maybe looking at diabetes—your blood sugar shouldn’t be above 99. But if you come in at 103, we’re not going to scare the bejeezus out of you.

Sal: Yeah.

DrMR: If you’re 203, different story.

Sal: Sure.

DrMR: Same thing with the thyroid antibodies. If you’re just over the edge there, 200—not that big of a deal. If you’re 1200, 1900—okay, we need to start looking into this more deeply. So that’s one thing.

Macronutrients and Microbiota

Sal: Now, in terms of nutrition, we talked a little bit about paleo and vegetarianism. Is it beneficial for people to vary not only the foods that they eat but their macronutrient profile to foster a more diverse microbiota? Does it do that? Or is it okay to stay—is it better to stay in one way?

For me, for example, I for sure have gut issues and have had them for a long time. And I just feel at my best at a very, very low carbohydrate, higher fat diet. But I also found over time that when I throw in days where I’d have more starches or I even have vegan days that I’ll do for myself, I seem to feel much better.

Am I promoting a better microbiota? Or does it have nothing to do with that?

DrMR: Well, I think there is some benefit to variability. And that’s probably just replicating the feed, fasting, and food variability cycles that we experienced when we were hunter/gatherers. It wasn’t always going to be the same. So I definitely think there’s some plausibility to that.

It’s also important to keep in mind that globally the hunter/gatherer diet changes from equator to the poles. And this has been well confirmed in the published anthropology literature.

The closer you are to the equator, the more of a high carb diet you should—and I don’t mean if you’re living there currently. I mean if your genes evolved there, of course.

So if you’re of genetic lineage of an Ecuadorian, then you probably do better on a high carb diet. If you’re of Irish descent, you’re probably going to do better on a low carb diet, because what we see is at the equator from about zero to 30 degrees of latitude, it tends to be a higher carb, lower fat diet.

Then from 30 to 40, where are we? Mediterranean. Guess what you have? Kind of an intermediary between high carb and low carb. Then you go +40, and you have a lower carb type of diet. So there’s definitely this variability built into the system in terms of who will do best on what kind of macronutrient composition.

To your question, I think variability definitely has some plausibility to it. But there’s another point here which is, now that we’re learning that the microbiota is important and having a diverse microbiota is important and that fiber, carbs, and probiotics can feed your microbiota, there’s this erroneous assumption forming that essentially states that if you want to have a healthy gut, you need to eat a lot of carbs, fiber, and prebiotics. And that’s wrong.

And it’s wrong because the people who have the worse gut health will do the worst on those interventions. So the highest risk of a negative reaction to fiber and prebiotics are those with IBS and IBS.

Sal: That’s me.

DrMR: Clearly been shown. And part of this may have to do—

Sal: You’re feeding the bad stuff maybe.

DrMR: Well, it may not even be the bad stuff. Part of it may have to do with the fact that your commensal microbiota, the stuff that should be there, your immune system is not well calibrated to manage that.

So even if you have a growth of the good guys, your immune system isn’t getting along with the good guys to begin with. So if you go and you feed the good guys, you’re feeding what is pissing off your immune system. So I think that that is one of the things that underlies that.

Now, there are so many levels of—god!—complexity to this argument because we see in healthier populations generally higher diversity. So in people with IBS and IBD, we see lower diversity. So it’s easy to draw the inference that we should be giving people with IBS and IBD lots of fiber and lots of prebiotics.

But it’s not that simple. This is a biological system. And I think what happens is the immune systems in IBS and IBD are forming adaptive responses to try to diminish the commensal population because the immune system doesn’t get along well with the commensals.

And the clinical data reinforces that. The observational data reinforces, “Eat a bunch of fiber and prebiotics.”

But when we do that with people, when we take people who have Crohn’s disease, for example, and put them on a high FODMAP diet, we see they have more inflammation, more disease activity. But yet their microbiota starts to look healthier. And they have more short chain fatty acids which may be healthy. So we see these glaring discrepancies.

There have also been some studies showing that after the administration of certain antibiotics, we can see diversity increase. And that may be because, to your earlier comment, that we’re killing off some of the bad guys that have been poisoning the good guys from growing.

So dysbiosis and inflammation can poison the environment and make it harder for the good guys to grow. So it’s not just to say we have to feed the good guys. Sometimes, it’s looking at this more from an environmental perspective of trying to figure out what the ecosystem needs.

And the analogy I like to use is different ecosystems require different parameters to be healthy. So if we say that carbs, fiber, and prebiotics are like rain because they feed stuff—southern California, too much rain causes mudslides and kills people.

So we shouldn’t say because there’s such pretty vegetation in the rain forest, every geographical climate should have a lot of rain. No! Do you see how stupid of an assumption that is?

But we do that where the African hunter/gatherers eat lots of fiber and have healthy guts, so we should all do that. Well, no, we shouldn’t do that, because if your gut ecosystem, like in your case, if your immune system hasn’t been ideally calibrated to deal with your commensal microbiota, then we go and try to feed that, you may have more inflammation because we’re feeding the thing that the immune system is struggling to keep in check to begin with.

Sal: And this was something that we talked about with Robb. It’s just so ironic that Western medicine doesn’t take anthropology into consideration when diagnosing. I just find that so fascinating that we don’t take that into consideration. It just seems so obvious when you use analogies like that.

Justin: It seems like anybody could benefit from getting their gut tested and just finding out how you respond best to it.

DrMR: I wrote an e-book called Start with the Gut that talks about this, because I’ve seen over so many years this concept just completely reinforced, which is once you get your diet and lifestyle in order, if you’re not feeling well, the place that’s most efficient to start is the gut. It’s not a guarantee. It’s not a panacea. But there are other things that are less common that you want to make sure that you do after the gut and only after the gut.

So Lyme disease, mold and mycotoxins toxicity, heavy metal toxicity—I think any expert in those areas will agree. Get your gut healthy first because it’s going to be easier to heal from this once you have that in order.

So I think that’s the one message to take away from this podcast if nothing else. Start with your gut.

Adam: Yeah.

Antibiotics and Probiotics

Sal: I was going to say. I had an interesting experience more recently, over the past few years, where I’ve had to take antibiotics a couple time. And with my antibiotics, I’ll separate—and I read that this is the way that you’re supposed to do it. And I don’t even know if this is accurate. But I’ll take my probiotic [sic] in the morning. And four hours later, I’ll take a probiotic obviously because I’m trying to protect—

DrMR: Antibiotic and probiotic.

Sal: Excuse me. Antibiotic and probiotic. And my gut health is amazing when I do this. I’m on an antibiotic, and then I have the best gut health ever. And then I go off the antibiotic, and then it takes two to four weeks, and then I go back to my old self.

DrMR: Yeah.

Sal: What’s going on? I must have something that’s overgrowing or that I’m killing with the antibiotic but then comes back.

DrMR: So I’ve got to get you a copy of my book which hopefully will be out late this year. Or I’ll just kill myself because at this point it’s been so long. I’m getting sick of writing it.

But we go through a process exactly for those types of people, because there’s definitely a subset of people that always feel better on some type of anti-microbial approach. Now, that might be a low carb diet. It might be a low carb, low FODMAP diet. It might be cyclical use of herbs that are anti-bacterial in nature.

Sal: By the way, which ones?

DrMR: Oregano, grapefruit seed, berberine, allicin garlic.

Sal: Got it.

DrMR: There are a whole bunch that can be used. But there’s definitely a subset of people that need to work to keep their microbiota in check.

So there are other foundational things that may preclude you from needing ongoing anti-microbial—the right probiotic regimen and the right dietary regimen may get you there. But there are definitely people that notice that they feel better when they’re on antibacterial type treatments.

So what that may mean in your case, you may fit a more standard, moderate IBS sort of presentation where you need to keep the shrubs trimmed. And so an analogy I like to use is we pull weeds, and we trim shrubs.

And so sometimes people have a hard time, thinking, “Well, don’t we not want to kill stuff in the gut?” Well, it’s not all about killing. Sometimes, it’s just about trimming.

And so sometimes when people are learning about SIBO or candida, they’re saying, “Well, don’t I want to completely eradicate my SIBO?” Well, it’s not that you want to eradicate those bacteria because those bacteria should be there. And the fungus and candida should be there. It’s just you don’t want them to be overgrown.

Just the same way to trim your shrubs, you don’t rip them out. You trim them. So some people need this ongoing trimming approach to keep things in balance. So that may be you.

Justin: That might be me.

Adam: Along these lines too, we talked—

Justin: Got to mow that lawn, man.

Sal: I don’t trim.

Adam: After the podcast, Taylor mentioned wanting to take you to Whole Foods. And you suggested something. I wanted you to share with what you suggested and why you suggested that. I think it’s an awesome thing that we can—

Sal: It was about probiotics.

DrMR: Yeah, yeah. I think one can get easily confused around probiotics because there are so many different formulas out there. But I think an easy way to approach probiotics is to try to organize them generally into classes.

And there are about four classes of probiotics. You have your Lactobacillus/Bifidobacterium mixtures. So when you look on the label, you’ll see predominantly Lactobacillus and Bifidobacterium listed. That’s class one

Another class is Saccharomyces boulardii, which is a healthy type of fungus. And on the label there, you’ll see just Saccharomyces boulardii.

A third is known as soil-based organisms. And you’ll see here mostly Bacillus-type species on the label. And there’ll be many of them. But you’re going to see Bacillus, Bacillus, Bacillus, Bacillus, Bacillus predominantly.

And then the fourth, you can’t buy it in the U.S. But you can go on the internet and buy it from Canada or wherever. And this is E. coli Nissle 1917. And people sometimes think, “Ooh, E. coli. Isn’t that bad?” Some E. coli, yes. But one of the major gut commensals, good guys, is actually E. coli. So you want to have robust E. coli in your gut naturally.

And this E. coli 1917—trade name is Mutaflor. There’s one other brand, but Mutaflor is probably the most well-known is the fourth class. And so what you can do is just try a probiotic of each one of those classes. If you’re sensitive, I would try them one at a time so that you can preempt or determine easily where a reaction is coming from.

Sal: I was just going to ask. Do you want to take them all together?

DrMR: Well, the healthier you are, the lower your probability of a reaction. So you can take them altogether.

Sal: Okay.

DrMR: But if you’re more sensitive, you notice you’re more reactive, I’d do them one at a time so you can parse out where a reaction is coming from, because while there, in my opinion, is an overwhelming number of literature that probiotics can help everything from depression to SIBO, not everyone is going to have a positive response.

There’s a small subset that will have a negative response. The most common negative response is bloating. Now, bloating for a couple days is not abnormal as things are adjusting.

But if after 3, 4, 5 days you’re still having persistent bloating or other negative symptoms, then that probiotic may not be for you. Try the others.

And if after trying all the probiotics you can’t find any that work well for you, you may just be, as a general class, a probiotic non-responder. And you don’t want to use them.

Sal: I was just going to ask you, because I’ve used most of those. I bought the soil-based one. Prescript Assist I think was the brand. And the Lactobacillus/Bifido one that I’ll use is Ultimate Flora. And I tried—what was the second one you named? It was a fungus—Saccro—

DrMR: Saccharomyces boulardii.

Sal: Saccharomyces destroyed me. I would take it and I’d have horrible gastro issues from it. And I tried it a few times, and it was just horrible for me. And obviously, I stopped taking it. And so that means, very simply, not for me.

DrMR: Exactly.

Sal: Probably not the right one to take.

DrMR: Yeah, two things there I should maybe mention really quick. With probiotics, you want to be careful that your probiotic does not have a high level of prebiotic in it. So you want to shoot for—

Sal: So it does not.

DrMR: Does not have a lot of prebiotic.

Sal: That’s funny because some of them include prebiotics, saying it’s better for you.

DrMR: Right. Well, theoretically, yes, because the prebiotic feeds the probiotic.

Sal: Right.

DrMR: But for people with IBS and IBD, they’re more prone to negatively react to prebiotics.

Sal: That’s me, again.

DrMR: Yeah, I recommend you shoot for underneath 1000 mg. Underneath 1000 mg is probably going to be okay. Most of the studies have shown that you can get away with 3-5 grams without risking a lot of negative reactions. But that’s something to be cognizant of. For example, that Saccharomyces boulardii, if it had 2, 3, 4, 5 grams of inulin in it, that may have been what you were reacting to.

Sal: Oh.

DrMR: So just try to do your best to isolate for the probiotics with a lower level of prebiotic.

Sal: And start with a low dose, like you said.

Justin: Now, how hard is this to find in just Whole Foods? Or can you—

DrMR: It shouldn’t be too hard. It’s just you want to read the label and maybe ask the person there, “Are any of these things prebiotics?” and then look and see the milligrams listed.

Sal: Well, the Lactobacillus and Bifido ones you can find easily. The soil-based ones, I had a tough time finding. I had to go online.

DrMR: I’m sorry. I thought you were asking how to determine the level of prebiotic in them. In terms of finding the formulas, yeah, the Lactos and the Saccharomyces probably at most health food stores. The soil-based probably online. And then the E. Coli, or trade name Mutaflor, definitely online because you can’t buy that here.

Sal: Here’s another thing that I observed with myself. I’ll take Lactobacillus and [Bifidobacterium] probiotics for a while. And they’ll be great. And then after a while, they seem to affect me negatively. And I’ll have to switch to the soil-based one. And then I’ll do great on that one. And then that will affect me negatively. And then I have to switch again. What’s going on with that? Am I getting overgrowth?

DrMR: Well, it is possible that you’re overdosing.

Sal: Okay.

DrMR: And so you may need, to say, cyclical dosing of it. Or you may just need less of a dose of the ones that you are getting. And I don’t think we have an answer here scientifically.

Sal: Okay.

DrMR: So experimentation and your own response as a barometer would be what I would use. However, I’m inclined to think that consistent dosing may be better just knowing the way the immune system works. It seems that consistent exposure is more synchronistic for the immune system whereas episodic exposure may be problematic.

Sal: I see.

DrMR: So maybe you cut your dose lower. Or you do it three days a week. But you try to use all the probiotic classes at once in a lower dose and maybe a little less often rather than cycling.

Sal: Now, with the probiotic—because when people take them, they take them all the time—is that showing that it’s more of a band-aid than anything? Because it’s not populating your gut. Or it’s not really changing anything. You’re just taking it to deal with your symptoms.

DrMR: Well, most probiotics do not colonize you. So that’s important to establish.

Sal: Now, okay. So I’m glad you said that. Let’s talk about that for a second. So what do you mean by that? It doesn’t actually help populate your gut with what you’re taking?

DrMR: Yeah, that’s a misnomer. Probiotics don’t colonize you.

Sal: Okay.

DrMR: Most. Most don’t. And they’ve even done studies using what’s called heat-killed probiotics, where they heat up probiotic until they’re dead. And then they administer them. And they’ve shown benefit with even those. So there may be more to the probiotics than—a live probiotic may not be essential for some of the benefit.

Probiotics do a couple things. They transiently—because they’re mostly, again, transient in nature. They don’t populate you. They release antibacterial peptides. So they can actually kill SIBO, kill fungus.

Sal: Oh.

DrMR: So part of what they may be doing is combating overgrowths. So they are antibacterial. They are also anti-inflammatory and immunomodulatory. So they dampen the inflammatory and immune response in the gut. They help with leaky gut by doing that. They may also partially degrade biofilms.

They help make the microbiota less skewed by antibiotic use. And they actually even have been shown to enhance the effectiveness of certain antibiotics when used for the treatment of certain infections. So there are many benefits of probiotics. But they tend to be somewhat transient.

Now, the way I would recommend using a probiotic is using them in more of a clinical application while you’re trying to get your gut re-balanced and then try to find the minimum dose needed in the long term. And in my print book that’s hopefully coming late 2017, we go through the whole story, all the stuff we’ve been talking about.

But then the end codifies all the information into an eight-step process that’s personalized. So at the end of every step, we reassess. And you either go one way or the other. If people respond optimally at step one, they go right to step five and finish.

If they respond optimally at step two, they go right to step five and finish. If they aren’t there by step two, they go through steps three and four which are built to be together.

But things like your response, which is you feel better on an antibiotic but then you regress afterward, those are factored into the plan. And really is this algorithm that I go through in the clinic.

And so what I recommend in the book and just as a general practice is try to be a little bit more robust in your intervention in the short term. See if we can get your microbiota to balance back out. And then wean off the interventions in terms of supplements or whatever. And then also try to broaden your diet.

So at the end, the endgame is minimal use of supplements, maximally broad diet. And that’s what we do in the long term.

Histamine Intolerance

Sal: Awesome. Lastly, I wanted to ask you about fermented foods. What role do they play in gut—

DrMR: Oh, that goes back to your histamine question. So I’m glad you asked that so we can tie back into that.

So fermented foods can be great for your gut. They’re a food form of probiotic.

Sal: Like kombucha.

DrMR: Kombucha, kimchi, sauerkraut. Yeah. So they can definitely be helpful. Fermented yogurts. And there are definitely some studies showing that these types of foods can be helpful for various conditions including gastrointestinal conditions.

However, there’s one important caveat with fermented foods. And that is there are some people—and some estimates come in at maybe 22% of patients with digestive symptoms—may have what’s known as histamine intolerance.

Now, what is histamine? Histamine is a byproduct formed from bacteria. So in fermented foods, because there’s a lot of bacterial activity, you’re going to have a lot of histamine. And for some people, what I notice is they go to a paleo/lower carb type diet and they inadvertently start eating lots of histamine.

Probiotic-rich foods like fermented foods plus things like spinach, avocado, fermented meats like jerkies and canned salmon, things like that—they all have a pretty whopping dose of histamine in them.

Now, for most people, it’s not a problem. But if you’re histamine sensitive, it can start manifesting as this histamine sensitive reaction. And there are a few things that can happen there.

There are neurological symptoms—brain fog, irritability. There are skin reactions—hives, rashing, flushed feeling. It can also cause insomnia. It can cause things like joint pain and can also cause gastrointestinal distress, like bloating or loose stools as some of the most typical, and maybe even joint pain.

So some of the key things there are if people notice they feel worse when they eat lots of fermented foods, then they may be histamine sensitive. And then you can look up a low histamine diet. Try following that diet for a few days. And usually, it only takes maybe a few days to start at least getting an inkling in terms of if you’re histamine sensitive or not.

And this actually happened to me. I was eating lots of histamine foods. I was eating tons of avocadoes and spinach and jerky because it was all so convenient and then washing a lot of that down with kombucha.

And I’d be at home office on a beautiful sunny day, no reason not to be perfectly happy. And I’d be like, “What the frick? I’m pissed off. What am I mad about?” And I felt foggy and irritated. And I finally did some reflecting. And I’m like, “Wow! There’s been a lot of histamine in my diet lately.”

And so I cut out all those high histamine foods, and I quickly figured out that I am a little bit histamine sensitive. So now, I can have those foods. I just can’t have a high histamine food every meal for days on end.

Justin: Overdo it.

Sal: That’s interesting, because especially if I take really hot showers, I’ll get some hives sometimes. And I notice if I take Claritin or anti-histamine-type medicine, my gut will feel better as well.

DrMR: Yeah, you’re at higher risk. So the IBS population is at higher risk for that histamine sensitivity.

Sal: That’s horrible.

Justin: You’re plagued, bro.

Adam: Now, you know.

Episode Wrap Up

Sal: Well, this has been great, man. It’s been awesome talking to you.

Justin: Yeah, I’m excited you’re close. I didn’t realize how close you were to us. We’ll definitely have to do this again. I’m pretty pumped.

Sal: I’m excited to go to the store with you right now and talk a little bit more about what products and stuff people should look for and what they should get and whatnot.

Adam: Yeah.

DrMR: Yeah, definitely.

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Dr. Ruscio is your leading functional and integrative doctor specializing in gut related disorders such as SIBO, leaky gut, Celiac, IBS and in thyroid disorders such as hypothyroid and hyperthyroid. For more information on how to become a patient, please contact our office. Serving the San Francisco bay area and distance patients via phone and Skype.