Answers on Low FODMAP, Intestinal Support, Gastroparesis, Over Supplementing

Intro:

Welcome to Dr. Ruscio Radio discussing the cutting edge in health, nutrition, and functional medicine. To make sure you’re up to date on this and other important topics, visit drruscio.com and sign up to receive weekly updates. That’s DrRuscio.com. The following discussion is for educational purposes only and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking with your doctor. Now let’s head to the show.

DrMichaelRuscio:

Welcome back to another episode of Dr. Ruscio radio. This is Dr. Ruscio. I’m here again with Erin Ryan, and we will be going into some listener questions. Hey Erin!

Does the Low FODMAP Diet Cause Nutritional Deficiencies

ErinRyan:

Hey there. Our first question is from Mike. Now I included this question because I’m not sure Mike has heard Dr. Ruscio on this properly. So I want to address this question. He says, “I’ve heard Dr. Pimentel and Dr. Ruscio mention several times that a low FODMAP diet causes nutritional deficiencies. Is that true? And if so, which nutrients would be lacking? When I’ve run them through a decent nutrient count calculator I didn’t notice any. Are there studies showing this?

DrMR:

Good question. The short answer to this is – well first let me first say, I have not said numerous times that a low FODMAP diet can cause nutrient deficiencies. There may be a similar but different remark I’ve made, which is that one should be careful not to put themselves on an overly restricted diet because that increases the theoretical likelihood of nutritional, micronutrient, macronutrient, or carbohydrate insufficiency. I’m not sure what Pimentel’s remarks are on this, but I think the spirit of that is kind of correct. There has been one study at least that did find deficiencies in certain micronutrients on a low FODMAP diet. I don’t recall off the top of my head what they were, I want to say calcium was one, potentially one or a few different B-vitamins. However, there is another study that found that long-term, I believe this was a two-year follow-up study to a modified low FODMAP diet, did not pose any deleterious health effects on the individual. Whether or not they showed any insufficiencies there, I don’t believe, but it’s been probably a year since I read that study. All that to say, if someone has a flagrant exacerbation of their symptoms from FODMAPs, we have to kind of make a pro-con analysis of that position. Meaning if disease activity, let’s say if it’s inflammatory bowel disease, or if function is lost because of eating certain FODMAPs, we have to weigh that against the risk of nutrient insufficiency. We like to think of things in absolutes, you’re either on low FODMAP or your not on low FODMAP and if you’re on low FODMAP long-term, then you could be deficient in something like B12, just as an arbitrary example. That’s not really the way these things play out in the real world. We would use a low FODMAP diet and then re-introduce and move to try to find the broadest diet possible in the long run.

DrMR:

If someone is unable to successfully re-introduce, meaning they have to stay in a really narrow band of foods, that tells us that there are likely other issues, non-dietary, in the gut causing that lack of ability to expand their diet. So any elimination type diets followed ardently in the longterm could run risks of insufficiencies. Now, if you have a savvy consumer, it sounds this gentleman is, who is running his diet. I’m assuming he’s doing a low FODMAP diet, and running it through something like a chronometer and not finding any deficiencies. That’s likely because he’s done a good job of minding food quality and getting a diverse array of healthy foods. So I do think it’s plausible to say, although I don’t have any data to support this, that if someone was focusing on food quality and eating a wide array of healthy foods, meaning organ meats, an array of fruits and vegetables albeit in this case low FODMAP, having some fermented foods, then that should greatly, at least in theory, diminish the likelihood of insufficiencies.

DrMR:

So yes, there is a risk of deficiencies. Yes, that has been published with a low FODMAP diet. The longer-term data on a modified or relaxed version of that diet seems not to show any problem, although I’m unclear on all the details there. I’m fairly sure that that is what the finding was. If someone is minding food quality and eating a diverse array of healthy foods then that risk is reduced. If someone is eating a crap-atarian diet, that’s really a straw man argument meaning those vegetarians are likely going to show insufficiencies of multiple nutrients because they are eating a low quality vegetarian diet. The same thing likely applies with all of these diets. So you should mitigate the risk of insufficiencies if you’re really focusing on food quality and the broadest array of foods that you can. It’s a great question. No, I’m not concerned about that because the ultimate aim with low-FODMAP and any other elimination diet is to use that as a conjunctive therapeutic towards gut healing, allowing the person to tolerate more foods over time, and broaden their diet with time. Then that really shouldn’t be an issue that is a nutrient deficiency.

ER:

Okay, good clarity on that. Our next question is from James. Let’s hear what James has to say.

Where Does Intestinal Support Formula Fit In?

James:

Hello, Dr. Ruscio. My name is James. I have been suffering with SIBO methane positive on tests and I’ve experienced constipation and bloating and a series of other events. I’ve been treated for this and am now going through your antimicrobial protocol for the second time. The first round of your antimicrobial protocol seemed to work out very well. That, of course, with the elimination as well as the probiotics. After a period of about four to five weeks, I started to get symptoms back again. I’m now on the second round of the antimicrobial protocol, adding in so many other adjunctive support for it.What I wanted to know is where does the Intestinal Support Formula fit into this or does it? Would it be something that I’d be able to take alongside with this as I am experiencing a little bit more from the endpoint of gastritis and I’ve had to stop taking the enzymes with the HCl as a result, which had a tendency to make it worse. Thank you for your time.

DrMR:

So a few things there to unpack. It was a little muffled on my end, so sorry if I don’t capture every bit of it. This essentially looks like a methane SIBO with constipation and bloating case who has responded to probiotics and antimicrobials as laid out in Healthy Gut, Healthy You, especially in the first round. I’m assuming that he saw some improvement, but not complete improvement and/or regressed a little bit after that first round. So he’s doing a second round. He hit a speed bump along the way in the sense that he experienced some gastritis. I’m assuming this is presumed gastritis, and it wasn’t something where there was an endoscopy to actually do the visual inspection to diagnose it. Rather he’s having some burning, stomach pains and potentially reflux, which can be one of the side effects of taking HCl, which is in the digestive enzyme with HCl that is recommended in Healthy Gut, Healthy You.

DrMR:

It’s not something that all people would benefit from, HCl. So I think that was the right choice. If you’re having those symptoms, you may have adequate stomach acid production, and you may have a little bit of common underlying gastritis that may have kind of exacerbated the HCl. The antimicrobials, when taken on an empty stomach, also appear to presumably aggravate gastritis in some. What I can say is that it aggravates those symptoms, it can aggravate gnawing stomach pain, potentially some burning. In those cases, we have individuals take the antimicrobials with food. Now, to your question of where does Intestinal Support Formula come in. There are a few different time points when it could come in. I would make the modification of taking antimicrobials with food rather than on an empty Gstomach.

DrMR:

I would also consider using gut Rebuild Nutrients. That can be helpful for gastritis and the combination of using the antimicrobials with food combined with using the Gut Rebuild Nutrients, which is a multi-ingredient formula that helps to repair the lining of the gut. Glutamine, aloe, zinc. So that may actually help quite a bit. I would give that some time and see if, with those modifications, especially coming off of the HCl, taking the antimicrobials with food and using some of that reparative compound, if you improve. Be careful not to expect improvements too quickly because if gastritis was caused by the HCl, that can take weeks for that to kind of diminish and heal. So be careful not to think that the somewhat fast improvements you saw from the probiotics and antimicrobials is the same timeline that all changes should follow.

DrMR:

I’m assuming there that you saw a somewhat quick response to probiotics and antimicrobials. Maybe you didn’t, but in case you did, one of the things that’s important for patients not to do is think of all response curves follow the same timeline or trajectory. What may be happening here is, as you’re improving, you’re experiencing some of the law of diminishing returns. This means as you get closer and closer to that 100% that you’re trying to reach the rate of improvement slows. That throws off some patients and it causes them to reach for and do more therapeutics. It’s one of the more common conversations I have in the clinic. If we are getting better, but the trend of improvement is slowing as we get closer to that 100% resolution, let’s not go too fast because if we go too fast, we can fumble and fall, crash and burn.

DrMR:

Then we have to kind of triage and clean up the mess. We’re much better off going slow and steady and not having to go through the triaging of a reaction. So when does the Intestinal Support Formula come in? Well, if you’ve gone through all those changes and you’ve been patient and given yourself months to evaluate if you are still improving and you see that you’ve slowed your rate of improvement and have clearly hit a plateau that is not 80% or above, that is when layering in another therapeutic can be helpful. Two things there I want to just touch on with what I just said. One, if people get to over 80%, I will usually give them time where they are and what people will sometimes notice is two or three months later, they feel like they’ve gotten a little bit better.

DrMR:

So it is important to give the body time. It’s more important the closer you get to complete resolution. The other is being confident that you have plateaued. Again, sometimes what happens is when the rate of progress slows people confuse that with a plateau and then they want to try to speed things up again. For lack of a better term, they get a little bit greedy or over ambitious and end up flaring themselves. So if you satisfied both of those requirements, that’s a good time to bring in the Intestinal Support Formula as a potential. Now, elemental dieting is another thing that you could also consider. The research with Intestinal Support Formula, or with immunoglobulins in general, has been in patients with diarrheal type IBS.

DrMR:

But I don’t think that means this is only effective for the diarrheal type. It’s still something that’s a viable trial if you have more constipated or methane IBS or SIBO. If you haven’t tried the Elemental Diet, I would like you to use that before the Intestinal Support Formula for two reasons. Cost and the research available on elemental diets with longer history reviews. It is also something that I think is easier to justify for repeat periodic gut resets, use it for a day or use it to replace half of your food for a few days here and there. So either one, the Intestinal Support Formula or the Elemental Diet has a place in your care plan going forward. I just prefer to lean in the direction, at least based upon this small snippet of information that I have, to use the elemental first. Then, if still after using that, you’re not seeing the results you’re looking for, that’s when I would then integrate into someone’s plan, the Intestinal Support Formula.

ER:

Okay. All right, James, I hope you wrote all that.

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How to Deal with Gastroparesis

ER:

Question came in from Instagram. This is from Tamara. What’s your best advice for dealing with gastroparesis?

DrMR:

Good question. Gastroparesis, just for the audience, is when there’s paralysis of the muscles that control motility in the stomach. Most people have likely heard of “slow motility” which usually means the small intestine and the migratory motor complex that controls motility there. There is a motility wave even in the esophagus and in the stomach also. So <gastro> = stomach, <paresis>= paralysis. So gastroparesis is when there is a deficiency of that movement. Sometimes the diagnosis I think is used a little bit loosely.There are some things to double check in terms of this diagnosis such as is this frank gastroparesis? Is this mild gastroparesis? There are still some unanswered questions with how definitive the diagnostic criteria for that are. Just a grain of salt here.

DrMR:

I haven’t taken a deep dive into fact checking all of that, but from the poking around that I did, it didn’t seem like there was a highly agreed upon standard there. Now I could have missed that. So again, grain of salt. That being said, how do you treat this? Well end phase, there is essentially a pacemaker that can be used. So if all else fails, that is a fallback option. There are upper GI prokinetics. I believe the one of choice is Cisapride. I may be off on that. That’s something you can check in with your GI doctor and I’m sure he or she is likely recommending some type of prokinetic anyway. I don’t believe Resolor or Prucalopride has a high effect on stomach motility. Although again, that’s a great question for your GI. Something else that can be helpful here is liquid dieting.

DrMR:

This is actually where I think Elemental Heal could potentially be very helpful because the stomach has an easier time emptying its contents with a liquid meal, as opposed to a whole foods meal. This is a little more speculative, but the macronutrient composition of your meal may have an impact. There are somewhat antithetical theories here. One is that you want to be careful of fats. The other, and this is even more speculative, is that part of what underlies gastroparesis could be secondary to type two diabetes or diabetic complications. That’s not so much speculative. That does apply to frank type two diabetes that has progressed to the point of neural pathology. I’m assuming that’s not the boat that you are in and the speculation is more so tied around could someone with a somewhat normal level of blood glucose, but perhaps high normal, or high for them be creating some kind of dysfunction and nerve function there.

DrMR:

Maybe. I had one patient who swore by that who had gastroparesis. They went on a very low carb diet and swore it was really helpful. He was also one of those types of patients that went deep into the rabbit hole of theory, speculation, internet reading. It’s much harder to get a solid read from those patients reported experiences because there just seems to be such a higher likelihood of skewing by bias. But that would be antithetical to the “avoid fat” because lower carb would presumably be higher fat. All that to say a lot of the same concepts that we harp on likely apply. Meaning, as one example, an Elemental Diet could be something that you find quite a bit of relief from. Also, there’s some evidence showing that motility can be halted by inflammation. If we can find a way to establish a less inflammatory state in the gut, the cells that regulate motility seem to have the ability to repair. It is inflammation that may kind of be putting on the emergency brake and not allowing those cells to repair, which is what they want to do if they can just get into normal physiology.

DrMR:

This is where all the stuff we typically harp on comes into play. That would be the foundation of what I would do. Then from there you can consider some of the pharmaceutical or even the natural prokinetics. Iberogast may not be a bad option that has been shown to have quite a bit of upper GI prokinesis. Pharmaceuticals and/or elemental dieting as a kind of periodic rescue therapy, if things are getting backed up. Finally, if all else fails, consider the gastric pacemaker. If you have unmanaged type two diabetes, which again, I’m assuming you don’t, that’s something that you’d definitely want to look into. So a lot of these cases end up being the core that we harp on and then some ancillary therapies on top of that. This is a little bit of an inversion of what happens in conventional medicine, because in these cases, oftentimes one is started with a prescription prokinetic, but they’re missing the inflammatory insult of diets, perhaps dysbiosis or SIBO that may be causing inflammation further. So it’s not to say one to the exclusion of the other, but I think it’s a sequencing issue that typically occurs. So you have a few things there to work on. I would definitely keep your GI in the loop and see what he or she has to offer. I would do that in conjunction with and stacked on top of some of these more foundational items, diet, probiotics, natural prokinetics, elemental dieting, and the like.

What is an Elemental Diet? What is Elemental Heal?

ER:

Okay. I wonder if, just for our audience, because I think this might come up in one other question, could you quickly go over what an elemental diet is? And also what Elemental Heal is?

DrMR:

Thank you. Elemental diet or Elemental Heal, which is one type of elemental diet, is a pre-digested meal replacement. They are formulated to be hypoallergenic and devoid of fiber and prebiotics. So in addition to not having any antigens or allergens in them, they can starve bacterial overgrowth, which has been documented in one study. I presume that they also starve fungal overgrowth and they’re quite anti-inflammatory as evidenced by a litany of papers, finding impressive benefits for inflammatory bowel disease and even a few studies finding benefit for rheumatoid arthritis. They essentially look just like a protein shake. You have proteins, carbs and depending on the formula, fat in there already, or fat that can be added externally. You simply drink these in place of eating food.

ER:

There’s a yummy one called Elemental Heal, that comes in either chocolate or vanilla on our website. Did I say it was yummy?

DrMR:

Yeah. I agree, if I do say so myself.

ER:

Compared to the others, it’s really good. I have it every morning for breakfast, so it’s good.

DrMR:

I think we really did a good job with the formulation on this. It makes it a little easier to commit to only liquid dieting. Although I have to say from when I did it and a number of my patients will echo this. It’s kind of nice. You don’t have to worry about cooking or cleaning or shopping. Just kind of sip on your bottle of chocolate or vanilla shake. You can focus on work school, being a mom, being a dad, doing whatever you have to do and if it’s a good fit for you, you should feel better. You have better energy, better mental clarity, better sleep, fewer digestive symptoms. So yeah, it’s a good therapeutic for an individual. There is a whole lot of benefit.

ER:

Totally. I’ve sort of made it my mom hack too. I’m a new mom. So I always forget to eat and I keep it in the diaper bag along with my little one’s formula so that I always have food and he always has food. You just go hours and hours of taking care of this child and forget to eat. Especially in my case where I’m really sensitive on food and it’s a chore to eat. Pretty much anybody in this type of gut health situation, it’s a chore to eat. So this offers me great relief on a regular basis, but mainly I just have it for breakfast every morning so I don’t have to think about it.

DrMR:

Yeah. So you have a bottle and he has a bottle.

ER:

Exactly. Everywhere I go, I take a big thing of water and I just keep that powder in the diaper bag. I can be out taking him for a hike or I can be out anywhere and I don’t have to think oh wait, I don’t have food. So it’s awesome.

DrMR:

Love it.

Over supplementation and Effect on Gut Health Symptoms

ER:

Okay. So our next question is from Jill. I’ll see if I can make this a little louder or clearer. The last one was kind of fuzzy.

Jill:

How does over supplementation affect gut health as well as possible other conditions like thyroid and things like that? I know someone who takes handfuls of supplementation for every single meal. She’s scared to death to stop that, but she has also had diarrhea now for three to four years. On the other hand is taking Imodium so that she doesn’t have the diarrhea. If you could address some of these, that would be awesome. Thank you.

DrMR:

Great question. This is something I’ve actually been thinking quite a bit about. As the clinic has expanded and I’ve brought on board two new doctors and we’re getting lined up to bring on a third, I’m thinking much more about what I do in the clinic every day and trying to take everything kind of out of my head and make sure that it’s built into a model. It really just as an algorithm and kind of series of decision trees that I’m using that lead to success. I’m really trying to be more conscious of, well, what am I doing? And then I write that down. Kind of like, I don’t know, if you had a really good technique for stretching your hamstrings and you didn’t even think about what you were doing. At some point, if you wanted to teach someone else, you’d have to say, the first thing I do is this with my hips, then that with my ankles and then turn it into a list of instructions.

DrMR:

This definitely applies in functional medicine. Specifically and in part to over supplementation. One of the reasons why I think over supplementation exists as a problem is actually due to a well-intentioned mistake. Clinicians want to help people who are sick. There is this thinking of “okay, this person is tired and they can’t sleep and they have diarrhea so I’m going to give them adrenal support and melatonin and then B6 and then probiotics, and also charcoal.” They try to treat everything because we want to help the person, which is absolutely understandable and laudable. The real problem is that when you treat too much, you miss what the underlying cause is. Oftentimes there is one thing that’s causing the insomnia, the fatigue and the diarrhea. That’s what has to be focused on. What ends up happening, unfortunately, is clinicians shotgun it with all those supports, the person feels better, and the clinician says, Oh, I did it. They needed all that stuff. Then that gets further ingrained with the confirmation bias repeating over time as it is done again, again, again, again, again. That’s one of the main sources of the over supplementation. The unforeseen negative of that is when patients are having reactions to one of the many supplements that they’re taking, but they can’t tell which one because they’re always taking like 15 things. We’ve released case studies of patients who literally saw all of the improvement they needed to see just by going through the simple exercise of a supplement holiday, meaning stop taking everything and then go back on one thing at a time to reaffirm what you need and what you don’t need. Supplements definitely cause reactions. This is something I think is not well reported enough in the field. Supplements definitely cause reactions, not for everyone, but I would say a good solid plurality of patients will eventually find one supplement that they react negatively to.

DrMR:

The more sensitive someone is and the more symptomatic someone is, those kind of go together, the more likely they are to be reacting to an individual supplement or a mix of supplements. Again, you can’t tell which one or ones are the culprit if you’ve never had a period of time where you’re not taking 15 different things. The other thing that can happen also is you can overwhelm, theoretically, the absorptive ability of the gut and you just end up having way too much filler or prebiotic or binder or some of these excipients that are in many supplements. In some cases it’s not nearly enough to be a problem. Many probiotics will have couple of hundred milligrams of let’s say inulin in them, not a big deal. But if there’s a couple of hundred in this, a couple hundred that, a couple of hundred in the other thing, then that can be a problem. The same thing with certain excipients or fillers like magnesium stearate, not a problem in a low dose, but multiplied by 15 supplements at maybe three capsules a day, well now that is at times 45.

DrMR:

Yeah, that can start to be a problem. So yes, over supplementation is a problem. It can literally be causing some of the symptoms people are plagued with, partially by the mechanism of interfering with one’s gut health, which is where these things like fillers, excipients and excessive amounts of prebiotics may manifest. Then all of that can have a spillover effect, not necessarily to the thyroid, I don’t know of any supplements that would, save a few, directly cause problems with thyroid. But if you are causing impairments of gut health, there is the gut. Thyroid connection. More plainly, if your supplement is causing a symptom, you may be attributing that symptom to your thyroid. Why am I always tired? Well, you’re always tired because you’re having this chronic inflammatory reaction to these three supplements, but you don’t realize you’re having this chronic inflammatory reaction which is causing fatigue. We know as one example, gut inflammation as seen in IBS, strongly correlates with fatigue. It’s been documented in a handful of studies. So this person now starts chasing thyroid. If they go see overzealous functional medicine doctor X, Y, Z, sadly, no matter what comes back in the labs, they’re going to be given thyroid hormone. That’s literally about how bad it is. Now it’s one more medication and then they start having some insomnia, but they didn’t really realize that the third medication was causing the insomnia. You see where this goes. It gets really ugly, really fast. Supplements can be helpful. We’ve released a myriad of case studies substantiating that. There’s plenty of published research also showing that, but over supplementation can be a problem. It does exist and it can be a problem for all those reasons. So for you and/or for your friend, I would definitely share this and go through the exercise. I understand it’s a little bit nerve wracking because you think you need all this stuff, but go through the exercise of coming off these things.

DrMR:

If you’re not comfortable doing it cold turkey, start systematically coming off of them one at a time and reassessing need. The other thing is the psychological piece. This is another thing that I think functional medicine is really doing a poor job with. Noceboing people. The noticeable effect is a negative expectation. The placebo is a positive expectation. So we run all these functional labs, many of which are garbage if I’m being fully honest, but there’s still all these highs and lows on the lab report. That gives people this nocebo effect. This “Oh my God, I have high candida”. But did you mention it was normal healthy levels of candida? No, that wasn’t in the conversation. Or “I have SIBO”. Did they mention to you were two points above the cutoff? Nope. So negative, negative, negative, nocebos adding up from the lab work and then you need the supplements to feel healthy.

DrMR:

That’s the placebo effect. So they think they feel better when they start going on the 15 supplements. Perhaps they do it first because of the placebo. One of the things that has been shown is that the placebo tends to wear off over time. Some of the studies have shown that there’s placebo up until the six month mark and then the placebo and the control show equivalent results. So now you have no more of the placebo, only the negative reaction from the supplement. The person is left worse off than they were at the beginning from the placebo wearing off, the supplements having negative effect and the nocebo effect from the labs making them think that they’re sicker than they actually are. Obviously, I have a lot here to say about this. This is the mess that I see in the clinic. Patients walk in and it’s like a ball of tangled yarn that you have to unwind. It doesn’t have to be that complicated. So directly to your question and with a lot of superfluous supportive context, supplements can and do impair people’s health, if overused. I would strongly advise your friend to consider the exercise of weaning off and trying to pair down to a minimal cast of supplements.

ER:

They are also wildly expensive.

DrMR:

Yes. I mean, I didn’t even hit the financial, but yes, that’s also another very deleterious impact of over supplementation. Good point.

Repairing the Microbiome

ER:

Okay. Our next question is from Natasha. She says coming out of three months of pulsed antibiotics for Lyme, my microbiome is destroyed. Despite taking nystatin for candida, high dose S. boulardii and spore form probiotics I wound up with a serious mast cell activation case with rashes all over my face. Aside from eating a low histamine diet and taking DOA enzymes, any suggestions to heal the gut? I’ve heard really good things about Butyrate for gut healing, any thoughts?

DrMR:

Okay. So longer term antibiotic use. I’m assuming it’s longer-term. Pulsed antibiotics, probably going to be in longer term. Taking S. boulardii and Nystatin I’m assuming to preempt a fungal overgrowth. Then ends up with some kind of histamine intolerance and MCAS type symptoms. One of the things there that you’re missing is using the three different categorical types of probiotics all at once. That can be a game changer for some of these cases. I would put that way before butyrate. Butyrate would be considered something that’s supported by very low level scientific evidence. Probiotics are something that’s supported by very high level of scientific evidence. Not to say it has to be either/or, but we want to organize the therapeutics in a hierarchy. The therapeutics that have the best evidence, therefore, the highest likelihood of helping you, should be first. Then the things with the least evidence, therefore, the lowest likelihood of helping you would be last, like Butyrate.

DrMR:

There is a real paucity of data. I don’t even know if there’s one clinical trial in IBS with the oral Butyrate supplement. There are more theoretical reports, where someone may have been given a probiotic, the prebiotic led to an improvement in symptoms, and that correlates with changes in fecal Butyrate. I don’t believe there’s anything, an IBS cohort using Butyrate. There are studies using Butyrate enemas and those with inflammatory bowel disease. So that’s something. With histamine and MCAS, I’m fairly positive, nothing. There are a number of studies that have found that histamine mediated conditions improve when using probiotics. Some of these studies are actually placebo control. So that is one thing I would do – definitely get yourself on the probiotic trio all three at the same time. Consider a low histamine diet, consider a low FODMAP diet. antimicrobial therapy may also be helpful, although given your history, I probably wouldn’t do that.

DrMR:

Scratch that recommendation, given your history. Elemental dieting is another thing that I would consider. As well as immunoglobulins. Really what I’m giving you direction. Go to the Healthy Gut, Healthy You treatment protocol or program and follow that. Histamine intolerance, mast cell activation are very tightly associated to the health of your gut. So the way to kind of rectify this is to fix the garden that is your gut. A uni interventional strategy, ie: Butyrate, is probably not going to get you there. A multi therapeutic model is the best approach. In this case – diet such as low FODMAP or low histamine as well as gut supportive things like probiotics then potentially leveraged by elemental dieting and/or use of immunoglobulins can all help. You’ve likely heard also that there are a host of natural anti-histamines. Vitamin C, quercetin, resveratrol, or even things like Benadryl, Zantac Claritin, can all be considered as a kind of over the counter anti-histamine protocol.

DrMR:

If you look up over the counter anti-histamine protocol, you should be able to find our handout that we made based upon mast observation researcher, Lawrence Afrins protocol. So there are a few things there for you to move on. A lot of this comes back to the fundamentals of gut health. As someone who had, I’m presuming histamine intolerance, I never had it officially diagnosed. I can say that the healthier my gut was the less food reactive brain fog and insomnia I had, which were the main ways that manifested for me. So I would definitely go back to your gut health. Butyrate I would try after all of those other therapeutics, because butyrate, although interesting, has the least research to support it.

DrRuscioResources:

Hi guys, just a quick announcement. My clinic is now version 2.0. Wait times have been reduced as I’ve hired two new doctors and a health coach. We’ve enhanced our services with new systems to make the process even easier for our patients. The location has transferred to Austin, Texas, and the clinic has been renamed to the Austin Center for Functional Medicine but we still offer the same telehealth services for people anywhere. If you’re in need of cost-effective, practical and science-based care, please visit my clinic website, AustinFM.com.

A Lifetime of IBS

ER:

Our next question is from Mary Lee.

MaryLee:

Hi, I’m calling because I have had IBS for over 35 years. It used to be bad, but it is much worse now as I’ve gotten older. I’m in my mid-seventies and it’s just terrible. No matter what I eat, I have a problem. I try to be very strict with my diet. I’ve done all the holistic things there are. I consult with the IBS center. I take many, many supplements, but nothing seems to really fix it for me. I’m doing acupuncture. I’ve tried everything. Anyway. I’m just wondering if you might have any advice about this bad thing that I was reading about the bacterial or how would you suggest I start tackling this? I’ve got to have a new start because everything I’ve done and all the money I’ve spent really haven’t helped it has gotten continually worse. I have many more food allergies than I used to, so I would really appreciate you answering my question as to where I start now and who I should see. Maybe it’s you. I don’t really know where to begin, but I appreciate this. You can contact me at my email, which I have given you, or I would appreciate letting you letting me know when this question might be answered so I don’t miss it. Thank you very much. My name is MaryLee. Thank you.

DrMR:

This is a great question. MaryLee, I’m sorry to hear of your troubles. That said, I see a fair amount of this exact type of patient at the clinic. So for whatever solace it may provide you, these situations are able to be remedied and I’ll see cases like this turnaround pretty much on a weekly basis. I don’t mean in a week, but I mean, every week. The foundational answers to your question is usually the reason why someone has been foundering is they haven’t had the right approach to improving their gut health, which is usually a slower and stepwise process where we discover the mixture of different supports that will get your gut to health and healing. The reason why I think that eludes many is because in the conventional model, they really lean toward kind of a monotherapeudic approach.

DrMR:

Well, let’s try an antispasmodic did that work? Nope. Okay. Let’s try Rifaximin. Did that work? Nope. Okay. Let’s try a trusted antidepressant. It seems that more of a melding together of different therapeutics is less often done. This is more so in your kind of “by the book” gastroenterologists. I’m sure there are some wonderful docs, and I actually know some wonderful more integrative gastroenterologists, but that could have been the case. Then on the alternative side of the fence, unfortunately, as I’ve kind of harped on a little bit today in the podcast, we’ve been really misled by all these lab tests. We chase the results and many are not validated labs. So even though it feels like you’re treating all this stuff, you’re actually just kind of throwing a dart at a bulls-eye with here with your eyes closed because these labs are not accurate.

DrMR:

So likely the way that you’ll get the results that you’re looking for is either going through the program in Healthy Gut, Healthy You, and/or work with me or someone at our office at the Austin Center for Functional Medicine. By the way, for our audience, I moved the clinic from Walnut Creek, California to Austin, Tx. And it’s now under a new name, the Austin Center for Functional Medicine. So anyone at my office will be very competent in kind of stewarding you through that discovery process. It usually starts with finding out what diet is going to help. To your point, no diet may be the complete resolving factor, but you may notice this diet feels the “least worst”. That is actually a step in the right direction. Then we interweave that, like with the last question, where the persons is only using one probiotic, there are clear case studies that we’ve published, where when using all three together, they see another, let’s say 20% improvement.

DrMR:

Then along with that, now that we’ve gotten maybe 10% from the diet, 20% from the probiotics. Now we do a course of antimicrobials while maintaining those other supports. And we see another 20%. Then we are at 50%. Now we’re not doing too bad. We continue in that kind of step wise personalization process of the available therapeutics, potentially navigating some reactions along the way. That is oftentimes the difference between success and failure. Now, sometimes patients have other issues like limbic imbalances from all the worry or patients have been eating a diet antithetical to healing because they’ve fallen into an overly restrictive diet. When they finally expand their diet, they feel better. Or we get them off of the handfuls of supplements, 15 at a time let’s say, and that actually opens up an avenue of healing for them. Or there could be something also happening like mold, although I think that’s not very common, there may be some choice cases. The point I’m driving at is, you need the right kind of advice that will really work in a stepwise fashion to try to problem solve how to solve the variable that is your gut health. It can be done. I would welcome you to go through the book protocol in Healthy Gut, Health You and/or reach out to the office. I’m pretty confident we’ll be able to get you moving in the right direction.

ER:

Well, let’s end on that good note.

Episode Wrap-Up

DrMR:

Awesome. I like it. Well, thank you guys for the questions. Keep sending them in. Let me just say one more time. The clinic has moved. I’m working on some announcements to kind of give you all the necessary “need to knows” in one place. The clinic has moved from Walnut Creek, California to Austin, Texas. I’ve brought on two doctors and we’re working collaboratively now to really build everything into a model. We’re also starting a new research project, unofficially, but we’re getting ramped up to start a study on hydrogen sulfide SIBO. So if you’re in need of help, I am still seeing patients, but I’m now lock armed with two other very bright clinicians. We are really kind of mapping all of this that we discuss on the podcast into a clinical system that can now be executed by other people because I’m trying to really make sure that these things are not dependent upon me.

DrMR:

Now they’re really integrated into a model that me and the other doctors in the office are all executing. That in addition to working to collect some data and publish some research. So if you are in need of help, please reach out to the clinic. I don’t want to sound self promotional, but it’s getting so bad now where more than once a day, I’m seeing a patient who I am just shocked at the advice that they’re being given by their doctors. I’m not happy to say this, but it’s getting worse over time. I was hoping that my tactful criticism, hopefully it was tactful anyway, would start nudging this in the right direction. But I think the fallacious, educational machine of functional medicine is just running too fast for us to be able to make a dent in it.

DrMR:

So I am working on building a bigger machine and a bigger platform. I’m also hoping, to make this maybe less of a point of criticism, that as the field grows, it will auto-correct. It’s definitely disheartening to see that yes, while functional medicine can really help people, it can really damage other people. I think that the people that really damages are those that don’t respond to frontline therapies of just simple dietary and lifestyle changes. The standard therapy supplements like fish oil, vitamin D, curcumin, B vitamins, probiotics, adrenal support. It’s the people that need one level beyond that, that I think really get put through the ringer. Again, the only reason why I keep making this criticism is I spend so much time talking people out of problems they think they have based upon bogus lab work. I have to convince them that they’re not as sick as they think. And they think they are sick because they treated all these labs and didn’t get any better, but they didn’t realize they were treating a uBiome, which is partially based upon dog poop as their normative ranges. No wonder you’re floundering.

DrMR:

So anyway, sorry to keep harping on this. I suppose what I’m doing is venting a little bit. It’s really disheartening seeing how often this is happening. I’m happy that we have other doctors at the clinic now and can offer more to people other than just seeing me and we are really just getting started. I’m really looking forward to continuing to expand the clinic so that if you or someone that you know, or love is in need of help, you can refer them in and they can be seen hopefully within about a month and really get competent, functional medicine care. There is a lot of good here. It’s just the field has some painful growth and needs to go through to excise out some of these, really erroneous practices. But in any case, the questions are really helpful because they help me stay attuned with what people need. Hopefully they’re helping you guys. Erin I appreciate you going through these and really helping to parse them and just throw over to me things that need to be addressed.

ER:

Sure. It’s my pleasure. Do we want to also include that the office is in Austin, but you can be seen by tele med as well. Is that correct?

DrMR:

Yep. The office is in Austin, but we are exclusively telehealth at the moment as many clinics are. So no matter where you are, we can help you. Also, for those who are international, we’ve just switched the shipping services that we’ve used, which, at least from my understanding should make the international shipping cheaper and more accurate. So for international patients who are also in need and may have been a little bit hesitant due to customs being a challenge, it will still be a challenge, but at least it will be a little bit easier now.

ER:

I actually had a question from someone from Brazil, but we’ll do that next month and I’m sure he’ll be delighted to hear that about your products. That’s a tough place to get things through, I’ll tell you.

DrMR:

Yeah. I don’t know much about the country by country, but yeah, there does seem to be a big variance. In any case, thank you, Erin. I thank you guys so much. Please keep the questions coming.

Outro:

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