Answers on Meat and SIBO, Better BMs, Gene Testing, MCT

Intro:

Welcome to Dr. Ruscio radio, providing practical and science-based solutions to feeling your best. To stay up to date on the latest topics as well as all of our prior episodes, make sure to subscribe in your podcast player. For weekly updates visit 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.

ErinRyan:

Hey everyone. This is Erin Ryan from Dr. Ruscio radio. Today on the show Dr. Ruscio answers your questions, but first we start the episode with Dr. Ruscio’s musings on ancestral stressors. Could stressors like cold exposure and prolonged breath-holding help condition us to better deal with everyday stress? Scott Carney and Wim Hoff seemed to think so. Then we get to your questions. Are GAGs in meat problematic for SIBO? Why do my BMs improve when I eat bad? Dr. Ruscio shares some insight on this phenomenon, why it happens, potential triggers, and what to do about it. Is it possible to have reactions to medium-chain fatty acids? Can you speak to the risk of EMF in full body scanners in airport security? How are you interpreting SIBO tests nowadays? (we get into the details and nuances of test results so stick around for that) And lastly, are you aware of Accutane being linked to abdominal adhesions? This was sort of a yes, but….kind of answer so you’ll have to keep listening to find out his take on how that would or wouldn’t impact a gut healing protocol. If you’d like to submit a question, visit Dr. ruscio.com/podcast-episodes, and click send us a voicemail at the top of the page. Please speak loud and clear and keep it as concise as you can enjoy the show.

DrMichaelRuscio:

Hi, everyone. Welcome back to another episode of Dr. Ruscio radio. This is Dr. Ruscio again with Erin Ryan, and we are going firstly into a few personal musings on stuff I’ve been experimenting with and then some listener questions. Erin, we’re back. How are you feeling? How’s your new year going?

ER:

Like everyone else’s I guess… 2021 is starting off promising. You all know what happened.

Ancestral Stressors

DrMR:

Tumultuous time, that’s for sure. That’s actually maybe a good transition to some of the things that I wanted to just kind of check in with our audience and share a few things I’ve been experimenting with and kind of this hypothesis that I’m developing, which is related to and regarding stress. Obviously it’s been stressful. Two books I really do highly recommend are both by Scott Carney “What Doesn’t Kill Us” which is kind of an investigative journalism probe into the world of Wim Hoff. The secondary book following that is “The Wedge”. In both these books, there’s this common idea that humans may be deprived of certain, I’ll call them hormetic or beneficial stressors. I think we’re all on the same page regarding fasting being one.

DrMR:

There are some nutritionists who hear “fasting” and their first thought is you’re going to have nutrient deficiencies. I always say relax. We’re not talking about not eating for a year. We’re talking about time-restricted feeding and focusing on nutrient-dense food. The reaction from some nutritionists hearkens to the fact that we’ve gotten, well, soft for lack of a better term in the sense of how some people look at fasting like this egregious stressor. There’s a promising body of research substantiating that this might be something that humans need for autophagy, for regulation of satiation, for metabolic flexibility. Extending that out there may be other stressors that when we don’t have them either our immune system, nervous systems, which also ties in with our limbic system or both may be imbalanced. Cold exposure is one that Wim Hoff has used, but there’s also this breathwork of essentially a hyperventilation followed by a full exhalation and holding your breath as long as you can. At the end, if you push yourself, that’s where I think a lot of the challenge, or perhaps as Carney may say, a lot of that wedge can kind of be exerted. As I’ve been experimenting with cold exposure therapy and the breathwork, it’s interesting to look at that, especially in the context of this kind of patient avatar that we sometimes discuss. The limbically skewed patient who may be very sensitive, very reactive.

DrMR:

Admittedly, I think I let some of my frustration from how challenging those patients are in the clinic bleed over to how I discuss them here. I want to thank some of our team members for making me aware of that, just so I can address these things perhaps a bit more tactfully. However, as I’ve been looking at some of this work, it makes me wonder if the reason why some people can handle stress better than others is that some people have built up the capacity to handle stress where others have not built up such a capacity. Looking at exercise tolerance, even my personal exercise tolerance only about a year and a half ago, I was much more inclined to want to veg out and watch Netflix or some docu-series at nighttime.

DrMR:

Now I am paying attention to both sleep and exercise, pushing my exercise threshold and tolerance higher and higher, even on a bad day. It’s almost like I can’t sit still. I don’t mean can’t sit still in an ADHD type of way. It’s just, I have so much more baseline energy. Even when I want to veg, my body has the capacity and desire to get up, walk around and move rather than feeling like I’m zombified on the couch. That’s an example of building up physical stress tolerance and what some of these other, what I’m kind of loosely terming and Carney has also termed, ancestral stressors may do is make our nervous system and potentially our immune systems better able to handle stress. I think about the patients who have a hard time with not feeling well. Perhaps why some people fall into this kind of self monitoring obsessive behavior is because they are overly sensitive to those signals. They don’t have enough other signals to dampen the relative strength of a signal like bloating.

DrMR:

To paint a really loose analogy, if you were exposing yourself to 40 degree water, that’s a shock to the nervous system and potentially to the immune system. In relation to the feeling of bloating, that may recalibrate the nervous system not to be so sensitive to some of these more mild symptoms related to bloating. Not to take anything away from that signal, but part of this might be a perception issue in that we’re not having enough of these other stressors to help us assign the appropriate level of reactivity to a given signal. This is something that I really find quite interesting. I’m hopeful that, especially for people who seem to be really succumbing to the tough road that it can be when not feeling well, these ancestral stressors will almost give them that light at the end of the tunnel. The light at the end of the tunnel when you’re confronting some of these ancestral stressors like prolonged breath holds would be that you’re going to live.

DrMR:

If you don’t get out of this cold water or you can’t hold your breath long enough, you’re going to die and that’s perhaps how the body perceives these events. So maybe we need to have enough of that ancestral primitive drive to overcome these pseudo life-threatening stressors to give people that confidence and that resolve to see their way through day to day dealing with some of these annoying symptoms. So I’m not sure how much of that fully lands Erin, and I’m definitely going to have Scott Carney back on the podcast to do a follow-up conversation so we can really try to kind of package this all up into a suite of recommendations. I just wanted to share some of my thinking about these ancestral stressors. Erin, anything that resonates, or am I just completely off the reservation here?

ER:

First I’ll say prolonged breathwork or breath holding work is something that should be done guided. Don’t listen to this podcast and start holding your breath for very long. Make sure you know what you’re doing, read about Wim Hoff.

DrMR:

Right, especially not if your driving.

ER:

Not if you’re driving, not if you’re swimming without someone else. I’ve heard some interesting stories about that. So make sure you’re doing your research first. Take that recommendation with the responsibility of what it comes with, and the precautions. Before we started this podcast, I was sharing with you how I feel just being a first-time mom and having a sick child. He’s sick at the moment. He has an earache. It’s the most unnerving thing I’ve ever experienced in my life. Maybe I haven’t done enough if it’s the most unnerving.

ER:

But it’s a different kind of unnerving because I’ve never had a child before. There’s this instinct that should be helping this person. When he cries, my insides cry. It’s the weirdest feeling ever. What I had to do to get rid of that feeling after three days of a crying baby who won’t take his medicine was last night, I went out into the freezing cold. Well, it’s not that cold here. It’s like forties. But I was doing jumping jacks. I was running back and forth on my balcony. I just had to get it out with another kind of stressor. Then I felt amazing. I feel like I turned into this nervous ball of stress of a terrible mom, and then literally nine minutes of just being out on the balcony and cold air and just pushing myself to the brink and listening to loud music. It was like, oh wow, I just totally counterbalanced that. So yeah, what you’re saying makes a lot of sense. I’ve got to get on that cold therapy thing a little more seriously. It’s so beneficial, but I’m such a wus when it comes to cold stuff.

DrMR:

Right

ER:

I’m like right next to like Austin and it’s like 65 degrees year round in that water. So I’m just going to start plunging. I’m just going to have to do it.

DrMR:

Well, you make a great point. There may be this aspect of, in many a case stressors are coupled with a physiological component. Oftentimes these stressors literally were like maybe your infant fell into a pond that was partially frozen over and you had to rescue them from the water. In fact, I believe in Mark Hyman’s book, Ultra Wellness, I may be off in my citation here. He discusses how North American Indians used to have this s past time. It was like a favorite thing to do first frost. They would break the ice over a pond and go swimming. So, you know, what may be happening is the stressors seem like their worst when they’re not coupled with some sort of physiological pairing. That example, if we look at marital stress or financial stress seems to hold. So what you may be doing there is just kind of self-medicating in the sense of you’re recoupling a stressor,in this case your child not feeling well, to a physiological stressor and that may have this buffering effect.

DrMR:

So yeah, it’s actually quite interesting and serendipitious that you were doing that as a way to feel better. What I’m wondering is let’s say someone has chronic abdominal pain and bloating, using that example from a second ago, perhaps some of these physiological stressors, prolonged breath holding with the breathwork and cold exposure would do a similar thing and help them feel better the way you’re describing.

ER:

Yeah, there was an element of it wasn’t Wim Hoff, but it was an element of breathwork that I did at one a Tony Robbins events. Gosh, I forgot what it was called, but at one of his events. It was amazing. So we did some of this prolonged breathwork, and I went to that event specifically while my gut was at its worst, because I was willing to try anything at this point. So that was my goal. You kind of go into these events with one goal that you want to walk out of there with. I’m telling you that event changed me physiologically, forever. Walking on hot coals, just showing my mind that I could do stuff I never thought I could do. And breathing was a huge element of that. He also kept the place super duper cold. So yeah, all of this makes a lot of sense and I’ve sort of been through some of these examples in my life and it checks out.

DrMR:

Yeah, I really do think there’s something here. This is kind of “The Wedge” as Carney describes it. The discrepancy between what your mind thinks you can do and what you can actually do. Part of the way we can improve that wedge of what your mind thinks you can do. Getting closer to your actual physiological capacity is using some of these stressors. As an example, it snowed in Austin yesterday, ironically, which I’m hoping I’m stewarding in a colder spell in Austin here, cause that would be fantastic. Me and a friend of mine went for a run around Lake Austin shirtless. We’re both guys who are doing this cold exposure training. So it was a choice opportunity.

DrMR:

But the point I’m driving at is people are looking at us like we were nuts, but you know, everyone looking at us could do the same thing. It doesn’t require any special conditioning. I mean, sure, we’ve been working our way up to it. But these are just mechanisms that we all have that we’re just kind of turning back on. I think it is empowering. As you start doing these things it’s empowering. That feeling of empowerment seems to, at least as best as I’m able to tell, carry over to multiple domains. So in any case, more to come on this, but just something I wanted to kind of throw a few musings out there regarding. It is interesting to me and it’s been helpful for me. I’m hoping that this will resonate with others and kind of get them to plug into some of Wim Hoff or Carney’s work. Why don’t we springboard now in to some listener questions?

GAGs and Impact on SIBO

ER:

Okay. This question has nothing to do with what we were just alking about. There’s no good transition here. So this question is from Alaska. She wants to know what are your thoughts on the topic of glycosaminoglycans and meat being problematic in SIBO?

DrMR:

Yeah. Great question. So glycoaminoglycans or GAGs for short. Reactions here in my clinical observation are rare, but they are possible.

ER:

What are they?

DrMR:

There are compounds I believe, which are predominantly found in the collagen and/or connective tissue. I believe to a much lesser extent in the actual meat tissue, the muscle tissue. So it’s essentially a form of connective tissue and they contain prebiotics so that’s how they may be problematic. This might be why some people have a hard time with soups, although I’m more inclined to think that’s a histamine issue. Reactions here are possible. They do seem to be more rare. Some people do react to carnivore as an example, even though it’s espoused as kind of the ultimate elimination diet. It probably is maybe most extreme elimination diet. While it is clearly helpful for maybe 70 ish percent of the patients, there are maybe 20-30% of patients who react negatively to it.

DrMR:

Could that be because of the glycosaminoglycans? Perhaps. I think it’s more likely perhaps a sulfur issue, maybe a pancreatic insufficiency issue or a histamine issue. This all boils down to what is the best approach? What do you do? My response? Experiment and listen to your body. Could you be one of the rare cases that does have reaction? Yes. Is there a lab test that will map this out for you? No. So what do you come back to? Well experiment with some of these various diets, like we always discuss. I would also do that in a greater context or larger guiding framework. Healthy Gut, Healthy You is the best thing I could point you to being written with that express intent of how do you take all the things you could do, put them in a list and and then organize that list in a sequence so that you can execute as effectively as possible. That will help you resolve this because some of the reactivity may be secondary to other things going on in the gut. So that’s why we want to use diet, but then also have a greater kind of hierarchy or framework we’re working within.

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Diet & Bowel Movements

ER:

Our next question is an audio question. So I’ll go ahead and play that.

Guest:

Hey, Dr. Ruscio. So, I really love your work just to start. I wanted to ask a really interesting question. I’ve been tracking my food and my bowel movements using the Bristol stool chart, giving it a number each day. I’ve been recording pretty diligently in a little journal for the last couple of weeks about what I’ve been eating. This past week it’s been pretty good. It’s been about a four. Not where I’d like it to be, but I’ve been eating pretty clean. Then yesterday I was like, you know what? I really just want to indulge and have some yummy food today. So yesterday I had a regular pancake. I had an omelet with goat cheese.

Guest:

I had a pizza last night with no cheese, but pizza with some veggies and everything. I went completely off from what I normally eat. This morning I had the best bowel movement I’ve had all week. So what I thought would have made things worse yesterday, today my bowel movement was so much better. What are your thoughts on that? I mean, the only thing I can think of is I had cheese yesterday. Goat cheese. So that’s something I normally don’t eat. I also didn’t have a smoothie, which normally I have a smoothie every single day. So maybe it’s something with that. I really don’t know. I’m not sure I’m giving you enough information and I know you’re not going to be able to give me a specific answer. I was just curious if you’ve had this experience yourself or with any patients. Somebody who goes off what they normally eat and they eat what seems to be pretty unhealthy and then they have a better bowel movement. I also had like regular bread yesterday. I had a biscuit, I had a pancake, all those things. So yeah. So I would love to hear what you think. Thank you.

DrMR:

Great question. Yes. This is the old, I feel better when I eat worse question. This is a question that comes up from time to time. If I can kind of paint an avatar of exactly what we would not want a functional medicine clinician to be, they would observe this and then double down on whatever their dietary philosophy is. Admittedly, that was probably me for a short time early in my career, because I just couldn’t conceive of the fact that someone would feel better by eating worse because it violated all of my kind of philosophical constructs. That’s why clinical practice is such a good teacher if you’re willing to listen and if you’re willing to learn. This is one of the reasons why I warn any patient against following the work of, or working with a clinician, who seems to be highly, highly confident.

DrMR:

You want to be confident, but you also want to be a little bit insecure and unsure. It’s like a yin and yang symbology. You have a sea of black with a little dot of white. That little dot of insecurity keeps you humble and learning and curious and wanting to listen to feedback. The potential triggers here could be one of a few things. The vegetables. Eating more vegetables, fiber, and/or roughage than your gut can handle or process is one of the most common reasons that people say “I ate worse and feel better”. Often what you see is I’m assuming you’re eating a higher vegetable diet at baseline, and then you had some regular bread. I think it was a pizza. So I’m assuming that was either rice crust or rice bread or regular bread, probably less vegetables.

DrMR:

If that smoothie was a high vegetable smoothie. This may be where some of the paleo carb renaissance came from. It’s this cohort of people who would do better eating less vegetables and more starches. I don’t have any definitive data here, but I just wonder if some of the reasons why people report feeling better when they up their carbs is because it’s oftentimes accompanied by people slightly curtailing back their vegetables and their fiber and getting more of this kind of starchy carb, which is often easier to digest, things like rice.

DrMR:

So it could be an issue of you’re eating too much vegetable fiber, fiber roughage in general. You would do better by going toward more of an almost kind of paleo antithetical framework of adding in rice, potatoes, potentially wheat or gluten containing grains. I know, this is blasphemous in my field, but that could be one. It could also be histamine. This is something that I was personally affected by. My day to day diet was too high in histamine rich foods like jerkies, canned tunas, avocados, fermented foods of various sorts like kombucha and sauerkraut. So that is another possibility, a little less common, but definitely possible. Stress is another. This is where when you advise someone, Hey, chill out a little bit , your diet’s good and I think right now you’re kind of going on the down slope of the law of diminishing returns. Any further attention to diet is actually going to cut against you because that further attention to diet makes you worry, reclusive and stressed out. If this was, “Hey, me and my girlfriend or my buddies or whatever decided to relax, not work, not stress, have some fun, have some pizza, socialize. Then you’re just kind of loosening up and this could be the stress component of that.

DrMR:

Already kind of touched on this. It could be that you’re too low carb and that the higher carb intake itself was beneficial, which it could be. It’s not all about fiber. It could be that your system or metabolically, you feel better when you have a higher carb intake. Finally, it could be that you’re eating the same thing too often, and you’re developing some acquired intolerances. Try lowering your vegetables and roughage plus, or minus going lower FODMAP, it may or may not be the FODMAP per se. It may just be the roughage and the fiber. You could try a low histamine. You could try relaxing about the diet and enjoying food more and thinking about health less. You could also try increasing carbs -things like rice, starches, gluten potatoes, and a good low FODMAP iteration of that would be the standard low FODMAP diet. This is part of the reason why I delineate between paleo low FODMAP and standard low FODMAP. With those things, you should be able to lock this in, hopefully anyway. Let us know.

Genetic Testing Podcast w/ Dr. Ballard

ER:

Okay. Our next question is from Elliot “regarding your interview on genetic testing with Dr. Ballard. In the last few minutes, he outlined the three types of clients that genetic testing is ideal for. And they all implied that it is for fringe clients or for after standard therapies have been tried. There also wasn’t much talk of studies supporting its use, as you often criticize. Were you satisfied with the interview and did you feel like it influenced your view of gene testing in any way?”

DrMR:

Great question. I appreciated the inteview and I appreciate Dr. Tom’s approach. I was not swayed by the interview and I still feel that gene testing offers more confusion than it does clarity. I’m becoming increasingly sensitive to clinicians who say well, this is what we do for patients who don’t respond to anything else. I think if any clinician really starts monitoring themselves, you have to be careful about these kind of hail Mary wastebasket diagnoses. And I am always monitoring myself, or am I just putting micro toxicity at the end of the differential diagnosis just because? Using mycotoxins or mold toxins, as an example, this can be exacerbated by the fact that the testing is really in its infancy. It’s hard to know how exactly to a given finding.

DrMR:

So, no, I wasn’t swayed by the conversation. I suspect that the clinician ends up going through a lot of the same motions they would with any other patient, but now they have this confusing information of trying to integrate into the treatment program the gene testing results. There are some clear evidentiary points for why the gene testing movement is predominantly, in my opinion, misguided. We’ll be releasing a Future of Functional Medicine Review Clinical newsletter in February of 2021 outlining a recent Medscape article looking at folic acid and MTHFR. One of the research studies we cite found that in MTHFR positive individuals, there was an equivalent effect for folic acid versus folate in lowering homocysteine. So that is one big data point in a well done trial substantiating that one of the most popular gene markers, MTHFR doesn’t really impact clinical practice. We’ve also had Ben Lynch on the podcast.

DrMR:

I think one of the, one of the doctors who is most responsible for increased awareness around MTHFR, who’s essentially reiterated the same concept. Saying basically that we need to pull back from this very literal use of gene testing. We’ve also discussed other research studies. One of the most remarkable that sticks out in my mind was in Asia. I want to say the sample size here was about 30,000. I’m sorry, it wasn’t 30,000. The reduction was a 30% reduction in stroke risk after giving folic acid to MTHFR positive individuals. So what seems to be true is you’re less efficient at metabolizing folic acid when you have MTHFR polymorphisms, yes. But the devil is always in the details regarding the effect size. Is the effect size enough to have any clinical impact or offer any detriment.

DrMR:

It seems the answer is no. This is something that Dr. Tommy Woods on the podcast outlined, and we discussed in some detail, and he also wrote this up in a peer reviewed journal publication paper. One example, the obesity has less of an impact than if you go to the bathroom before or after you weigh yourself. So there is this gene, it does impact your weight. But if you go to the bathroom before, after you weigh yourself, that has more of an impact than the gene does. So if you factor that all in, and if that holds true for multiple different domains of gene testing, then we have a whole lot of information that has a very low level of meaning, not enough to really be clinically meaningful, in my opinion. Now there are some exceptions to that, but these are more so things that standard conventional medicine would be checking for, not really what we’re putting underneath the rubric of gene testing in the functional realm. So no, I was not swayed. There’s interesting stuff here, but the main thing that seems to be the trip wire is the effect size. It’s different to say this gene impacts function x. That’s very different than this gene has a clinically meaningful impact on gene x and therefore we should treat you with therapy Y. That’s what really has not yet to be proven for most, if not all of the functional medicine, gene testing.

Medium-chain Fatty Acids

ER:

All right, our next question is from Genevieve.

Genevieve:

Hi, my name is Genevieve, and I’m wondering if it is possible to have a problem specifically with medium-chain fatty acids. And if so, does this point to the need to support the liver with certain nutrients? I’ve struggled with histamine issues for years, food intolerances that are high in histamine, but recently realized that I think medium-chain fatty acids are a problem for me. Specifically, MCT oil derived from coconuts and whole fat dairy produce an anger reaction in me. So I’m trying to figure that out. Thanks.

DrMR:

Okay. Thank you for the question. Are reactions possible? Yes. I reaction to anything is possible. There are some patients who react to vitamin D. I, myself personally, frustratingly, don’t seem to tolerate collagen beyond just a small dusting. I can’t do a whole scoop of collagen, it gives me insomnia. I have no idea why. These idiosyncratic reactions do exist. I don’t think that they’re abnormal. The use of dietary supplements is probably more abnormal than it is normal. When, in nature, would you confront, the equivalent of two heaping of collagen now? Can those things be used for improving skin? Yes. I’m just framing this in this way so people don’t view a reaction to collagen as something that requires gene testing and all this stuff.

DrMR:

Then they get on this kind of crusade to figure out why they have a handful of reactions. That seems to be more the norm where there’s a few things in the vast array of supplements and herbs out there, there’s a few things that any given individual could react to. Things as seemingly benign and innocuous as vitamin D or collagen. Diarrhea is obviously the most common side effect from MCT oil. So you probably know that, but just worthwhile to mention. If so, that can be resolved by just decreasing your dose. I also personally have found that MCT oil powder is less likely to at least send me careening to the bathroom than would MCT oil itself. Context, over the period of the past couple of years, my gut has gone from pretty good to great.

DrMR:

I’ve explained how I think the main thing that helped me turn that corner outside of doing a better job with sleep was really getting on gut rebuild nutrients consistently and all three probiotics together in synergy. That really brought my tolerance up to another level. So it may not be that powder is truly better for me as compared to oil. It may just have been the timing cause I tried the oil first and then the powder later. But that being said, it may be better tolerated as a powder. Now regarding liver support, if you mean, do you need liver support to better produce bile? Not to my knowledge. Now, I don’t have a meticulous command of all the different ways in which MCT has digested, but I’m fairly certain that MCT can absorb directly through the enterocytes or the intestinal cells and you don’t require pancreatic enzyme release or a bile release to digest.

DrMR:

So on that note, if you notice a more consistent intolerance to fats, the most common culprit for that maybe pancreatic insufficiency or epi (exocrine pancreatic insufficiency). So you may want to consider a trial on slowly titrating up your dosage of pancreatic enzymes if you’re noticing more of a global fat intolerance. Or, it could be, if you’re noticing histamine intolerance and many histamine foods are a problem. In my mind, there are two things I look at. We need to figure out how to modify your gut environment to account for that. So a lower histamine diet as one example, but then what is driving the histamine intolerance? This is where things like probiotics can help, potentially elemental dieting, potentially anti-microbial therapy, because there’s likely a degree of either overgrowth, dysbiosis and/or permeability that are driving that. So there’s a few things for you to kind of explore, and hopefully you can get that all sorted out.

SIBO Testing Ranges

ER:

Our next question is from Michael. “In the episode about your SIBO treatment protocol, you say you don’t want to see hydrogen above the 20 mark and methane, usually above three, but in your other conversation with Dr Seibecker, you’re referring to the increase or rise of 20 or more above baseline leading to a positive SIBO test. Which do you believe is more accurate to a positive test?”

DrMR:

Great question. And this is one of the challenges about the podcast episodes to go back now, I think …

ER:

300 episodes we’ve done..

DrMR:

We’ve done a lot. I think we’re going on five years maybe. So depending on what conversation with Alison and I you’re looking at, there could have been a different consensus in the published literature, or just a different feeling that either one of us had clinically. It’s something I’m always really kind of interrogating. I will say over the past few years, the most significant change in how I’m looking at SIBO breath testing is being much more cautious in how I interpret them. I used to look at any time point where hydrogen was above 20, even at 120 minutes and say, well, that’s positive. As more and more research has been published and we’re getting a better handle on this, really using the 80 to 90 minute caught off would be one important aspect that I look at.

DrMR:

So things after that, you’re not considered SIBO. Also what is the extent or the magnitude of the elevation and the absolute levels. So the AGA, the American Gastroenterology Association, I believe is what that acronym stands for. It’s funny. I always say AGA, I never actually talk about what the acronym actually stands for. So the AGA, their current consensus is for hydrogen, a rise of 20. For methane, anything that is an absolute value of 10 or above. So absolute doesn’t mean rise. For hydrogen sulfide, although there’s a real paucity of data here, a rise of 5. So I’m generally in agreement with that with looking for a rise of 20 to really have your technical SIBO, for hydrogen that is. I’ll look at nuance. If someone’s not demonstrating a rise of 20, but their absolute levels are 90, then it could be task preparation error.

DrMR:

If you’re seeing someone with their first, second, third time points, which are normally pretty low, because that’s the very early sections of the small intestine, they may not have done the preparation and so you’re getting a falsely skewed test. I will look at the rise and the absolute levels in conjunction with a patient check-in asking “hey, did you actually do the SIBO preparation diet the day before”. If they go “what diet?” then there likely wasn’t the appropriate prep. If they say, yes, I did it to a T. Then I’ll look at a little bit more nuance. Zooming way out, not looking at the test beyond 80-90 minutes, maybe you go to a hundred, but roughly establishing here’s where we’re now in the large intestine where we’re expecting to see elevations on the one hand looking for the rise of about 20.

DrMR:

Let’s say early in the tests, they are at a one. Then at 80 minutes, they’re at a 22. Am I going to consider that a positive? I mean, technically it is positive. It fits thecriteria, but would we say that someone with a blood sugar of 101 needs to really scale back their carb intake? Probably not. So it’s the not only meeting the criteria of being able to say they are a positive, but also looking at the extent of the positive, because what we don’t want to do is look at an individual who’s just over the cusp and squarely label them as SIBO. In my mind, a real kind of smack dab in the bulls-eye SIBO case would be someone who had that rise of 20, but they may start off at, let’s say 5 and then they rock it up to 75. That in my mind is okay, this is a true SIBO case. The same thing for hydrogen applies. The same thinking. If they’re at an 11 or 12, maybe there’s something there, but is that a real frank case? Probably not. If their methane is flatline in the thirties. Yeah. I mean, that’s much more something to pay attention to. So hopefully that helps you with how I’m kind of thinking through the diagnostic criteria.

RuscioResources:

Hi everyone. This is Dr. Ruscio. In case you need help, I wanted to quickly make you aware of what resources are available to you. If you go to drruscio.com/Resources, you will see a few links you can click through for more. Firstly, there is the clinic, which I’m immensely proud of. The fact that we deliver, cost-effective, simple, but highly efficacious, functional medicine. There’s also my book, Healthy Gut, Healthy You, which has been proven to allow those who’ve been unable to improve their health, even after seeing numerous doctors, to be able to help them finally feel better. There’s also our store where there’s a number of products like our Elemental Heal line, our probiotic line, and other gut supportive and health-supportive supplements. We now offer health coaching. So if you’ve read the book or listened to a podcast like this one, or are reading about a product and you need some help with how or when to use, or how to integrate with diet, we now offer health coaching to help you along your way. And then finally, if you are a clinician, there is our clinicians’ newsletter, the Future of Functional Medicine Review. I’m very proud to say, we’ve now had doctors who’ve read that newsletter, find challenging cases in their practices, apply what we teach in the newsletter and be able to help these patients who were otherwise considered challenging cases. Everything for these resources can be accessed through drruscio.com/Resources. Alrighty, back to the show.

EMFs and Full Body Scanners

ER:

So our next question is a listener who is asking if we can talk about this in a future episode, but also I think it’s a good question for us to see if we can answer.

Marayah:

Hi, my name is Marayah. Thank you for your coverage of EMF issues. My question is, for your next show on EMF, if you could talk about or ask your guests about full body scanners in the security section of airports, I’d appreciate that. Thanks for your show.

DrMR:

Okay. Great question. I don’t know if this has come up, we’ve done now I think four total episodes on EMF. High level, the way I look at EMF is what can you do to reasonably reduce your exposure. I’m assuming if we probe into the literature, there might be some studies on exposure to your airport or scanners, but there’s likely not anything definitive. We’re probably going to come away with well, it may have an effect. The heritetics are going to tell you that it’s a conspiracy theory to make people sterile. The evidence-based, snobby crew will look down at you as being a kook for even entertaining the idea. The middle ground here, that seems reasonable in my mind, while I’m attempting to piss off everyone I can…

ER:

This episode is going GREAT so far….

DrMR:

But hey, I’ll include myself in that where there are times when I fall into either one of those avatars. Just to clarify for our audience, these are all kind of characters I have in my own head where sometimes the evidence-based snob says something snarky, and then the other side has to answer back. There are definitely these multiple characters in my head, which I think we all have, and we want to listen to all of them, but then listen to their arguments and let who has the best evidence for their arguments kind of win the point. So in this case, I’m assuming that there’s no definitive data. So what do we come away with? We come away with, well, what can we do that’s practical? I should also quickly qualify that I have not done a search query directly on this, but from the ones I have done, there’s not conclusive evidence.

DrMR:

So when we don’t have conclusive or nearly conclusive evidence, we can come away with, okay, how can we practically reduce our EMF exposure? Do you have to wear a silver lined beanie everywhere? Probably not. You know, this would be the more en vogue version of a tinfoil hat. No. Could you turn off devices at nighttime, including your router? Yes. Could you not position your router right next to you? Yes. Have I taken a meter and clearly quantified that the closer you are to the source of the EMF, like your wifi router, the higher the exposure is? Yes. There are some practical things that you can do to reduce your exposure, which we’ve outlined in prior episodes. Now regarding the airport, there was one point when I only did the opt-out and to be honest, I got sick of having to wait around.

DrMR:

So I got TSA pre-check and that’s where you go through the metal detector, not the full kind of radiation scan. So that, to my knowledge, is less exposure and it’s a lot more convenient. So what you may want to do there is go through, and it’s a little bit of a pain getting set up, but once you are the TSA pre-check, in my mind has been well, well, well worth it. So hopefully that helps you kind of navigate this, but yeah, with EMF, it seems reasonable to practically reduce your exposure because there could be something there. There some initial evidence that’s suggests that something is there. Some of the experts we’ve had on the podcast have made proclamations and make it sound like the evidence is super definitive. I fact-checked a few of those studies and I didn’t find the super definitive answer that I was being informed about. So it makes me come to the following: There is there’s something there. The extent of the something has yet to be determined. So reasonable mitigation strategies seem like the best play at current.

ER:

Yeah. I’ve done the same thing. We put our router in the office and not anywhere near the bedrooms and airplane mode at night. You just gotta do what you gotta do. I ended up opting out during my whole pregnancy, for some reason I was traveling a lot during then during that time. I felt better doing that. Do you know, like, just in case, cause you got a fetus in there, so you got to protect it in any way you can. Also at one point the airport staff kind of expected me to. They were like, Oh, you want to be in this line and I’m like, Oh yeah, I guess I do. So there’s maybe they know something we don’t, I don’t know. That’s one measure you could take if you’re worried about it.

DrMR:

There was a study, I think in China showing that reduced exposure improves sperm, quality or motility. So that’s why I said that there is something there. Keeping with my own philosophy, just showing an effect is different than showing a clinically impactful effect. Given the fact that there, at least to my knowledge, there isn’t more conclusive data set, the reasonable mitigation strategies seem to be what are the most advised.

Accutane & Abdominal Adhesions

ER:

Yeah. Alrighty. And yes, TSA pre-check is so worth it. So worth it. Let’s see. Our last question is from Nick and he says, are you aware of any research linking isotretinoin (How do you say it? I’m butchering that.) It’s Accutane. Are you aware of any research linking isotretinoin to abdominal adhesions? Then Nick linked to a study from 2012. I know you had a chance to look at that.

DrMR:

I give this a quick look. A couple of things. Okay. So there has been, from what I have gathered, some documentation linking Accutane to an increased prevalence of inflammatory bowel disease. The extent of that, I’m not sure what the effect size here is. I know this is something that’s come up as one identified side effect of Accutane. Just a little earlier today I was doing a quick query in pub med. There’s a few studies finding that Accutane leads to pancreatitis. So that’s something else to be aware of. Now in the clinic, for a couple of years, I was really taking note of who is on Accutane and looking for correlation to gut health and also to inflammatory bowel disease. I didn’t see a signal there. So I’m assuming it’s a mild or a smaller effect size. Yes, there are some of these deleterious effects documented from Accutane. Does this mean that those things are going to happen to you?

DrMR:

I’m not so sure. Meaning, it could be a very rare manifestation. The reason why I share this is, and this, this ties in with a conversation Jeff Moss and I were having over the winter break, which is how impactful are some of these historical findings. You were on Accutane. Does that guarantee you’re going to have inflammatory bowel disease? No. Does it increase your risk to a small extent? Yes. Does it tell us at all in any way, in my opinion here to better manage the inflammatory bowel disease? No. Would it tell us any better, if you’re going to have adhesions? No. In fact, would I violate the typical kind of hierarchy which I construct for a patient and maybe put adhesions earlier in the hierarchy, based upon the history of Accutane. No. You’d look for clinical signs and symptoms. Meaning do they have a somewhat consolidated abdominal pain in the same region all the time. Then maybe.

DrMR:

Do they report feeling better after abdominal massage? Then maybe. But there are other things that may relieve the symptoms that could be attributable to in this case, abdominal adhesions. So we start with more of a kind of process of elimination, especially because bear in mind, you can’t just check off a box on a LabCorp requisition and say, test for abdominal adhesions. It almost always requires a therapist to get your hands on you. Then the therapy itself can be expensive. It’s not always expensive. The Clear Passage therapy is more expensive than most, but they’ve also done a really good job of documenting that what they do works in peer reviewed medical journals with high quality research. They have a robust protocol that they’ve pioneered. Does it tell us how to treat you any differently?

DrMR:

No. The thing Jeff Moss and I were debating, and we had a difference of opinion on this, which is fine. Not everyone’s going to agree on every point. But one of the things I no longer ask for in history is were you breastfed. Now, Jeff is totally correct in the point he made during our conversation, which is we know that that increases risk of an array of digestive and immune and inflammatory conditions. Yes. But does that definitively tell us you’re going to have any of those? No. Does it tell us what one you’re going to have? No. Jeff’s counter argument was, well, it may tell us that someone’s going to have more chronicity or more recalcitrance to therapeutics. Maybe. But again, because it doesn’t tell us who is and who isn’t going to be more chronic.

DrMR:

I look at, today with the person sitting in front of me, how are they doing? That’s how I’ll decide if they’re going to be labeled a chronic or recalcitrant case. You can drive yourself crazy with the vast array of things from the past that can cause something in the present, but there seem to be only a few that really would help me decide to treat an individual differently. One example would be, were you physically or emotionally abused? Now that’s important because, and I don’t necessarily need to know all the details, but that’s important because that could be a referral for therapy, EMDR, limbic retraining. Now, if there’s none of that in the history, then it reduces the rationale. If we see a prior abusive episode or episodes or period, paired with someone who is exhibiting signs and symptoms of being limbically imbalanced, that’s going to put very early in the hierarchy, either limbic retraining, EMDR, CBT, or something like that.

DrMR:

You can also even argue that you wouldn’t even need to know that historical data about prior abuse, but because that adds or doesn’t add to the hierarchy of one line of treatment, I see that as being helpful to know. Prior intestinal surgery, that’s a prior historical finding that’s helpful to know because there’s a different therapy that I’m not normally doing that can resolve that issue, or the scar tissue that builds in the wake of that issue. If someone was not breastfed or took Accutane, it doesn’t give me a different therapeutic to add into their hierarchy. So if it doesn’t, then I don’t find that data incredibly useful. Sure. It can be used to kind of weave this tapestry of the patient, but at the end of the day, as you’ve probably heard me mention the podcast before I look at this very much like a biological mathmatical equation.

DrMR:

If a given historical finding doesn’t help me better solve the equation, then I’m not that interested in it. We could tell a cooler story about the patient with all that history data, but at the end of the day, all that filters down to the math that goes into the hierarchy and either enables you or does not enable you to solve. So in this case, there are certain things from the history and sorry, I know I’m giving you way more than you asked, but just to try to kind of paint the context here as vividly as I can. There are certain things from the past that put new therapeutics into their hierarchy that otherwise would not be there. Those are the historical findings I find relevant. The other ones, I don’t find incredibly relevant and hopeful. You take solace in that, meaning that if you were on Accutane, like I actually was myself, it doesn’t guarantee you’re going to have a certain outcome and it doesn’t tell us anything about what therapies to put in the toolkit of your algorithm to help solve the problem of gut health for you. So sorry for the long one there, but hopefully it helps not only with your question, but a greater context to examine it in.

Episode Wrap-Up

ER:

Yeah. That makes a lot of sense. All right. Well, that’s all we have for today.

DrMR:

Thank you guys for the continued questions and hopefully these are helping you navigate all the options you have out there for improving your gut health. Remember about Healthy Gut, Healthy You. I’m extremely biased because I spent half of my days for three years in a row working on that to try to give a person everything I could to help them figure this out in a step-wise fashion. So if you’re in need of, let’s say I took Accutane. I’m still struggling with how to improve my gut health. What do I do? The book helps you navigate all those therapeutics that we could put in the algorithm and it lays out an algorithm for you that is personalized or personalizable and kind of evolves to your needs. So just a little a plug there for a Healthy Gut, Healthy You as we come to a close

ER:

I could have used that after Accutane. I got a little messed up by it. I’m not going to lie.

DrMR:

It wasn’t pleasant during.

ER:

But yeah, get Healthy Gut, Healthy You.

DrMR:

Awesome. Well, thank you, Erin. And thanks guys. We’ll talk to you next time.

Outro:

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