Answers on SIBO, Elemental Diet, Thyroid & More

Listener Questions – Elemental Diet for Ulcers, Keto Diet and Thyroid Disease, Red Light Therapy for the Gut

Today we will cover listener questions, including…

• Elemental Heal for Ulcers
• Inulin Intolerance
• Keto Diet and Thyroid
• H. Pylori False Positives
• Red Light Therapy for The Gut
• Biofilms and the Elemental Diet

Episode Intro

Dr. Michael Ruscio, DC: Hey everyone, welcome to Dr. Ruscio Radio. This is Dr. Ruscio. Today I’m here with Erin Ryan and we are doing more questions from you guys. Erin, welcome, and looking forward to some more questions.

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Do Elemental Diets Help Gastritis or Ulcers?

Erin Ryan: Yeah, great. The first question we’ll start off with is a written question. It came in via email. Davida wants to know, “Would using Elemental Heal for one week potentially be helpful for gastritis and/or ulcers?” Just for the audience, Elemental Heal is our semi-elemental diet formula.

DrMR:   This is a great question. I think the answer here is really a maybe. I don’t know of any literature, although there may be some published that I missed. But we went through pretty much all the data on elemental diets—at least that we could find—when we were researching the different formulas, how to use, when I was writing the book and everything else. I don’t know if there’s really been much published on gastritis and ulcers.

The reason why I say maybe is because I think it depends on what’s happening in the person’s system that’s driving the gastritis and the ulcers. If it’s something like H. pylori—and this is me just speculating based upon the physiology, based upon clinical reflections—actively driving high acid, like a bacteria, then I think it’s less likely you’re going to see healing. An elemental diet, as far as I understand it, will not starve H. pylori (that’s a bacteria that’s been documented to cause ulcers and can modulate stomach acid levels and cause gastritis). So the elemental diet likely won’t have an anti-H. pylori effect as it will an anti-SIBO effect.

Now, what if you’re someone wherein the gastritis and ulcerations are being caused by food reactivity, that’s caught in this kind of food-reactivity, histamine-intolerant, gastritis syndrome, which is definitely a presentation type? People clearly tend to fall into this category of having a lot of upper GI symptomatology. They may have burping, reflux, a sense of fullness. They may have documented gastritis or ulcers that may also accompany this. Gastritis and ulcers are more common in this population. The person may continually eat foods that seem to be causing a reaction, and part of the reaction in this whole cascade is, the food irritates your system, that causes immune activation, that immune activation releases histamine, histamine signals stomach acid release. And then if stomach acid is too high for too long you could have things like gastritis and ulcers. If it’s that type of person, then yes, an Elemental Heal will help.

What you could do is simply try it, and if you notice that your symptoms improve, that tells you you’re doing the right thing. If you feel like your symptoms regress—as some people may notice that they have an exacerbation of some of these gastritis, heart-burn-y type symptoms on an elemental diet—then that means it’s not the right fit for you, and I’d consider another therapy.

Just one other thing there: how long do you need to evaluate? I’d say by two days you should have a pretty good idea, and by the time you get through the four days, even better. This is why one of the applications I write about for how to use elemental diets is in a two to four day reset. So give yourself two to four days. If you’re not clearly able to say, “Yeah, this seems to be helping,” then you’ve given it long enough to run the experiment.

ER: Okay, great.

Does Prebiotic Intolerance Mean SIBO?

Next we have an audio question from Theresa.

Theresa: Hi, my name’s Theresa. I enjoyed reading your book. It was very helpful. My question is, I’m very intolerant of prebiotics like inulin and chicory root which are being added to many food products, and sugar alcohols and gum and candy. Is this indicative of an issue like SIBO?

DrMR:   Thank you, Theresa, for your compliment on the book and for your question. It could mean SIBO, but it doesn’t guarantee SIBO. This is one of the things that gets tricky about using symptoms to try to definitively diagnose what conditions may be present. So many conditions have overlap, which is one of the main reasons why, in the book, I do not recommend, “Go out and have a bunch of testing.” You really end up coming back to a clinical hierarchy. That’s the Great-In-8 plan, which helps you progress through a series of modifications that you can make, that will unravel this whole confusing knot of causality. So while prebiotic intolerance could indicate SIBO, it could also just indicate hypersensitivity to gas pressure, it could indicate classical non-SIBO IBS.

So what do you do? You start with some of the basics, like the book protocol lays out, and you work your way through it. Again, there’s not a definitive answer on that. It may indicate SIBO, it may not indicate SIBO. How you sort that out is by working stepwise through the process in Healthy Gut, Healthy You, which will help to balance any dysbiosis (that may include SIBO) and heal your gut. Then, later on in the process, we’ll try to expand your diet and include some prebiotics to see if we can utilize them for some of the benefit that they can have, but won’t have for everyone. This is another maybe, in terms of how we answer the question. I would simply work through the book protocol and it will help you figure out what path is going to be the best for you.

Is Keto Diet Detrimental for “Functionally Low” Thyroid?

ER: Okay. Next we have a question from Liz. She wants to know if you have any opinion on whether or not keto could be detrimental for those with low thyroid, due to the reduced T3 conversion that can happen on a low-carb diet. If someone is functionally hypothyroid versus clinically, would it be less of a concern?

DrMR:   This is a great question. This is one that I think often gets misrepresented on various blogs or what have you. What was really informative for me was looking at a few different research studies. Most notably, one diet was a paleo diet. They actually had people follow both a paleo diet and a paleo lifestyle, and compared this to a control group. But there have been other studies that just employed either a lower carb or a paleo diet compared to a control group. And what you see in the treatment group—whether it be paleo or low carb—is improved body weight, improved body composition, improved scores of subjective well-being and energy. So overall these people are getting happier, healthier, and seeing improvements in their body composition. Yet sometimes you see a decrease in free T3 fractions.

So it was very informative in showing me that we should not obsess over T3 levels—and this is one of the main reasons why I’ve been making this proclamation in various ways—because you can see T3 levels go down as someone is becoming way healthier.

This doesn’t mean that a ketogenic diet is going to be right for everyone, but I don’t think we can use T3 to predict who will and will not respond optimally to a ketogenic diet. Now, I don’t know this for a fact. I don’t know that this question has been analyzed in this level of detail in peer-reviewed studies. But essentially what I’m assuming would happen—should a study looking at this meticulously be done—is we would see that people going on a ketogenic diet would all likely see a decrease in their T3 levels, some would have eventual negative symptoms occur, while others would feel fine the entire time. And I don’t think T3 would really change significantly from one person to the other.

So in answer to your question, no, I do not think—and there doesn’t seem to be any conclusive data showing—that result in those with normal thyroid function. That is, they’re not hypothyroid, or they’re “functionally low” thyroid, which really doesn’t mean a whole lot in my opinion. It’s just observing your T3 is a little bit low, and that tells us, in my opinion, little to nothing. It may tell you a sliver, but it’s a pretty inconsequential sliver of information that you get there.

The question then is, are you someone who should be on a ketogenic diet in the long-term? Because using a ketogenic diet in the short term is pretty hard to argue with, giving it a one-, two-, three-week trial, and then kind of bringing your carbs back up. This is just like Christopher Gardner discussed with his limbo titration method, where they bring people’s carbs down and then have them bring them back up to what seems to be a suitable level. That’s a very, very tenable recommendation to make, and I think that’s a good exercise for people to go through.

Again, some people will eventually start to feel poorly on a ketogenic diet, and that tells them, “I need to bump up my carb intake.” Simple there. Now when it comes to someone who’s truly hypothyroid and they’re on medication, does that change the rules? Again, I don’t think so. We don’t have really good data to answer this, because this is a very particular study that would have to be done. Meaning, you take a group of patients who are hypothyroid, who are on levothyroxine, and then they’re put on the ketogenic diet, and then they track whether or not there’s a major dropoff in their T3 fractions after four weeks, eight weeks, 12 weeks. That’s a very particular study, that to my knowledge hasn’t been done yet. But again, I don’t think it’s going to make much of a difference.

The majority of people are fine to use a T4-only medication. I know this sounds totally heretical to what much of the field says. In our May edition of the Future of Functional Medicine Review clinical newsletter, Dr. Robert Abbott supplied us with a case study. He’s one of our readers and has been applying this in his practice, and he literally undiagnosed someone who was told that they were low thyroid by a functional medicine doctor. This person was feeling worse on thyroid hormone because they were being given it when they didn’t need it. And the key to resolving this person’s symptoms was, surprise, surprise, improving their digestive function.

So the majority of opinions that people are often given regarding their thyroid blood work are not great, unfortunately. And the majority of studies have shown that most people are okay with just T4. About 10%, maybe 15%, of people may need T4 plus T3. But are T3 levels highly predictive? No. There’s some evidence showing that people may feel better when their T3 gets a little bit higher, but there’s also data showing that there’s no correlation between changes in T3 levels and if people feel better on T3 medication. Some of those studies have been done.

I know some of this isn’t directly answering the question. But I’m just trying to shade in some of the relevant context, which is this whole theory that there’s a tight correlation between how someone feels and their T3 levels. I think there’s some evidence there, but if you look at the wider body of evidence you see that that’s more a red herring. And I can say—as I’ve been approaching the T3 as less relevant and focusing more on other factors, like their gut, like their female hormones—the results I’ve been seeing have been fantastic. Now we’re seeing clinicians who are reading my newsletter, applying this with patients, and seeing the same thing. So it’s not that it’s unique to me. This is a good read of the evidence that I’ve transitioned into a simple algorithm, and others are now applying that algorithm and they’re having the same effect.

So all this to say, in somewhat of a long-winded way, I’m not concerned about the ketogenic diet’s effect on T3 levels, and I’m not highly concerned about T3 levels, in and of themselves. I would simply try the diet, see how you feel, and be on the lookout for any signs that you’re too low-carb for too long, which I do provide a specific list regarding in Healthy Gut, Healthy You. But you’re essentially looking for things like not sleeping well, carb cravings, stimulant cravings, being fatigued during the day, brain fog, and depressed mood.

ER: Okay. I think a lot of that background is helpful, for sure.

DrMR:   Yeah, I think we have to contend with so many people parroting the message of T3 being so important, and so many doctors saying the reason you’re not feeling well is because your T3 is low, and you need to be on a combination of formula—which is a T4 plus T3 formula, like Armour or Nature Throid—which I thought for years.

As I started questioning that, I started realizing, wow, there’s a decent amount of patients who, A, are diagnosed as hypothyroid and actually are not, or B, have been put on a combination formula too early and felt poorly on that. And then, surprise, surprise, you cross-reference this with the medical literature, in a non-biased way, and you say, “Holy smokes, there have been literally two meta-analyses looking at whether patients look better on T4 plus T3, and the answer is no.”

The majority of the data show that most patients do not do better on a combination therapy. In fact, you have a higher incidence of negative side effects when you do that. There are a small subset of patients who will only feel best on a combination therapy, but to say we have to put everyone on a combination therapy is a mistake.

Also, to say, “Well, this person’s on levothyroxine and they’re not feeling well, so now I’m going to jump to a combination therapy like Armour or Nature Throid,” is a mistake if you’re overlooking their gut health. And that happens all the time. Just like this case study that Robert published in the Future of Functional Medicine Review clinical newsletter, the person was erroneously diagnosed, erroneously put on thyroid hormone medication, and their gut was overlooked. Fixed the gut, and 90% of the problems went away in a couple months.

ER: Yeah, when you throw diet on top of all of that, and people really don’t know what’s going on, it’s easier to blame the diet than the treatment they’re getting.

Sponsored Resources

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How Do I Resolve Chronic Fatigue?

ER: This is an audio question from Mike. Short and sweet.

Mike: Hello, Dr. Ruscio. I’m going on three years of chronic fatigue syndrome after a food poisoning incident. My resulting SIBO has largely been resolved, but the chronic fatigue remains. I’m wondering, is this common, and if so, how do you go about resolving the chronic fatigue symptoms? Thanks.

DrMR:   Good question. One of the challenges with a question like this is, when people say SIBO—and this is something I think it’s helpful for everyone, patient and provider, to be a little bit more discerning regarding, because we often times will use a lab finding to represent a cluster of symptoms, but we shouldn’t be so loosey-goosey, saying, “My SIBO is better,”—what do you mean?

Do you mean that your previous constipation and bloating is better, and you’ve never actually had a SIBO breath test, but you assume you have SIBO because of those symptoms? Or have you had a lab test and it was abnormal, you treated, and now it’s normal? Or have you done both? Did you have a positive SIBO breath test plus symptoms, then you were treated, now your symptoms are gone and your lab tests are normal?

I don’t know if he’s saying that his lab tests are normal but he’s still fatigued, or if he has seen his gut symptoms improve and he’s still fatigued. So knowing that and sorting that out would be helpful. Because it is possible that there could still be an issue in the gut, and it’s just that we don’t know exactly what that is because of the somewhat vague terminology used. So if SIBO has been cleared on the testing, there could be another gut issue present. This person could have, for example, taken rifaximin (an antibiotic for SIBO) and cleared the SIBO, but they still have a fungal overgrowth that the rifaximin didn’t touch. This is one potential scenario.

It’s also possible that this person has seen their digestive symptoms improve, but they still have chronic fatigue syndrome. Now, it’s a much safer bet that if all of your digestive symptoms are gone, that you also do not have any dysbiosis in the gut. It’s not a guarantee, but you’re much safer to say, if I have no symptoms, I have no problem with SIBO or any other related imbalances like dysbiosis, generally speaking. If that were the case, there are other things that you could look at.

This is when looking at someone’s thyroid status may actually be relevant. If someone has elevated TSH and low T4, and they’re hypothyroid, then that’s a no-brainer: get them on thyroid hormone. This could also be someone who has a mildly elevated TSH and a normal T4. That’s where we’d want to use the liquid chromatography with mass spectrometry methodology to test the T4. They may have T4 that’s actually low—but being confounded by binding proteins in the blood—and when we recast them on this different methodology, we actually find that now their T4 actually flags low. So that’s something to consider, a good thyroid assessment, essentially.

But you have to also be careful that you are not going to be told you’re hypothyroid when you’re not, by an overzealous functional medicine practitioner who thinks thyroid hormone replacement is the answer to every problem. I know I’ve said this a few times: this is the next book I’m going to write because it’s just so badly needed, in addition to the gut book that I’ve already written.

Something else to consider would be looking at your ferritin levels. There’s been some published evidence out of Finland by an author named Soppi, who’s essentially finding that if ferritin is below 100, that these people do well with supplementation. About 70% of women in one study who had ferritin below 100, then had it supplemented to above 100, saw their symptoms improve. And their symptoms were: they were hypothyroid, put on hypothyroid medications, and their symptoms didn’t respond. So I’m extrapolating a little bit, that this may also apply to someone who does not have hypothyroidism. But I think it’s a pretty safe bet to say, look at your ferritin. If your ferritin is low (and ferritin is just a marker in the iron family), you would just take supplemental iron. I don’t think we have to be incredibly circumspect with making a recommendation to supplement with iron.

Those are a couple things to think about. Also, looking at some of the basics, like your sleep, stress levels, diet, and then there’s also potential for other infectious agents. Viral infections, although I think those are pretty infrequent, could be a possibility. Lyme… although you have to be very careful, because with some Lyme providers, everyone who goes into the office has Lyme. I’m not trying to hate on the field, but these are just things you have to be circumspect about. Because unfortunately there is that chance that if I specialize in Lyme, everyone’s going to get treated for Lyme. I wish that wasn’t the case.

Those are a few other things to think about. Double-check your gut based upon what we said before. Make sure that you’re not just assuming, because your SIBO breath tests might be normal, that that means your gut is fully sorted out. If your gut symptoms are, in fact, all gone then you might want to think of some other things, like a thyroid evaluation. An evaluation for anemia (including ferritin). And then potentially think about some of your lifestyle factors, or other agents like infection. That’s a pretty good place to start. That’s not a comprehensive list of every possible issue, but that’ll get you pretty darn far.

ER: Yeah, I was going to say, what about low testosterone, since we’re dealing with a male. Potentially?

DrMR:   Yeah, maybe. He’s not describing any symptoms of sexual dysfunction.

ER: True.

DrMR:   So it makes me less prone to think that testosterone could be the issue. It could be, but I think unless you’re seeing some other male-hormone-mediated symptoms going awry, then it’s less likely. That’s what’s challenging about these types of questions, because I’m just getting little snippets.

ER: Yeah, never know.

DrMR:   Yeah, I try to give the best answer to that snippet, but there’s certainly more that one could consider.

What Do I Make of Conflicting H. Pylori Test Results?

ER: Great. Our next question is from Zoe. The question is, why would someone test positive for H. pylori on GI-MAP but negative on a biopsy?

DrMR:   Good question. Biopsying is limited by the fact that they’re only taking tissue from a certain area in the stomach. This has always been one of the challenges with biopsies. You get a very close look at a very small area. So you can’t say that a biopsy has a 100% accuracy. Now conversely, the GI-MAP, being a DNA test, does suffer from some false positives. So we can’t say that the GI-MAP stool test is going to be fully accurate either.

So what do you do? Well, you can look at your symptoms and see, do you have classic symptoms associated with H. pylori? Meaning, do you have a history of gastritis or ulcers, or do you have reflux- or heartburn-type symptoms? The other thing that you can look at is followup testing, where I would recommend doing a stool antigen test paired with a breath test. Blood testing can also be helpful. But I’m now doing a little bit less blood testing and more relying on the stool antigen test combined with the breath test, and that can help firm up whether that’s a negative or a positive.

So yeah, that’s a great question. This is why I have repeatedly said, lab testing is not definitive. One of the worst things a patient can do is look at their lab testing literally. I mean, sometimes, yes. There are some lab tests, like blood sugar, if you’re fast and you’ve done it the right way, they’re pretty clear cut. But with many of these GI tests, there are strengths and weaknesses to each test, which always have to be examined in juxtaposition to the patient context to really figure out how to interpret results. In this case, it’s not definitive where you are in terms of H. pylori based upon this data. A little bit of followup assessment could be helpful to sort that out.

Advice on Diverticulitis and Diverticulosis?

ER: Next we have a question from Joy. This is an audio question.

Joy: Hi, Dr. Ruscio. I have not heard you talk much about diverticulitis and diverticulosis. I wonder what you have to recommend for handling those situations.

DrMR:   Good question. Diverticulitis, diverticulosis. I don’t look at these much different than IBS, IBD, functional gastrointestinal symptomatology. I tend to fall into the same clinical hierarchy that I do for gut ailments in general. There are some proposed dietary nuances that may be helpful, and anybody with diverticulitis or diverticulosis has probably read these. Avoiding things like seeds and corn and some nightshades can be helpful. Then there’s also, I believe, at least one randomized control trial showing a low-FODMAP diet to be helpful.

And outside of the basics that we talk about all the time—start with an elimination diet (akin to a paleo-type diet), and then maybe consider something like low-FODMAP, then probiotics, and then potentially looking at something like a course of antimicrobials or a course of Elemental Heal—you also may want to consider cannabis. There have been a few patients of mine who swore by cannabis, with diverticulitis specifically, to really help with that.

I also have to contextualize that. These were usually patients who weren’t doing much in the way of diet, lifestyle, and other gut therapies. So when someone hasn’t done anything else, there’s a good probability whatever thing they do, they’re going to see a response to. So I want to bridle that a little bit, so people don’t think that cannabis is this miracle for diverticulitis, but I think a lot of the same rules apply.

I also want to make one caveat, that I haven’t looked incredibly deeply into the literature on diverticulitis and diverticulosis. What I’m actually going to do now in light of this is start a PubMed search and make sure that I am not missing some of the research being published there. I don’t see a lot of this research coming into my information feed, and I want to make sure that I’m not missing anything. So I want to thank her for posing the question to make sure that I don’t have a blind spot here in the literature that I’m following.

When writing the book and in clinical practice, for patients who come in with diverticulitis or diverticulosis, I follow, again, the same principles as I do more broadly. And they seem to work pretty well. But if I do find anything novel or exciting for either of these, I will definitely report back on the podcast.

ER: Okay, that sounds good.

Can Near-Infrared Light Heal My Gut?

So we have time for one more, and this one is from Bart. He says, “After hearing one of your shows, I purchased a near-infrared light device and have thought of pointing it towards my gut as a way to possibly help my SIBO healing process. But I wonder if it might be possible that I would be making it worse by energizing the bacteria that I’m trying to get rid of. Do you have any thoughts on this?”

DrMR:   Yeah, this is a great question, and I don’t have a good answer. This is something I’ve discussed with Ari Whitten, offline and in personal email correspondence. And he did allude to this during our last podcast, saying that for people who are fairly thin and don’t have much abdominal fat to get in the way, you may be able to see some benefit, presumably from stimulating the enterocytes (the cells in the lining of the gut) using the red light. For anyone with a moderate or more amount of body fat, there will likely not be an ability to penetrate. As I understand it, and this is more drawing from Ari’s extensive review of the literature on this, there are not any research studies looking at this.

So, due to the location, I’m not sure if the intestines will benefit highly from red light therapy, other than fairly thin, lower body fat populations. But that is completely based upon my assumption. There may be a study published in the future that counters that. I’m assuming, now that we’ve been talking about it on the podcast, we’ll have people sending in their experimentation. And hopefully soon we’ll get little pings, and I’ll have some feedback on that for you. But I don’t really know.

Regarding, would you feed or stimulate your bacteria? Again, my thinking would be, if you’re able to reach the intestinal cells, if you’re thin enough, you would probably end up with a net positive rather than a net negative. Meaning, maybe you partially stimulate these intestinal bacteria, if that’s physiologically even possible, I don’t know. But let’s say that you do. This really depends on if the organisms have mitochondria or don’t have mitochondria. That’s the main mechanism of how the laser works, which is stimulating the mitochondria.

So I’m fuzzy on those details, but I can draw an inference extrapolating from what we see with the skin. We know part of what leads to skin lesions, irritation, and things like atopic dermatitis can be—not always, but can be—dysbiosis of the skin microbiota. And since the red light helps with skin conditions, my thinking is, the effect you’re getting is a net benefit. Meaning, let’s presume that the hypothesis he’s putting forth is correct, which is, you could stimulate the bad bacteria on your skin. You’re someone with current rashing, and you start using the laser or the LED light, and your skin improves, as it’s been documented in the literature. That would tell us that you’re seeing more of a benefit for your skin cells than you are the bad bacteria on your skin, thus you’re hitting a clinical benefit. I would assume that same thing would apply in the intestines. But again, this is me speculating off of a chain of inference.

So I could totally be wrong. There is no answer to that question at the moment. But I wouldn’t really be concerned that you would do any negative effects to your gut. I would say at best, nothing would happen. There’s a chance something good would happen, depending on how much abdominal fat that may be impeding the light.

View Dr. Ruscio’s Additional Resources

ER: We’re at about 32 minutes, do you want to do one more?

DrMR:   Sure.

Can the Elemental Diet Cause Harmful Biofilms?

ER: Okay. This one’s from Hannah. She says, “Studies have shown that starving bacteria can induce biofilm formation as a protective mechanism. Could the elemental diet cause further problems, as starving the bacteria creates thick biofilms that protect the bacteria from antimicrobials?”

DrMR:   This is a great question. This is a great question because it’s making a presumption where we don’t know if it’s meaningful. This is one of the most destructive things that both patients and clinicians do. If you remember back to my last question from just a second ago, I cautioned that I am drawing inferences. So we really don’t know.

What this lady is doing—and I’m not criticizing her, I’m just criticizing the line of thinking that I think we all could benefit from being more mindful regarding—is basing this off of… I don’t know, I’m assuming it’s some kind of cell culture study. Perhaps it was something in humans interventionally. But it’s fairly difficult to assess these things in humans, because assessing biofilm is pretty darn hard to do. So to say this is based upon any high-level science, I think, is fairly unlikely. It’s likely that they took some samples of intestinal tissue from animals, and put them in a Petri dish essentially, they starved the bacteria, and they witnessed what happened to the biofilms.

Does that mean that there is a clinical translation? Does that correlate into a model of free-living humans, when they go on a bacterial starving diet, like a low FODMAP diet, or a very low carb diet, or using Elemental Heal? I don’t know that this question has been accurately answered in a randomized clinical trial setup. However, when we look at what happens to people who use lower carb diets, lower FODMAP diets, elemental diets, the overwhelming majority of people improve. Overwhelming. So my thinking is that any impact on biofilms would be infinitesimally small and absolutely clinically insignificant.

But the thing I want to point out here, again, which I think is more important, is it’s this type of hyper-focused thinking that I see so many patients struggle with. They talk themselves out of so many therapies because maybe one practitioner two years ago told them that they probably have biofilms. Now they think they have this whole biofilm issue. By the way, it’s very difficult to diagnose a biofilm. Almost no one is actually going to have a true diagnosis of biofilm.

So I think they have this biofilm issue because they were told this. And the practitioner may have only said it in a nonchalant way, like, “There are a few different things that could be going on right now, one of them could be biofilm.” But oftentimes patients will take something like that and say, “I have a biofilm issue.” And they latch onto it and they carry forward with them. Then they start reading, in who-knows-what study (but potentially, some cell culture study in a Petri dish), that starvation of bacteria can make biofilms worse. And they don’t do low FODMAP, they don’t do an elemental diet, and they suffer needlessly for years because they’re afraid to try either one of these therapies. Only to then end up in my office and ask this question, I give them this answer, they decide to try the therapy, and they feel great.

This is one of the main reasons why I have a whole chapter of the book dedicated to levels of evidence. It’s so important that people don’t talk themselves out of a therapy because of a theoretical question. It’s a great question and I applaud the listener for reading and educating herself, but I would never not do a therapy because of this sort of small observational finding. If there’s a therapy that’s been done in humans—and we know that there have been a number of clinical trials published using elemental diets, using low FODMAP diets—or if you just know a lot of people have done these things and felt well, it’s fairly safe to assume that you should at least give it a trial. And not stop yourself from trialing a therapy because of a certain mechanism or an exception or what have you.

So again, a long-winded answer here, but the thinking that underlies it is such an important thing. If more patients, I think, better understood this, it would really save them from spinning their wheels, reading a bunch of stuff, getting confused, getting scared about doing X, Y, or Z.

Another thing that you sometimes hear is, don’t do an elemental diet if you’ve had a fungal overgrowth. This is also erroneous. And if people would just learn to trust in a well-constructed therapeutic hierarchy and work through it, and understand some things are going to help, other things may not help, it would just make people’s lives so much easier. You want to run through the hierarchy and not get distracted by these things that are really more just research questions that don’t have any place in the clinical setting yet, or certainly not with the lay public yet, because they haven’t been shown to be relevant to clinical care.

So it’s a great question, I’m so glad that she asked. And hopefully that answer helps her with just a simple decision to trial an elemental diet. There is a high likelihood it’ll be helpful. Not guaranteed, doesn’t help everyone. But I would certainly try it, and I definitely would not be scared about causing any major biofilm issue.

ER: Yeah, that’s exactly why I like to include these types of questions, because that right there was like me four or five years ago. I’m researching like mad, I found out I was positive for SIBO, and I actually paid something like $750 for some SIBO program I found online. The bulk of it was all about penetrating these biofilms, and I became biofilm-crazy for a while, like “Oh man, this is going to be so difficult.”

It’s amazing, when you’re that desperate for information and for healing, you can really talk yourself into believing whatever it is that’s out there, if it’s going to give you a leg up on healing (or not). So I’ll always include these types of questions because I think it’s really important to point out exactly what you just did. There’s plenty of evidence out there for the elemental diet too. There’s strong evidence for that.

DrMR:   Right. There’s strong evidence for that. And then regarding biofilm, it’s a very new area of research where there are only just a couple of interventional studies in humans treating biofilms. There’s still very, very much we have to learn about this field. Erin, how did you find your way out of that scenario of being hyper-focused?

ER: Oh boy. You know me and my personality. I’m research-focused, I’m try-everything-focused, I don’t give up. I’d say really, this is going to sound really cheesy because I’m on the podcast right now. But I found your podcast, and you weren’t talking about a lot of the things that I was reading in these specific forums. You just had a more relaxed approach to the whole thing. I don’t know if relaxed is the right word, but it just seemed like an approach that had more room for real life. More practical.

And that was super inspiring to me, because I was starting to feel like I was living in a cave, under this dark tunnel. Taking a handful of this, a handful of that, all these tinctures, to try to bust up these biofilms and detox. And I was also researching histamine intolerance at the time, because I seemed to react to everything that I was trying in that protocol that I tried. So I ended up finding your website actually, and your podcast. That’s kind of how I found my way out.

DrMR:   That’s great. It makes me feel really good about the work that we’re doing, and the fact that I just blew all that hot air on that question for about three to four minutes. But yeah, you’re an example of exactly what I was outlining before, which is how important it is we don’t get zoomed into these things.

For clinicians… these were all things I was doing early in my career, because if you educate yourself in functional medicine, this is the default programming you come away with. And one of the key things that I think led me out of this—and it’s something that I’ve talked about in our clinical newsletter—is you have to spend time reflecting on patient cases.

So, in my clinic, I don’t spend a tremendous amount of time with each patient, because I don’t need to. What’s more important is reflecting on their cases. I’m looking at the clinical hierarchy I’ve created for each individual, in juxtaposition to how they’re responding. I’m talking some time to ruminate and think on their case before and after each visit. This is one of the things that patients don’t really see, but they will appreciate because it’ll allow you to get them better results.

You’ve got to take some time to think. And one of the things that I ended up thinking on was, “Boy, I’m doing all these tests, and these tests don’t really seem to be telling me anything significant. I feel like I’m doing all this stuff, treating all these markers and what have you, but it doesn’t seem to be advancing how well these patients are responding.” Taking that time to question what you’re doing, and think on what you’re doing, can be so hugely impactful. So I just want to make sure to remark on that, because it’s been one of the most helpful things in my personal clinical development.

The other thing that I want to tie to that is, limiting your focus in terms of how many conditions that you treat. I think one of the only ways you can start to piece these things together is if you’re not the Lyme guy, the mold guy, the thyroid guy, the gut guy, the musculoskeletal rehab guy, the oxidation guy. If you’re doing all these things, it’s going to be very hard to have enough cases where you can start to see patterns and make connections.

I think it was Allison Siebecker who said she has to see a few hundred cases of a given thing before she feels like she really starts to get a good grasp on that thing. And I think that’s absolutely true. So think about if you’re treating 20 different things: how long will it take you to see a few hundred cases, or a couple hundred cases of that thing? But if you have a more narrowed focus, then you’ll be able to see those couple hundred cases in a decent frame of time, and be able to make the connections needed to figure out what’s working and what’s not working.

So, great question. And Erin, thank you for sharing your story. It’s awesome that the podcast was one of the things able to nudge you out of that rut.

ER: Yeah, I appreciated it for sure. All right, that’s all the time we have today.

DrMR:   All right, guys. Thank you for your questions, and keep them coming.

ER: Yeah, definitely. Thanks..

What do you think? I would like to hear your thoughts or experience with this.

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