Answers on SIBO Testing, Worms, Imodium, Elemental Diet

Plus, iron infusions and gut diversity.

Today we will cover Listener Questions, including:

  • What percentage of probiotics make it through the gut?
  • What to do when SIBO clears but symptoms persist?
  • Iron infusions for correcting low ferritin, is it safe?
  • Elemental Heal says it contains milk, but I can’t have dairy, what to do?
  • What to do if there are potential worms in the stool?
  • Does Imodium cause problems with the migrating motor complex?

In This Episode

Intro … 00:00:02
Altering the Microbiome … 00:00:54
Independent Factors Affect the Microbiome … 00:06:01
Elemental Health … 00:12:35
Iron Infusions for Low Ferritin … 00:23:32
Ongoing Symptoms Post – SIBO Resolution … 00:26:52
Effect of Imodium on Migrating Motor Complex (MMC) … 00:35:20
“Worms” in the Stool … 00:39:16
Shining a Light on Functional Medicine … 00:52:13
Wrap-Up … 01:00:38

Answers on SIBO Testing, Worms, Imodium, Elemental Diet -

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Welcome back to another episode of Dr. Ruscio Radio. This is Dr. Ruscio I am back again with Erin Ryan, and we are going to be going into another episode of listener questions. So, I guess we can jump right in.


Sponsored Resources

Let’s talk about one of my favorite tests for digestive health, the GI-MAP from Diagnostic Solutions, who has helped to make this podcast possible. Now if you’ve been reading any of the case studies that I’ve published in the Future of Functional Medicine Review clinical newsletter, you’ve likely seen that this test, the GI-MAP, is a test I frequently use in my practice.

Answers on SIBO Testing, Worms, Imodium, Elemental Diet - diagnostic solutions

Why? Well, one of my favorite things about this test is it has excellent insurance coverage. So this is a few hundred dollars that I save patients. This lab is also CLIA certified, which is essentially the quality assurance bureau for labs. So it’s important that these labs are being monitored, not cutting any corners. That’s where you get your CLIA certification.

Now, this test uses quantitative PCR technology. So it’s a DNA test. And you’ll get a good read on dysbiosis with this test because they will assess and report out various types of bacteria, yeast, and parasites including protozoa, worms, and amoeba. They also have some valuable and helpful clinical markers like calprotectin which can help rule in or out inflammatory bowel disease, and zonulin, a marker of leaky gut. So head over to DiagnosticSolutionsLab.com to learn more and to order your test.

➕ Full Podcast Transcript

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 am back again with Erin Ryan, and we are going to be going into another episode of listener questions. So, I guess we can jump right in.

ErinRyan:

Okay. Our first question is from Ben. He said, “I’ve heard that the makeup of your microbiome is difficult to alter long-term and new bugs often can’t compete for real estate with the existing bugs. Thus things may change temporarily, but we’ll revert back to the pre-supplement baseline once you stop supplementing. If that’s true are stool samples an actual representation of the bacteria in the gut, or just the bacteria that didn’t take hold in the gut. What percentage do you think of the bugs from a probiotic make it through the gut?”

MR:

Okay. So a few things there to try to answer. This is a kind of a multifaceted question. There’s a lot here to unpack. The important thing to take away is that the microbiome seems to be in constant flux. Food has an impact. Sleep has an impact. There may even be a diurnal or night/day changes in the microbiome. That’s not to say that because of the changing, there’s an inability to read the microbiota and get any kind of read from it. We can to some extent, but I think we are, in many a case, trying to put the cart before the horse or pin the tail on the wrong end of the donkey. We are still in the early infancy of understanding what a given microbiota finding means. We should clarify that the term microbiota is used as kind of a catchall. When we drill down to testing assessments, do we mean something like a SIBO breath test that tells us that there is a potentially harmful disruption of the levels of bacteria in the gut? Do we mean that there is a parasite or pathogen? Is there something that’s a potential pathogen? Or are we looking at a reading that’s truly a mapping of the microbiota that tells us something about the thousand some odd species of bacteria, grouping those into certain taxonomical categories, perhaps even phylotypes, and using all that information to be leveraged and analyzed by a computer program to give us a readout of this multitude of findings with maybe 1300 various organisms that tells us whether this is considered normal or dysbiotic. So we are definitely in our infancy with the mapping of the microbiota. When this becomes relevant to the conversation of how you use information to steer your healthcare related decisions is when people are looking to the microbiota and changes in it to be informative.

MR:

When I say the microbiotia, I mean more so mapping the microbiotia changes in this whole community of bacteria and looking at those results as a way to tell us what we should do clinically. This is where we don’t really have data. Even the most advanced test, which right now for mapping the microbiota likely the GI-MAP out of Norway, or it’s US-based compendium, which is through the Doctor’s Data GI 360 stool profile. We do have research validated association of different findings in the microbiota to IBS, IBD or healthy controls. So that’s what we do know. So the measure has been validated to be able to say, consistently, we see differences in how we are labeling the microbiota between those with IBS (inflammatory bowel disease) or healthy, normal controls. But in terms of someone saying “I took a probiotic and that led to a shift in the microbiota”, whatever type of shift that would be, “so that tells me I should or should not be using the probiotic”. We don’t really have that level of sophistication. Now we do know, as I’ve said many times, with the items that have a known clinical corollary like parasites, pathogens, and worms. H. pylori kind of straddles the fence because it’s not really a parasite but it can be problematic or it may become commensal. Also SIBO and candida. These factors that we know are pathogenic or oftentimes tend to be somewhat pathogenic, or maybe we could label them as dysbiotic. We know that using various interventions like probiotics or antimicrobials or antibiotic therapy can help. But in terms of using a probiotic, manipulating the microbiota, expecting those changes to “stick”, this is just littered with erroneous thinking in terms of how we’re looking at the information regarding the microbiota. It gets convoluted because research papers are filtering with certain populations who are healthier, have this certain microbiota.

Independent Factors Affect the Microbiome

MR:

Then people think, well, if I take a probiotic or a prebiotic, and I try to push my microbiota in that direction, will I become healthier? Like the observed better health in this cohort that had whatever the balance in the microbiota was, but that is severely flawed in its thinking, because it assumes that there is this one way direction between the gut microbiota in one’s health. It misses the fact that people may have grown up in an environment that is more conducive to having a healthy immune system. Therefore the immune system’s impact on the microbiota has been greatly shifted by the immune training they got early in their life. They may live in a blue zone or green zone, which we know correlate to a lower all cause mortality and a longer life expectancy. These individuals may have better stress management. There may be in a society that is less imbued by stress. They may be looking at a population that has better sleep. There may be a socioeconomic variable that confounds the region. There’s all these reasons for why you should not be looking at the microbiota in such a way as this question is framed. We know that changes happen. Are the lab test findings predictive? Meaning if I do a poop test and I see this, I should do that treatment. We are not really there yet with the microbiota mapping.We are with other things like SIBO breath testing, and stool testing for certain types of pathogens or potential pathogens. This question obfuscates from the much more accurate endeavor, which is using these therapeutics, not being concerned with what exactly is going on in the complex ecosystem of your gut, but rather looking to the end result.

MR:

I sleep better. I have less joint pain. I have clearer thinking. These are the measures that you have to look at because these are not confounded by the litany of factors I just listed. So do probiotics stick or colonize to you longterm? Probably not. Does that mean that probiotics are not beneficial to use? Definitely not. In fact, we know that probiotics can eradicate SIBO and ostensibly that SIBO stays away after you’ve eradicated the SIBO by using the probiotic. Now, does every colony forming unit have a probiotic capsule you take hang out in your gut forever? No, but that’s not the point of the probiotics. The point of the probiotics is to nudge the ecosystem to a healthier balance so that it can maintain a healthier balance in the longterm. Same thing with diet, especially in the initial phase. Some people may need a low FODMAP diet that causes a shift in the microbiota. Is that good or bad? We don’t really know. But what we do know is that these people tend to have lower inflammatory cytokines, lower leaky gut scores, lower levels of certain inflammatory peptides, potentially better motility. So people use a low FODMAP diet, they see clinical benefit and then over time they reintroduced to the healthiest diet possible likely because as a microbiota rebalances and the immune system kind of wind up attenuates, they can tolerate more foods. So all this to say that we could talk for a very long amount of time about all of the mechanisms and corollaries, but unfortunately it’s really not productive to do so because while we have scientific tidbits that are super interesting and they sound like potentially the next miracle breakthrough in medicine and healthcare, many of these are still in the realm of academic observations and trends for where the clinical translations have not yet been fully mapped out.

MR:

By focusing on those one can distract themselves from looking at the clinical end points. Like I had mentioned earlier, your sleep, your joint pain, your skin, your bloating, your reflux, your constipation, what have you, and choosing what therapeutics supports or dietary changes to employ. The array of changes that happen in between the therapeutic change (diet, probiotics, etc) and the endpoint of symptoms is vast. There is so much complexity there that if you try to get into those weeds, there is a very high probability that you’re going to do the wrong thing because you’re looking at one of 500 mechanisms. The one or two mechanisms that you’re focusing on, don’t tend to be the primary movers of the clinical endpoint of less joint pain, better sleep, less bloating that you’re concerned with. So I know that there’s a lot there, but it’s really important for us to continually acknowledge the fact that there are some real severe limitations.

MR:

Unfortunately there are a array of lab companies out there who are exploiting people who don’t feel well and making many promises with their microbiota mapping test to uncover for them what dietary changes to make or what supplements to use. There’s not really any data to support that. So the foundations we want to focus on are the hard clinical endpoints and what gut therapeutics can be used to achieve those hard clinical endpoints. Everything else really distracts you from achieving the angle that you’re trying to achieve. So, sorry for the kind of long answer on that question, but there is a lot there to unpack and unfortunately the better your understanding here gets, the more simplified your answer tends to be. One of the challenges is if you’re earlier on the road where your understanding isn’t that evolved, you tend to fall into those weeds.

MR:

This is exactly the evolution I followed when writing Healthy Gut, Healthy You, and also paralleling the research for that book with my clinical experience. After a year of looking at this research for three to four hours every morning, I started to piece together that there were so many contradictions in the academic literature, and they were only reconciled when following the evidence based model of evidence. Making decisions based upon clinical trial and outcome data. So again, long answer, philosophically incredibly important. Cause if you understand this answer, it will help protect you from getting swept away by all the new novel and kind of flashy, buzzwords and tests that are out there on the market.

Elemental Heal

ErMR:

Okay. I think that was pretty thorough.

MR:

Polite way of saying long.

ER:

I mean, we get those types of questions a lot, and there’s still so much we don’t know. So I think it’s important to really dig in on that. So our next question is from Mary Lou, it’s a quick elemental heal question that I think we get really often. So I thought it was important to play here.

Mary Lou:

I noticed that your elemental heal contains milk. Is it safe to use for someone who has a milk sensitivity, which was determined by IgG antibody testing and an elimination diet?

MR:

Yep. This is a great question. Yeah. We definitely see the same type of question kind of over and over, and I’m happy to keep answering these types of questions because it just shows me how pervasive the messaging is in the field that sucks people into not listening to your body, not listening to these kinds of clinical end points and rather getting swept up in the testing. So this is another good example of how a little bit of scientific looking information can actually lead you to make a decision that is not in your best interest. So regarding Elemental Heal containing milk. Yes, it does contain “milk”. It is also lactose and casein free, which makes a massive difference because most people who are intolerant to dairy, it may not technically be over 50%, but certainly a sizable proportion of people who have problems with dairy actually have problems with the lactose.

MR:

So as it says on the label it is lactose free. It has also casein free. So this greatly diminishes the likelihood that someone will have a problem with Elemental Heal who has a problem with milk or with dairy. It doesn’t guarantee, but it greatly reduces likelihood. We also do have a whey protein or a dairy free version of Elemental Heal, but I would recommend, because the regular version of Elemental Heal is less expensive, that people start with the traditional or the regular formula. Again, because if you have a problem with milk, then you shouldn’t conflate milk and Elemental Heal as the same thing. Milk is certainly not lactose and casein free. So you may want to try the regular formula. If you do have reaction to that, you may want to try the way free formula. Regarding the IgG testing. This is something I talked about in Healthy Gut, Healthy You. There is some evidence showing that food allergy testing can help people identify the foods that don’t work for them. However, when you look at the main findings that are yielded from food allergy testing, they tend to be the first foods that one eliminates on your standard elimination/reintroduction diet. Foods such as wheat, dairy, soy, perhaps shellfish, or nuts, these are some of the most common kinds of flagged foods. You could get the same amount of data regarding food allergies for free that may cost you $1000 -$2,000, depending on the depth of the array of the food allergy test. I wouldn’t recommend doing the testing. More so, the fact that there are other mechanisms that may cause intolerance to food that do not show up on tests like histamine or FODMAP strengthens the rationale for not relying on these tests as an exclusive guiding evidence for your diet.

MR:

In this case, it comes back to this seemingly less scientific, but much more clinically accurate method of listening to your body. So with the first question, you’re changing variables like probiotics and listening to your body or listening to your symptoms in this case. You’re trying Elemental Heal or diet in this case, dairy or different types of dairy and listening to your body there. Because the food allergy testing may not provide you everything that you need to adjudicate if a food works for you, or if it doesn’t work for you. Also remember that there is clinical trial evidence showing that probiotics have shown the ability to improve dairy tolerance in those who are lactose intolerant. What a travesty it would be if you were avoiding dairy forever because you had this one test two years ago, yet you were one of the people who could tolerate dairy again after using a probiotic.

MR:

Now, is that a guarantee? No. Should you placebo yourself in to thinking that if you have a problem with dairy but you take probiotics, you’ll be bulletproof? No. But what you should do is objectively run an experiment to see if using a probiotic improves your dairy tolerance. What may be happening there? Well, we know that the microvilli, the ends of the villi of the intestine secrete the enzymes that are needed to break down dairy. So likely what happens is as a probiotic helps improve gut health and presumably with healing of the gut lining, the section of the intestine that releases the enzymes to break down the lactose gets repaired and voila you are able to tolerate lactose again because of the healing that occurred thus potentially negating the results of the food allergy test from two years ago. So for all these reasons, I would start with just trying the traditional or regular Elemental Heal and see how it goes. If you tolerate it, great, if not, you can try whey free. Remember that probiotics can help with dairy tolerance and that food allergy testing is not the end all and be all for determining if a food works for you. Incorporate that data, but always make your chief gauge how you react to that food.

ER:

All right. I think if I would have heard that three minute answer that you just provided about four years ago, it would have saved me, I don’t know, like $8,000 and like testing and trying a lot of different things out. All the while it was histamine issues, which is what you discovered. It didn’t matter how many tests I took, how many foods I eliminated because I kept ending up right in the same spot. So you’re exactly right. There’s not, there’s not a test out there for everything. And man, was that a long road that I didn’t have to go down?

MR:

Yeah. Thank you for sharing Erin. And you know, it’s just so important to keep reiterating this because it’s so sad to me when people spend years and thousands of dollars testing, thinking that the tests hold the answers. This is a problem endemic to functional natural integrative medicine. Giving the tests far more weight than they should have. They do have a role, but firstly, as we’ve discussed, many of the tests are somewhat bogus. Also many of the tests require interpretation in the context of the individual. Unfortunately the field uses many tests that are not valid, but also looks at even some of the more validated tests, like a SIBO breath test as to be interpreted as the be all, end all. Instead of, as I say, about one fourth of the information that we need to make a decision. Then really interpreting the test results in the context of the patient, their symptoms, their response to treatment, their history and their onset. You’re a great example of that and yeah, hopefully as we continue to kind of go through these questions in the podcast, it will really help people from not going down that road.

ER:

Yeah. For whatever it’s worth, the Elemental Heal, Mary Lou, if you’re listening, if you have chronic, like I do, cause the histamine levels come and go, now I know what to do. So I use my Elemental Heal every morning for breakfast. That helps me start my day in with a good baseline. I don’t over do it with histamines. So I can start my day feeling well and then see how I feel from there and monitor things, try this or that in terms of what foods I’m going to eat that day. But starting my day with that has been really helpful. Then if I feel like I’m in histamine overload because of whatever I ate while I was out and about for a few days, I just go like two days on Elemental Heal and I feel like I’m right back at baseline. So it’s really helpful to use as a tool if you have some chronic things going on too, at least in terms of my experience.

MR:

Great. I love the way you’re using that. Just to piggyback upon that concept, everyone has different variables that they need to have controlled to run at optimal. I think sometimes perhaps when someone hears that they may think “Oh my God, you’ve got to do this and that”. Well, no, not necessarily. The analogy I always parallel is some kind of musculoskeletal injury. If you had a really bad ankle sprain or knee sprain in college you may need to, every once in a while, revisit those strengthening or stretching exercises because your knee is now aching because you’ve been sitting a lot and you haven’t been moving enough. Someone wouldn’t necessarily feel like, Oh my God, I’ve got this thing. They would just do what they needed to to return their knee to proper functioning. Unfortunately, with internal issues, like in the gut, we have more of a tendency to internalize them and get more emotionally involved in them.

MR:

We should start looking at these things a little differently. We’ve all had some knocks, no one grew up, likely anyway, in the perfect environment. So there’s a little bit of residual that’s gonna stay with you. That is your system. Some people need eight hours of sleep. Some people can thrive on six. Some people can’t eat a lot of carbs. Some people can have any kind of carb intake and be fine. Some people can take a lot of exercise. Other people need a certain threshold underneath which they have to stay or they start to kind of overreach and crash. So I just want to try to reframe these things so that people don’t think of them as pathological or abnormal. Rather, you understanding your system. So you can manipulate the variables for the beautiful machine that is you. So that you can run it.

ER:

Yeah. For me, I love the taste of Elemental Heal. So it’s not a downer for me to go to that at all. I look forward to it every morning cause it’s way easier than making breakfast.

MR:

Sure. Yeah. And a lot of people do morning smoothies. So this is really just a different iteration of that.

Iron Infusions for Low Ferritin

ER:

Okay. Our next question is from Christine, she wants to know, how do you feel about iron infusions for correcting low ferritin? Is that harmful to the liver if gut health is already compromised?

MR:

Great question. I have not really looked into all the nuances behind the pros and cons of iron infusion. My thinking is the best way to determine if that’s something that you should do, would be through the process of elimination. So if you’ve gone through an extensive kind of gut health optimization plan, whether it’s Healthy Gut, Healthy You or working with a clinician, and you’ve gotten your gut health as far along as you can. You’ve checked in with your conventional doctor and looked for other risk factors, chronic bleeds or issues like that. If you’re a menstruating woman, if you have very, very heavy periods then it’s possible that getting your hormones balanced, so your bleeding isn’t so heavy may also help with that. But once you’ve gotten all these kind of preliminary factors addressed, and you’re using iron supplementation, if you haven’t been able to get the ferritin up, it seems like you are now in the best position to use the infusions because you’ve exhausted all the other alternatives.

MR:

It’s almost like someone saying, well, I’ve had chronic IBS, I’ve tried two probiotics and it hasn’t worked. Should I do an FMT (fecal microbial transplant)? Probably not. That’s probably going to an endphase therapeutic before you’ve exhausted all the other alternatives in between. So I’d offer you the same thinking here in terms of how to sequence it into your hierarchy, but in terms of what are the pros and the cons, I haven’t looked deep enough into that body of literature to be able to give you a specific answer.

SponsoredResources:

Let’s talk about one of my favorite tests for digestive health, the GI-MAP from Diagnostic Solutions, who has helped to make this podcast possible. Now if you’ve been reading any of the case studies that I’ve published in the Future of Functional Medicine Review clinical newsletter, you’ve likely seen that this test, the GI-MAP, is a test I frequently use in my practice. Why? Well, one of my favorite things about this test is it has excellent insurance coverage. So this is a few hundred dollars that I save patients. This lab is also CLIA certified, which is essentially the quality assurance bureau for labs. So it’s important that these labs are being monitored, not cutting any corners. That’s where you get your CLIA certification. Now, this test uses quantitative PCR technology. So it’s a DNA test. And you’ll get a good read on dysbiosis with this test because they will assess and report out various types of bacteria, yeast, and parasites including protozoa, worms, and amoeba. They also have some valuable and helpful clinical markers like calprotectin which can help rule in or out inflammatory bowel disease, and zonulin, a marker of leaky gut. So head over to DiagnosticSolutionsLab.com to learn more and to order your test.

MR:

So it’s a bit lengthier of question, but I thought it would be something interesting to try. So this next question is from Jessica, she’s actually a practitioner asking a question on behalf of a patient. That she’s trying to help out. We haven’t done too many of these before. So I’m curious to hear back from the audience, if you like these types of questions and hearing this type of thing.

Ongoing Symptoms Post – SIBO Resolution

Jessica:

Hi, Dr. Ruscio, this is Jessica. Big fan of your show. Always take away useful information after each and every one of your sessions. Keep up the great work. My question is regarding a SIBO patient that is now SIBO free based on several subsequent tests. They were methane dominant, did the elemental diet followed by an immediate SIBO test, which confirmed that the overgrowth was reduced significantly to levels that were undetectable. For all intents and purposes, no longer SIBO. That was then followed by the herbals for specifically methane dominant SIBO. During this period of time, we were following a low FODMAP diet and continued that low FODMAP diet for about a year. Upon wanting to reintroduce some of the higher FODMAP foods we noticed a return of some of the symptoms, the main one being loose stool. This was the main symptom in addition to bloating when the client was methane dominant, SIBO confirmed. So we retested and the test showed us that in fact, the methane dominance was still gone as was the hydrogen. So that was not the issue. The issue must be the reintroduction of these specific FODMAP foods. So I’m curious in your experience, do you have a timeline to expect a particular client to be able to come back to full enjoyment of the higher FODMAP vegetables? That’s really their concern right now. They want to get more vegetables in. They feel like they’ve eaten enough salad, kale and chard to last a lifetime and they really want to get back into having brussel sprouts, broccoli, cauliflower, basically the cruciferous vegetables and the ones that tend to be problematic for them.

Jessica:

We have dabbled a little bit with something like the fast track diet and also the bi-phasic diet from Dr. Nirala Jacobi, basically limiting the amount, but still having them there. They do seem to do okay with that. But it’s fairly new that we’ve started this approach and it’s just really hard to only have one or two spears of asparagus at a meal. So just curious what your thoughts would be on how long this will persist and if in fact you think the healing of the small intestine in the villi can actually get back to what it was prior to SIBO. This particular client had SIBO for probably three and a half years, undiagnosed. So they just put it off and didn’t get tested until they had it for three and a half years. Then it was about a year that it took to get rid of it between elemental diets and herbals, two rounds of both. So just would like your feedback on this and what your thoughts are. Thanks so much.

MR:

Okay, good question. A lot there to unpack, very much in theme though, the answer that is with much of what we’ve already kind of laid out there. So, SIBO patient, I’m assuming this was a breath test that was used, they had methane dominant SIBO, elemental heal cleared it. Then they went on herbals, she said for methane, but I’m assuming what she meant was the elemental diet cleared the methane. Then when they retested it and they noticed the clearing of the methane, there was some residual hydrogen, which is why they want on a course of herbals because I’m assuming the test wasn’t fully clear. If the test was fully cleared, why would you go on herbals if you’re using kind of the “testing to guide treatment” model? So again in recap, SIBO positive with both hydrogen and methane, but it was predominantly methane. The elemental diet cleared the methane, but there were still some residual hydrogen.

MR:

So herbal antimicrobials were used for the hydrogen and upon another retest, they were both cleared. But down the road upon FODMAP reintroduction, this person had some bumpy waters or had some reactions. So the short answer here is you could be missing opportunities to further heal the person’s gut because you’re only treating the tests. So there could be other symptoms present that may be able to be further remedied by, as an example, probiotics. Are those being used? Enzymes. We know that some of these patients who have chronic issues may have extra pancreatic insufficiency, they may have a hydrochloric acid insufficiency. They may have another type of dysbiosis. These cases are exactly why I am not a fan of serial retesting for SIBO, because this is only looking at a fraction of what we know happens in the gut.

MR:

As an example, SIFO could still be a problem or some other type of bacterial dysbiosis, potentially hydrogen sulfide. So even though FODMAP reintroduction isn’t reported to flare SIFO, perhaps it’s flaring hydrogen sulfide. So the more important point is to not limit the way you’re treating this individual’s gut to the testing. This is in theme with a philosophy we’ve been trying to impart through this podcast, there are a litany of other supports or imbalances in that gut that may need to be explored in order to help this individual. This is why, in the clinic, I use a hierarchy based treatment model. Based upon their history, their symptoms, their onset, their presentation, and their response to ongoing treatment at the clinic I navigate them through this therapeutic hierarchy that I create for them. The gut is more complicated and certainly getting someone’s gut ecosystem back to balance and thriving requires more than treating one test result.

MR:

That’s likely the primary problem here. So this is someone who potentially probiotics could help mitigate their food reactivity. HCL could. Enzymes could. Maybe they needed to do some time on immunoglobulin therapy. Perhaps elemental dieting in a somewhat cyclical or hybrid fashion, kind of like you’re doing Erin, could help. So there are an array of things that need to be personalized to this individual. So the good news is you’ve gotten rid of SIBO. So that’s one validated measure that we can look to. So that is good. I’m not trying to discount that, but there are many other things that can also be done to enhance their gut health that you can and should still do even though the SIBO breath test is normal. This is one of the main reasons why I’m a little bit tenuous with how heavily some look to a SIBO breath test. It is helpful. It is valid. It is a good measure. It’s not perfect, it’s been criticized, but it certainly has validation behind it. But we don’t want to fall into the hubris of thinking that because we have one valid test that that one valid test tells us everything that’s going on in a person’s gut. So in this case, there’s likely more you can do for this person’s GI. You’ve got to start thinking a little bit outside of the testing box and more about what therapeutics we know can heal the gut, apply those in a personalized fashion, and you should be able to get this person to a better tolerance.

Effect of Imodium on Migrating Motor Complex (MMC)

ER:

Awesome. Well, thanks for tackling that practitioner question. So our next question is from Mike, he wants to know does Imodium or Loperamide cause problems for MMC. Does it stop or slow the cleaning of your gut? A look seems to indicate no, but I’m not the best at interpreting the findings that I found.

MR:

Good question. I know we’ve discussed in the past that there was a study finding that Imodium could reduce leaky gut. I don’t know what the research shows regarding motility. Although the way I look at motility is more through the lens whether a given intervention is improving one’s symptoms and presumably their gut health, because usually symptoms are a good indicator of their gut health. One of the things that Allison Seibecker and I discussed recently is that part of what may lead to problems with the MMC or with motility is chronic low level dysbiosis and perhaps the inflammation that ensues secondarily to that. We’ve discussed on the podcast, years ago now, my hypothesis based upon some of the mechanistic findings that inflammation retards the ability of the interstitial cells of Cajal to repair and to regenerate. This is why I’ve always been a real advocate of trying to establish the healthiest, most asymptomatic and presumably most anti-inflammatory state in the gut. It seems that if we can achieve that, and if you’re not inflamed, you’re also likely addressing any dysbiosis. Because dysbiosis and inflammation go hand in hand. We know inflammation skews the milieu, making the gut more prone to dysbiosis. This is where there is a paucity of data so all we can really do is just draw inferences. The logic here is that if lubiprostone or Imodium leads to a reduction of inflammation, and we discussed that evidence has found that it produces a leaky gut – leaky gut and inflammation can be used somewhat interchangeably, although not exclusively – but if Imodium reduces leaky gut and the inflammation that likely accompanies that, then that should help also with inflammation and with dysbiosis, allowing the ICC cells that dictate motility to heal. This allows the resurrection of motility. So that’s the way I look at this. If you’re finding that Imodium is helpful for you, that’s fine to use in the here and now.

MR:

I would also look for other more reparative options. If you’re not using the 3 for BALANCE probiotic protocol or potentially Elemental Heal, these other things that synergize, continue to do that and to create the personalized plan for your gut and Imodium can definitely be part of that. I’d focus firstly on trying to reduce your symptoms as much as you can and holding and maintaining that state, at least in my inferential opinion, can lead to an improvement of motility over time. Hopefully that helps. I don’t have any reservations about using Imodium. As long as again, you’re using it as part of this larger plan with the eventual goal of finding the minimum effective dose of everything, including things like probiotics and the broadest diet. So hopefully that helps. Likely it could help with motility. Again, I don’t know if that has specifically been demonstrated, but I think there’s a fairly logical inferential, kind of “connect the dots” scenario that we can go through to get there.

“Worms” in the Stool

ER:

Yeah, I think that makes a lot of sense. All right. So I think we have time for one more question. This is from Emily.

Emily:

Hi Dr. Ruscio. My name is Emily. I had a quick question regarding digestion. I think for the past probably year and a half, two years, I’ve been eliminating what at first I thought were worms. Kind of like long mucus-like strings and I wasn’t really sure what to do about it. I’ve had kind of a history of a lot of stress. Overactive sympathetic system post consuming grains and dairy, which I’ve been intolerant to for quite a while. So I have stopped those. I have also been kind of underweight and malnourished for a little while too. I know that contributes to the GI tract? So I wasn’t sure if, you know, using your book and all the protocols in that would resolve this mysterious worm-like issue or if there is something else I should be looking at functionally or anything like that, anything you have to say, I would greatly appreciate it. Have a good day.

MR:

The old worm in the stool question, which surfaces every once in a while, and it is a little bit of a clinical quagmire. So the short answer to your question is yes, I would absolutely continue through the plan in Healthy Gut, Healthy You because irrespective of if this is or is not a worm, we’re looking at restoration of the healthiest gut ecology with the plan in Healthy Gut, Healthy You. That is likely going to put you in the best possible position, so as to have the best possible health. Again, because the plan in Healthy Gut, Healthy You is very personalized to the individual. Now, to the question of worms, this is a challenging one because there have been a handful of cases in which patients were convinced that they had worms. In every instance, when we’ve attempted to identify those worms via stool testing, either the patient hasn’t wanted to, which almost makes me wonder if there’s some sort, in these patients in particular, some sort of fear of discovering that there actually aren’t worms there causing them to subconsciously not want to take that thing that is not a worm out of the stool, put it in a vial and send it to the lab. Because the buy-in from those patients has been about zero. There are other patients who’ve done just general stool tests and not taking the worm-like object out of the stool or out of the toilet and put it into a vial. I haven’t been able in one of those cases to be able to correlate that to a worm. Said more simply, we haven’t been seen worms come back positive in those cases. Now we do see some worms come back positive, via stool testing, but they’re quite rare. I’m also a little bit wary of some of the kind of specialty labs outside of the country that essentially find a parasite in everyone that is tested because that just doesn’t jive with the stats.

MR:

So if every person is coming back positive, I’m open if there is good evidence demonstrating that it is accurate, but I’m also quite circumspect and suspicious. I should also say, we should look at this against the backdrop of worm eradication campaigns in the US were quite successful. As someone who spent five or six years of my career doing overlapping stool tests on pretty much every patient, and these were your progressive, functional medicine stool tests looking at antibodies for some worms or antigen recognition for others. They are quite rare. So it does correlate with the public health data showing that eradication campaigns for worms in the US have been vastly successful. Now, does that mean that everyone is worm free? No, because there are still worms in the environment. There are people who travel from in and outside of the country themselves, or people who handle your food, who travel from in and outside the country or food itself that goes from inside and out of the country through areas that may have not undergone a public health campaign to de-worm the population.

MR:

So it is possible. My suspicion is that in the vast majority of these cases, you’re actually seeing you mucosal shreds or mucus shreds from the lining of the gut and not actually a worm. Now, does that demonstrably change the way that we treat an individual? Probably not. And I say probably not because we know that these anti-microbials can be helpful for worms. In the Healthy Gut, Health You plan, step three is the anti-microbials. Within step three, there’s kind of a step three A, step three B and step three C, hence kind of like the personalized nature of the plan in Healthy Gut, Healthy Gut. The “three B” so to speak, is repeat treatment with herbal microbials plus high dose artemisinin and a pulsed one week on two weeks off, one week on dosing regimen, which is supposed to be quite effective for worms. I say supposed to be, because I don’t know that the one week on two weeks off, one week on has been robustly demonstrated to be better for worm eradication, but at least that’s the theory.

MR:

Plus we know that artemisinin in high dose is a derivative of wormwood is effective for warmer medication, but it’s also anti-inflammatory. So if these people are having these mucosal shreds slough off, which I believe is one thing that IBD patients are also more inclined to see as a byproduct of the inflammation that presents in IBD, then why someone who reports these worms or worm-like shreds in the stool couldn’t improve from the artemisinin could be due to the antiworm nature of the artemisinin or due to the anti-inflammatory nature of the artemisinin. Also remember, that in some centers like William Parker over at Duke, who has been on the podcast, they are putting worms back into people because they are finding, and the data here are definitely mixed, and I don’t want to overstate this case by any measure, but they are finding that worms may be commensal and anti-inflammatory.

MR:

So if we look at this through the lens of the recommendation in Healthy Gut, Healthy You of not micromanaging an ecosystem, the objective here may not be, potentially full worm eradication. I mean, some of the nuance here does matter, but let’s say you’ve gone through stool testing, there’s no highly pathogenic worm and you’re kind of not sure what’s going on. Well, another way of framing this could be, it may not be about strict worm medication or strict H. pylori eradication, but rather making the ecosystem of your gut as healthy as possible so there’s harmony amongst these various players. That’s a little bit harder to justify with worms because there’s much less data here. Although we do know that in most third world countries, people do have worms and they seem to be fairly healthy. I should say more so in hunter gatherer societies, not third world, cause there are some third world places that are, are quite unhealthy.

MR:

In hunter gatherer populations being colonized by worms is quite common and they seem to be in very robust health. Although that’s confounded by a number of things like living in the dirt, constant contact with animals and this immune training and much better circadian and sleep health. So we can’t point just to the worms and say, Oh, it’s all because of that. But it does partially make the point that worms, like many other things may not be exclusively deleterious to your gut health. So the endeavor may more so be about making your gut as healthy as possible for which Healthy Gut, Healthy You lays out an action plan for how to use diets, probiotics, to get there. Also remember that there are other inputs that encourage your gut health towards optimal such as sleep, stress, time in nature, exercise, which are also important inputs.

MR:

As an example, we know that sleep or being sedentary will lead to a reduction of diversity in your microbiota. That diversity probably needs to be at a certain healthy level to co-manage if there is a worm, keeping that in check to some extent. So all that to kind of say, continue forward with the protocol in Healthy Gut, Healthy You. Continue to make sure to listen to your body. I wouldn’t overly stress about what’s going on in the stool. I would definitely do at least one visit your local primary care and/or GI, at the same time you do one visit with a functional medicine doctor, although be careful with the functional medicine doctors that they don’t take you down this rabbit hole of incessant testing and treatment of the testing because oftentimes the Healthy Gut, Healthy You protocol actually works better than that. Sorry for my colleagues, I don’t mean to disparage the field.

MR:

But until it gets on better footing with not over testing, that’s going to be a valid criticism. I would make sure to have a healthcare provider weigh in just to be on the safe side. As long as there’s no overt findings there. And again, be very careful with the narrative you get from natural providers, because it’s so easy to fall over that event horizon into ridiculousness. But as long as nothing major flags there, then just keep going through the Healthy Gut, Healthy You protocol and you should see that abate as your system gets healthier. Whether it was a worm and you’ve changed the environment to make that worm now a happy player and the group of commensals, or it was mucus shreds due to inflammation, that is less important. Again, as long as you have a checkup and what’s more important is focusing on getting your gut milieu as healthy as possible.

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, 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.

ER:

Well, I think that’s all we have time for this week

MR:

Boy long answers today. Either I drank too much caffeine or these are just deeper questions or maybe both.

ER:

I mean we had a couple of questions that we don’t get too often. Like I don’t think we get a worm question very often. So I think it’s good that we dove in on that. And the elemental heal question I think, as I said comes up a lot. So that dairy question, you know, it’s good to revisit that. So I think it’s good.

Shining a Light on Functional Medicine

MR:

Good. Well, yeah. Thank you, Erin. And thank you also for sharing your story. You legitimize some of the criticisms that I make of the field because you actually were an example of that yourself. And so, you know, it’s important for those in the audience who haven’t ever utilized this type of healthcare to understand that these things happen fairly often. It’s not just me, looking at 3% of the field and actively criticizing them and making it look like it’s endemic when it’s not. Unfortunately these things are fairly prevalent. So I appreciate you sharing your experience.

ER:

Yeah. It’s not just my experience either. I mediated a Facebook page for someone who had a SIBO Facebook page and they just needed someone who had experience with SIBO to just sort of mediate and make sure there wasn’t anything crazy on there. It’s not that I’m ever giving advice, but I’m happy to share my story or what works for me, but certainly not medical advice. I would say 90% of the people that I was watching in conversations day in and day out, and what you speak about in terms of the functional medicine experience, I’m grateful for functional medicine because Googling functional medicine is how I found you, but this generalized experience of over-testing or completely relying on the test or people getting all their emotions and hopes and dreams caught up on tests. I saw on a daily basis and there were several hundred people in this Facebook community. It was just very common and kind of sad and depressing. After a while I kind of had to step away from it because I was like, this is just getting depressing. I don’t think anything is moving in the right direction here. So for me, I hear those stories playing back in my memory. And also that exact thing happened to me. So I’m happy to validate that.

MR:

Well thank you. Something for the audience I’ve been thinking more and more about is, I’m starting to see progressively how some people really scoff at natural and alternative medicine. It makes me sad on the one hand, but validated as well. The things that I criticize, imagine that coming from someone outside of the community. Let’s say Harvard is thinking about having someone from Harvard medical rub shoulders with someone in the integrative and alternative camp. They’re thinking about rolling out a new facet of it for functional medicine. Depending on who they talk to, that person at this major institution that could really help to bring the important and accurate part of the field to the public, could be shut down if that person still had many of these things in their care model that were inaccurate, overzealous, superfluous, what have you. So I see where those criticisms come from, and I’m really hoping that the listenership of the podcast is appreciating that it’s not me trying to knock down the field, but rather really call attention to it. As I said before, if you want to permeate more into a lay audience and have this movement become more broadly accepted, we have to get our house in order. That can’t be a situation where we tell patients “if you want to do functional medicine, it’s three to $5,000 of lab tests to get started”. First of all, that’s not accurate. Secondly, that is hellacious wasteful, but thirdly, and I think something I’ve become more appreciative of over the past year or two is the emotional damage this does the people, I think makes it tantamount to medical malpractice.

MR:

Every time you run a test and every time you have this positive finding or negative finding, depending on what direction the test points, everything attached to that most people tend to internalize and they will be having a flare and then on their phone Googling symptoms of MTHFR, or can adrenal fatigue cause depression. You’re gonna find stuff that reinforces the worst possible case scenario that you’re thinking. This is going to further ingrain you into this despair and “there’s something wrong with me” mentality. I’m sorry if I’m being long winded here, but I guess that’s in line with today’s theme. But why that’s so devastating is that it doesn’t help the individual. Now, if someone has progressed type two diabetes, and you’re telling them “you’ve got to cut back on XYZ in your diet”. Sure. A little bit of fear there is good. Looking up how many grams of carbs are in a Wendy’s big gulp. Yeah, that is good. Feeling a little bit of fear when they realize that there are 120 grams of carbs or whatever it is. That would be an example of when this could be used perhaps the right way. But like the case that we discussed a few weeks ago, the gentleman who was I believe he was 62 or 64, going to Asia quarterly in generally good health and just wanted to try to preempt some of the wear and tear on his body from that travel. When he had to undergo $2,300- $2,400 worth of lab testing, was told he had adrenal fatigue, he couldn’t drink coffee, had to pop handfuls of supplements. Now this poor guy got put through the wringer and got no better. This is the kind of stuff that has to be excised on the field. It really, really hurts people. So I guess all this to kind of say, and I’m just saying how a lot of criticism lately, but it’s because of these things are very common.

MR:

If we really want to help people, we’ve got to clean these things up. We can still help people, I would argue even more, If we do less testing. It’s just getting the providers to go out on that limb of faith of you can actually fix people without having a test to support every decision that you make. I think we’ve really been crippled and handicapped by testing because now natural providers went from the one extreme, never doing any testing, you know, way back in the day to now feeling like they have to justify almost everything they do with the lab marker. Understandably so, but you know, if those labs aren’t accurate, we end up in this whole mess that we’re currently in. So again, sorry if I’m being a little bit preachy on this podcast, but it’s going to take providers and patients alike all proclaiming and aiming for a better standard.

MR:

So the doctors and the clinicians have to reeducate the patients and the patients have to start calling out the providers in a polite, supportive way, who are trying to lead them into the success of model and, or find someone who’s not going to make them a party to that excessive model. So it’s going to be a team effort on all of our parts, but if we do it right, 5-10 years from now, functional medicine and natural medicine, whatever you want to call, it could be much more widely endorsed. But again, we’ve got to get our house in order first.

ER:

Yeah. I think you’re right about consumers or patients being just as responsible for that and not demanding tests because I was in a position where I was demanding tests. I had been to three or four different gastroenterologists that basically just put cameras all throughout me, and did MRIs. I swallowed a camera at one point none of that did anything. So when I did find a functional medicine doctor before I found you, I was at that point just hell-bent on “I want to test, I want to know what is wrong with me” because no one could figure it out and I know I’m not crazy. So it’s also just about the patient and the consumer having trust and hopefully having trust in who you’re working with. And if they say, look, we don’t have, we don’t necessarily need a test to go forward with this kind of a program, then just trust them and try it.

Episode Wrap-Up

MR:

Yep. Agreed. I’m hoping that the podcast really helps to reeducate patients so that they don’t go into the doctor’s office, just like you said Erin, saying, well, I need all these tests. I think a lot of this, unfortunately, has come from patients being miseducated probably because there’s been too much influence by supplement companies and lab companies. So it’s not the patients fault. They don’t know. They’re just trying to get better. So they’re listening to podcasts and reading and whatever. Then the doctors are trying to help their patients. The poor doctors on the one side, the patients are coming in now pre-educated to demand these tests. Then on the other end, their CE credits are being progressively manipulated by this problem on the other end. So, you know, the poor clinicians are probably getting it really from both sides.

MR:

But you know, again, hopefully this, this podcast functions as, as a partial ray of light for people. At the clinic now I’ve hired a couple of doctors and I’ll be training more over time. So the offering at the clinic has been broadened. So I offer that to people if they need help and/or hopefully this helps the clinician have a way of balancing them out on one side. And then for the patients, there’ll be more empathetic to the clinician who may be wanting to use a mitigated testing model. Because patients do come in and they will say, I’ll do anything to get better. I’ll say back to them, I understand. But it doesn’t mean we’ve got to spend a bunch of money, like I’m with you. I will do anything to get you better, but it doesn’t mean I have to run every test I have account with get you better. I think that’s a key thing also to keep in mind.

ER:

And you have a new health coach on board too, right?

MR:

Yeah. We also have health coaching too. So if people need help, this is one thing now that many of the other things that I’ve been working on with the website and everything else are bit less in need of all my time. I’ve been really putting much more of my attention back to the clinic and expanding the clinical offering so that people who need help can get it because, you know there’s a lot of need out there and I’m trying to just do the best I can with servicing as much of this need as I can.

ER:

There’s only one you Dr. Ruscio. Well, this has a great episode today and we’ll talk next time. Send in your questions.

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