Today we will cover listener questions, including…
Protocol suggestions for redundant colon
IBS – Smart test
SIBO and the ileocecal valve
SIBO and histamine.
Dr. Michael Ruscio, DC: Hey everyone, welcome back to Dr. Ruscio Radio. This is Dr. Ruscio. I’m here again with Erin Ryan and we’re going to be fielding questions from you. Let’s see what kind of questions we have today.
Erin Ryan: Today we have kind of a mixed bag. Our first question is from Dee. She asks, “Do you have any diet, lifestyle, or protocol suggestions for people with redundant colon?”
Suggestions for Redundant Colon
DrMR: Redundant colon, for lack of a more medical definition, essentially means that you have a kind of a twisty, turny colon that may make it more prone to having inflection points where stool is slowed or can get stuck. While it is something that, anatomically, is a little bit outside of the norm, I wouldn’t say it means anything is wrong or broken, just that some people have different lengths or curvatures in their intestinal tract or different sized stomachs. While these can be a bit outside the norm, it doesn’t necessarily mean that it will create a problem.
In this case, there may be a part of the colon that is more prone to stuff getting slowed down or temporarily stuck. You sometimes see this in patients who have scleroderma, which is a condition where connective tissue can over grow and can impede on the intestines. There’s not really great “treatment” for either one of these situations, meaning there’s no one treatment that can be done that leads to a lasting resolution. However, that doesn’t mean that there aren’t simple things one can do as upkeep to reduce symptoms. We oftentimes use a musculoskeletal injury analogy, so I’ll keep with that theme. Consider an athlete who may have blown out their ACL in college. Even after having surgery by the best surgeon, they may never be able to return to exactly the same function as before the injury, and may need to periodically perform stabilization exercises or stretches to keep the knee functional and devoid of pain.
Same thing can happen when you have anatomical abnormalities in your intestinal tract or if you have some type of scar tissue or other issue present that impedes the tube of your intestines and creates points where fecal material or the food stuff in the intestines slows down. One of the reasons why this slowdown can be problematic is that you can over growths of bacteria and fungus as well as fermentation of the food stuff, and that can lead to gas and pain.
Many of the treatments that we discuss in the podcast and the book can be used in this type of application. For the strongest intervention, someone could periodically spend a few days on our elemental heal meal replacement shakes or really any kind of elemental diet (a liquid meal replacement that is easily digestable). Theoretically what happens here is that you have this point where potentially scar tissue is impeding the intestines or there’s this redundant colon, a series of sharp turns where the material in the colon may get slowed down. A short period on exclusive liquid nutrition would allow everything to kind of clear out of the intestines and allow your system to have a reset, so to speak.
Probiotics may also be helpful. In this case, if you’re having these recurrent over growths due to slowing points, then probiotics may facilitate moving food through the intestines, because probiotics can help to stimulate motility, or movement. Also, probiotics can be antimicrobial. So if there is a bacterial or fungal overgrowth, probiotics can help with that. Another option is a water fast which, in many ways, achieves the same thing as an elemental diet. The challenging thing about a water fast is…. it’s a water fast, and doing that for more than a day can be challenging for many people.
So my favorite recommendation for this type of general situation and the many nuanced similar types of situations would be to consider the elemental diet to help allow the system a chance to kind of flush out any hard food particles by allowing a period of liquid only nutrition so that everything can move its way out of the intestinal tract. This acts as a reset to the intestinal tract. Remember, with elemental diets, you have flexibility. You don’t have to use them for two weeks as in the SIBO study or even use them exclusively. Recently I did a modified process, fasting for two days per week, alternating between elemental heal and the master’s cleanse solution all day just depending on what I was in the mood for, and then I’d have one meal at night. This was after some vacation and travel time where I felt like I probably ate too much and didn’t get enough sleep. I felt like my gut needed a little bit of a break, but I didn’t feel like I needed to go all the way to the extreme of doing a full on four-day elemental diet reset. I followed this for two week and for me, it was a huge win. It really got me back on track quickly. As someone with a redundant colon, you can experiment with that application or you could go a few days exclusively and try that application. This can be a way to get the system to reset and everything flowing through more smoothly.
The IBS Smart Test and Treatment Approach
ER: Our next question is from Mike. He asks, “Have you used the ibs-smart test in your practice? If so, what if anything has changed in how you treat patients based on the results?”
DrMR: The ibs-smart test is the newest iteration of the testing for anti-CdtB antibodies and anti-vinculin antibodies, usually acquired after food poisoning. Oftentimes a bout of food poisoning or traveler’s diarrhea is over within a couple of days to a week, but digestive symptoms such as gas, bloating or abdominal pain last beyond that. This is known as post-infectious IBS, or irritable bowel syndrome.
The ibs-smart test is a way of testing for what can be an autoimmune condition in the gut that was started from food poisoning. This is exciting because it may tell us where some cases of IBS come from. This test has validity only for those who have diarrheal type IBS. If you have constipation type IBS, this test has not been validated and this test has not been shown to be positive in that population. When we take a group of controls and a group with constipation type IBS, the amount this test flags positive is the same, so it’s not diagnostic in constipation type IBS. It is diagnostic for mixed and diarrheal type IBS. That is important to understand.
Now to the question, “Am I using the ibs-smart?” We have had the inventor of the test, Dr. Mark Pimentel on the podcast in the past. Currently I am using this test in select cases. I’m not using it in constipation patients unless they absolutely want to run the test in which case I am willing to humor them as it is not an expensive test. But only in mixed or diarrheal patients. How I’m using it is to predict if we want to be extra liberal with our use of antimicrobials after we’ve gone through eradication therapy.
Is there any evidence showing that a positive ibs-smart test tells you that you should be using prokinetic therapy? No. What is prokinetic therapy? Often times when we treat small intestinal bacterial overgrowth, after we’ve “killed it” with antimicrobials, antibiotics, and elemental diets, a prokinetic will be used to help keep food moving through the intestines so we don’t see that slow down like we talked about with the redundant colon which allows bacteria to over grow. This has become a practice in the SIBO community as a result of one or two studies showing that people will remain in remission if they use prokinetics after being given antimicrobial therapy. There is no data showing that the ibs-smart test predicts that. Hopefully that will be published. I think it’s really debatable right now.
My general take on the ibs-smart test is that it is interesting, it has great utility if a clinician is trying to figure out whether diarrhea is from inflammatory bowel disease or from IBS. That’s where the test really shines. In terms of how it actually helps a clinician guide the process with a SIBO patient, it’s debatable right now. Some would have you believe that it must be used and those patients will require strong prokinetic therapy. I don’t necessarily agree with that. Again, there’s no data here to answer this question, but I do think the importance of motility and treatment with prokinetics has been vastly overstated by the SIBO community.
In answer to your question, I am running it in patients. I’m trying to see if it correlates with patients who either are more severe cases or do better on prokinetic therapy, but there’s no evidence that shows that just yet. If you’re trying to piece together how to improve your gut health, I would not recommend the ibs-smart test as a key indicator in that process. However, if you’re someone who has diarrhea and you’re trying to figure out if you have IBS or inflammatory bowel disease, then this test makes a ton of sense, especially if you have a family history of inflammatory bowel disease, Crohn’s, colitis, lymphocytic colitis, or microscopic colitis because it could help you more quickly come to a diagnosis. I do feel that the test is being overused in the SIBO community, although it is certainly an exciting test and I think Dr. Pimentel has done a fantastic job of advancing the science to this point. Now we need more data to clarify exactly how to use it in clinical practice.
ER: Is the ibs-smart test something that you can ask for from a traditional gastroenterologist or is this mainly used by the integrative/functional medicine community?
DrMR: There is an attempt to get this test more broadly dispersed into the conventional system. This is because that’s where it really has the highest level of applicability, with gastroenterologists who are trying to determine, “Is this diarrheal patient IBS or IBD?” There’s less functional and integrative practitioners who are trying to make those differentiations. Oftentimes, someone already has a diagnosis when they’re trying to get a second opinion with an alternative doctor.
You can certainly ask your gastroenterologist. There’s decent literature here to support this test, so in my mind an open minded gastroenterologist would at least give it a look as there is validated published evidence in the gastroenterology journals showing this test has utility. It will be hit or miss whether or not different doctors, gastroenterologists, are actually using those.
It is important to note, this test is not something that can be requested from Quest or LabCorp, the conventional big box labs. Quest at one point was offering this test, but I believe they were in violation of some of the patents behind that test and they had to stop offering it. The ibs-smart is a kit that you would take down to a local lab center that is connected with ibs-smart in order to run the markers and draw the blood.
ER: All right, our next question is from Laura. It’s about acid blockers. This is going to be an audio question, so here we go.
Acid Blocking Therapy
Laura: Hi, Dr. Ruscio, my name is Laura. I’m 35 years old, I’ve been suffering with gut issues for the past year, which came on quite suddenly. Initially, it was treated with short term antibiotics for five days and acid blockers, Zantac and Nexium. As soon as I took the acid blockers, I started getting a burning sensation above my navel which seems to get aggravated with chicken, beef, and coconut oil. I haven’t been able to get rid of it completely. Some weeks I don’t have it at all and some weeks it’s quite bad. I’d love to hear your thoughts as to what you think it may be. I had colonoscopy/gastroscopy, which came up significant gastritis … I definitely have low stomach acid and am hesitant to supplement with HCL considering the burning sensation. My other symptoms are low pancreatic enzymes and malabsorption and undigested food in stool. Initially, I lost a lot of weight, but I gained it back since supplementing with enzymes … I had SIBO, which came up negative and uBiome test as well. I’d love to hear your thoughts and love your podcast. Thanks, bye.
DrMR: This patient is not alone in being put on acid blocking therapy quite quickly. There is a time and a place for various acid blocking therapy like Zantac and Nexium, but it’s only in a short term application. Usually one to two months you can see a fairly impressive ability to heal ulcers using acid blocking therapy. This is where the therapy has merit. However, it’s when we then go into a long term application for symptom management that this becomes problematic.
Gastroenterologists are using this, in part, because they’re trying to prevent a larger problem down the road known as Barrett’s esophagus, which can lead to potentially cancerous changes in the tissue in the throat from chronic reflux. So it’s not to say that the gastroenterologists have bad intentions, they’re thinking about a short term loss (potentially lower stomach acid, which can lead to lower bone mineral density and may increase the risk of bacterial overgrowth) for a long term win of preventing Barrett’s esophagus. Barrett’s esophagus is caused by changes in the throat tissue as a result of continued exposure to acid. The throat tissue isn’t meant to handle acid, and thus scar tissue develops. This scarring of the tissue can lead to dysplasia or changes in tissue growth, which can in some cases be cancerous. So that’s part of the reason why the gastroenterologists are using the acid blocking medications.
It’s interesting to hear that those caused burning in your case, which tells us that the mechanism may not only be that acid is high, there may be another problem underlying that that has not yet been addressed. One of the things that we know can flare reflux is food allergies. There’s an impressive amount of research showing either a 4-, 6-, or 8- food elimination diet can help with a similar condition known as eosinophilic esophagitis. There are a number of trials showing that just basic removal of offending foods (for example: wheat, dairy, spicy foods, alcohol, ibuprofen or non-steroidal anti-inflammatories) can improve reflux. I believe there’s been at least one study showing that a low FODMAP diet can improve reflux. We know that IBS and reflux tend to be interconnected, so you’re more prone to have reflux if you have IBS.
It comes down to food being a trigger. Those foods can vary from person to person. In this case, it sounds like you’ve already identified that chicken, beef, and coconut cause you to flare. So what you may want to do is take some time away from chicken, beef, and coconut and then reintroduce them later on. You may notice that just by eliminating and avoiding triggers for a period, you regain the ability to tolerate those. It’s no surprise that gastritis was found on your endoscopy, meaning inflammation of the lining of the stomach. So first, you want to avoid your food triggers. That doesn’t mean you have to avoid them forever, but if it is something that’s irritating your system, it’s hard for the system to heal and then tolerate that thing if you’re actively consuming what it is that’s irritating your system. It’s just like if you had a sprained ankle and you kept running on it, it would never heal. If I said to you, “Well, in this case, take some time away from those foods,” and you went, “Ah, but I don’t want to avoid those foods forever,” it’s just like saying that if someone tells you to stop running on your ankle because you sprained it, “Well, I don’t want to stop running forever.” It does not have to be a permanent change, just a short term intervention for a longer term healing gain.
So start there with the avoidance of those foods. If you haven’t tried a more thorough elimination diet, like a paleo diet, that cuts out gluten, dairy, soy, processed foods, alcohol, caffeine, spicy foods and other typical foods that are known to propagate reflux, that would be a great place to start. Give that a bit of time. I outline this basic elimination diet in Healthy Gut, Healthy You. If that doesn’t help consider a trial on a low FODMAP diet. That may help you significantly improve by remedying the food triggers. That will also help the gastritis.
Our gut rebuild nutrients powder, contains a mixture of things like glutamine, aloe, slippery elm that can help to repair the lining of the stomach which may be something to consider. Digestive enzymes will likely be quite helpful in your case if you have diagnosed pancreatic insufficiency and if you’re seeing fat in your stool.
So along with the diet, which could be more a traditional elimination or it could be low FODMAP – you’ll have to do some experimentation to figure that out – plus some nutrient support for the lining of your stomach or gut rebuild nutrients, plus an enzyme. That’s going to make a big difference. Now with the enzyme, you want to look for a pancreatic enzyme and include bile in that, especially if you have fat in your stool. You want to avoid an enzyme that has hydrochloric acid as it is not recommended for people with gastritis. Its really not that complicated. Elimination diet plus or minus low FODMAP plus a gut healing nutrient support cocktail that has glutamine, aloe, slippery elm, and a few others, plus an enzyme. I would also recommend using a probiotic, because if you have some over growth as a byproduct of this situation or if your gut is a little bit leaky, probiotics can also help reduce the leakiness in the gut, calm down the immune system, and get to another part of the root cause of this whole cascade of food reactivity that you’re experiencing.
If this sounds familiar, that is because this is exactly the trajectory you would follow if you read Healthy Gut, Healthy You and follow the steps. Or if you’re really busy, do our gut quiz and it will give you a personalized quick start guide. That can be viewed at drruscio.com/gutquiz. This constellation of symptoms is something I see quite often in the clinic, and shouldn’t be hard to fix. It responds very well to the number of steps I outlined just now and those are organized for you either in Healthy Gut, Healthy You or in the quick start guide.
I would advise you to follow those steps. There is a very high probability that you’ll be able to see your reflux and food reactivity clear and not need any long term acid lowering medication. It’s really great news that you’re willing to take steps, because you’re the type of person that won’t need to have your symptoms managed by a medication like Nexium and you can actually make some changes to treat the underlying cause. I’m confident that you will be on your way to being reflux free in only a matter of weeks, or worse case scenario, a couple months.
ER: I’m really glad that you gave a quick look at why the long term therapy is sometimes given to people, because I’ve always had a chip on my shoulder about that. I remember in high school I was given Nexium and Zantac for acid reflux. It was almost definitely my diet because I was a high schooler, but I couldn’t understand why they would just put me on a medication and expect me to take it the rest of my life. No one has ever explained it to me like that and I have carried a chip on my shoulder about it, so it really helps to understand the motivation of the more traditional gastroenterologists in their treatment approach.
DrMR: I do think it’s important that we all keep in mind that many medical doctors are in a tough situation, especially depending on the patient population that they serve. I think we kind of forget about it, because we live in this bubble where people are really proactive about their health. There’s a large percentage of the population that are unwilling to make even the most basic dietary changes, and so all you can really do is try to manage their disease process. So in this case, what is the bigger thing you’re trying to overcome? It’s potentially protect against what could be precancerous or cancerous changes in the throat or run a risk of reduced bone mineral density and increased risk of bacterial overgrowth. It’s a tough calculus to make, but the point is that oftentimes the conventional method of a doctor in a very conventional practice, is based on the population that they treat and their willingness to actively participate in their care. Sadly, sometimes it comes down to “Well, what pill can we give you if you’re unwilling to make any other changes?”
ER: Yeah, that’s a shame for them, because they don’t get to be very creative, it sounds like.
DrMR: I don’t envy being in that position. I feel so grateful the patients we have in the clinic are just wonderful. They are willing to really take recommendations and act on them. Sometimes when I talk to friends of mine who are in a more conventional medicine setting, it’s such a breath of fresh air and I kind of have a chance to appreciate it from a different perspective. A commendation to everyone listening to this or reading this that it’s amazing how fun it can be to be a clinician when your patients actually listen to your advice. So thank you everyone for listening.
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The Heidelberg Test
ER: Our next question is from David. He wants to know, “What are your thoughts on the Heidelberg test?”
DrMR: It’s funny that he asks this because I’ve recently had the opportunity to learn more about this test. The Heidelberg test is able to quantify your level of stomach acid.
I believe the test is accurate and is validated, although I have not done a firsthand check of the evidence supporting that test. It’s a little bit expensive and a little bit invasive. I don’t routinely recommend using the test, because you can usually get a fairly decent read on if someone needs to supplement with acid if you first focus on their diet and also cleaning up any imbalances in their gut.
Change the diet, that can cause reflux. Get rid of things like SIBO or Candida, those may flare reflux. Then the person should have little to no symptoms, but they may have this reflux that’s still there or other digestive symptoms. Now that you’ve addressed the diet variable, and likely remedied any imbalances in fungi and bacteria by using probiotics, you have a more definitive opportunity to run an experiment with supplemental hydrochloric acid and see if symptoms improve. You have to get rid of some of the noise through diet first. Diet and probiotics are a really good place to start. Usually after doing that, you see a number of symptoms drop off. Then you can form a trial with hydrochloric acid, usually two to three weeks is long enough to get a good read. Here are some symptoms that may be more prone to improve using hydrochloric acid: bloating, feeling of prolonged fullness, food particles in stool, and reflux. Those may improve after using acid supplementation for a few weeks. There may not be this huge need to use stomach acid.
Also, and I write about this in Healthy Gut, Healthy You, if you have a history of anemia, an autoimmune condition or are over age 65, the probability that you may need stomach acid increases. Then go through a few steps to quiet the noise of symptoms and get rid of as many symptoms as possible with diet and with probiotics. Then try an experimental period of 2-3 weeks on supplemental acid. Look for either an improvement in your symptoms, no change at all, or if you feel worse. Then that can help you determine if you need to use supplemental acid in the long term.
The Heidelberg test can be a little bit pricey and a little bit invasive, so I try to do this with more of an empiric experimentation methodology. I hope one day we have easier to administer tests that will tell us if someone needs stomach acid, but for right now, I’d rather do it through trial and error.
Philly: Hi, Dr. Ruscio. This is Philly from Florida. About ten years ago, my ileocecal valve was removed during a hemicolectomy for cecal volvulus. I suffer from some SIBO and was just diagnosed with a hiatal hernia and Barrett’s esophagus, even though I have a great diet. I’m just wondering if you can comment on how I can best address the SIBO when the situation is compounded by not having an ileocecal valve. Thank you.
DrMR: Barrett’s esophagus is what we were just talking about in terms of chronic reflux that can start to damage the throat tissue and lead to these dysplastic changes or changes of the tissue that can lead to Barrett’s esophagus. So in this case, the ileocecal valve has been removed. This is the valve that separates the small intestine from the large intestine. The IC valve is oftentimes portrayed as being this hugely impactful point where the small intestine meets the large intestine for intestinal health and preventing SIBO, but I don’t think we can fully say that from an evidence based perspective. There’s debate in terms of how important this valve is. There is some evidence in both directions, but, to the best of my memory, there have been studies showing no increased incidence of small intestinal bacterial overgrowth in people who have had their ileocecal valve removed.
So what do you do if you are suffering with Barrett’s esophagus and you have SIBO? Well, in your case, the same rules really apply that apply to anybody else, meaning the same things that we would do for SIBO we would do for your case. Now, that could involve probiotics, that could involve diet, that could involve antimicrobials, that could involve elemental dieting.
The one change that may occur in your case considers the possibility that your lack of IC valve is creating problems. You may be more prone to relapse. That’s where potentially prokinetic therapy could have some benefit for you. So this is using various natural or pharmaceutical prokinetic agents that can help keep the food moving downward and prevent it from refluxing back upward into the small intestine and causing SIBO. As Dr. Richard McCallum shared when he came on the podcast recently, there is some question now if many SIBO cases occur via that mechanism, or if maybe more of these SIBO cases are top down, meaning that bacteria from the mouth make their way into the small intestine and cause a bacterial overgrowth, which shoots a hole in the importance of the ileocecal valve, because, remember, that valve is seen to be the gate that prevents colonic bacteria from refluxing up into the small intestine and causing SIBO.
This is why I have a moderate stance on some of these things, because there’s evidence that we can argue against the importance of the IC valve or the ileocecal valve in SIBO. So maybe a prokinetic would help you. While debatable, it’s certainly worth a shot.
However, if you’re someone who seems to have recurring IBS symptoms or recurring SIBO, you may just need to undergo repeat rounds of treatment. I know that sounds like an unsavory recommendation, however, if you had to do four days of elemental heal and maybe you had one small meal on each one of those days, and you had to do that once a month, and that kept you feeling good and prevented you from having a regression, wouldn’t that be worth it? Or using our three probiotics and finding the minimal effective dose, is that the worst path in the world? Or maybe using two pearls of our Oregano Biota-Clear 1a each day to help prevent this overgrowth from recurring, is that the worst situation in the world to be in? No.
So again, the fact that you don’t have the ileocecal valve may or may not be a problem. Barrett’s is more of an issue. That is where going through a more robust gut healing program makes sense. This is where I would highly recommend going through the full program in Healthy Gut, Healthy You and also trying to find a way of monitoring reflux.
This could be a silent reflux, meaning you don’t even know you have it. Those cases can be more challenging, because there’s not an easy symptom. If someone has heart burn, it’s easy to be able to say, “Oh, I did X, and now I’m having heartburn,” or, “I’ve been using treatment Y and my heartburn is getting better.” If it’s a silent reflux and you have no symptoms that accompany it, it’s a little bit more challenging to gauge, but you can still go through the same healing plan laid out in Healthy Gut, Healthy You. SIBO may be an important part of that. If you have a positive SIBO breath test, that might be something that you look at more closely, because there’s no symptoms to gauge. I’ve talked about it in the podcast before that testing is only one slice of the new information to steer decision making of treatment. If you don’t have symptoms to read, then the SIBO breath test can give you an objective measure.
If you do have symptoms, I would look at your symptoms globally. Let’s say you have the silent reflux, so there’s no reflux symptoms, but you do have some bloating and constipation. Look at the bloating and constipation as your symptomatic gauges, and that will likely correlate with your silent reflux. If the bloating and constipation get worse, it’s fairly safe to assume that your silent reflux is probably getting worse. Then you can combine that with the SIBO breath test to help you figure out if you’ve treated yourself enough or if you need to treat further.
We come back to the same process of looking at your symptoms, and in this case, if symptoms can’t help you to determine if you’re doing the right treatments, look at an objective lab value like a SIBO breath test. Run through the same kind of treatment hierarchy, which would involve diet and then potentially escalating to probiotics and then potentially escalating to antimicrobials. Then you can consider elemental dieting. That will get you well on your way. Also our gut rebuild nutrients might be a good idea, because they help to repair some of the intestinal tissue, and that might be a nice adjunct to prevent and help provide some of the nutrition like glutamine and aloe which can both help to repair the lining of the gut and to soothe inflammation as part of this process of treating the root cause which the Healthy Gut, Healthy You protocol does, and then using natural vitamin supplement like gut rebuild nutrients to synergize with that and treat some of the resultant damage in the throat as a byproduct of SIBO and whatever else is driving some of the symptoms.
ER: Thanks for clarifying that. I remember when I was working on healing my SIBO on my own, the ileocecal valve sound byte was really popular in all the SIBO sites and articles and blogs that I was reading. I think one protocol that I was doing I was physically supposed to be closing my ileocecal valve several times a day. At one point I was like, “What am I doing?” It’s just funny that you’re talking about that, because I wasn’t probably doing anything to help myself except for giving myself a bruise.
DrMR: I am open to it if something credible is published there, but the only thing I think happens when people do these ileocecal valve closing maneuvers is they might be seeing some of the benefits that one sees from performing abdominal self massage or visceral therapy. Gary and Belinda Wurn have done a great job of publishing how their intensive visceral therapy at Clear Passage can help people. I’ve had some patients experiment with just simple abdominal self massage, and that seems to help potentially just through mobilizing some of the tissues that might get a little bit stuck and maybe mobilize air pockets or gas pockets. But to think that on this pliable tube that is your intestine, through all this tissue that you can close a valve is hard to wrap my head around. I’m open to it if someone documents its success, but it just seems that’s probably not what’s happening. However, you may still achieve some benefit from it, it just may not be because you’re specifically closing the valve.
ER: Okay, let’s see, I think we have time for one more question. I’ll play Amanda’s audio question about SIBO and histamine.
The Relationship Between SIBO and Histamine
Amanda: Hi, Dr. Ruscio. I suffer from hydrogen and methane SIBO and have found that I have severe issues with histamines. I have been keto for almost two years and I have been finding that I have been reacting very badly to coconut, coconut flour and olive oil, so this has lead me to think that I have a salicylate sensitivity. What would you recommend I do? I do like keto, because I like higher fat, but I just find that for keto a lot of the staples are coconut and almond flours, so I’m kind of left in the dark here. I do follow low FODMAP as well, but I just wanted to reach out and see if you could help me. Thank you.
DrMR: One of the first things that I would want to do is see if there’s a non-dietary problem that is leading to some of her food reactivity. If she’s gone all the way to keto low FODMAP and she’s histamine sensitive, then in my mind, that’s a pretty good tell that there’s something else that has not been addressed. It sounds like it could be SIBO. If she’s being as specific as saying she has hydrogen and methane positive SIBO, then in her case, she may not need to go a lot further with her diet and what may actually allow her to incorporate more foods into her diet could be successful treatment of the SIBO or any other imbalances in the gut that are occurring.
In regards to salicylate content of the diet and how beneficial a low salicylate diet is, I can’t speak to that firsthand. I really haven’t gotten far enough into salicylates to be able to say that there is a big improvement from having people go on the lower salicylate diet. I do see some patients who report this, but it tends to be the realm of patient who are so symptomatic and reactive that I would venture to guess that if I asked them again three months later, and I believe there actually has been a few cases of this, they would say “Oh, I don’t think salicylates are a problem anymore.” You do get to this point where if non-dietary problems in the gut are left unchecked long enough, one can start to have these chronic symptoms that can lead them into thinking that they have a problem with almost any food group, and because they’re going through this constant up and down pattern, if they happen to try a diet at the same time they’re going into an improvement phase, they can falsely associate certain foods as being the culprit.
I actually personally have noticed I am much less histamine sensitive when I’m doing better with everything else. One of the things I have noticed to be quite helpful for me to improve my histamine tolerance is to incorporate a bit of fasting. In fact, one of the main things I was noticing was that I was becoming more intolerant to dietary histamines. In my case, the simple intervention of two days where I was only having one meal per day led to a significant improvement in my histamine tolerability.
Now in your case, perhaps fasting would be helpful, but I also suspect that an underlying issue has not been fully addressed, so that might be SIBO. You may want to try our three probiotics taken together if you haven’t done this yet. It’s very important to delineate between taking individual probiotics versus all three at one time. There’s certainly a subset of people that when they actually take all three types of probiotics at the same time, that’s when they see a measurable jump in how they feel.
Something else you may want to consider that can help tone down the immune reactivity in your gut is immunoglobulin therapy. You may want to try our intestinal support formula as one option or try our gut rebuilt nutrients is another option. Also think about more aggressive revisitation of the SIBO treatment if you haven’t done antimicrobial therapy yet. I would certainly consider antimicrobial therapy, because that can very much help reduce the amount of food reactivity someone has. Another method of antimicrobial therapy would be elemental dieting.
A lot of this comes down to essentially the Healthy Gut, Healthy You protocol. I know it’s more attractive if I say, “If you have SIBO and salicylates, this one thing is a home run for those things.” Unfortunately, there are not that many differences from gut to gut, it’s just having this core process that I talk about in Healthy Gut, Healthy You and then going through it. You may notice some nuance in terms of you may be someone who does better on a keto diet within the realm of the Healthy Gut, Healthy You program as compared to someone else who has been on a higher carb diet. So there is nuance built into the treatment plan laid out in Healthy Gut, Healthy You, but my thinking is there’s something that’s been missed. The program should help you figure out what that is and the right treatments for it that’s causing these tightened food reactivity issues that are occurring with time. What I’m hoping will happen for you is you’ll notice your dietary tolerance to histamines and salicylates improves and maybe even you can come off keto. Not that you need to, but you may notice that you have more dietary leeway even with carbohydrates.
Start with the Healthy Gut, Healthy You program. If you’ve gone there before, revisit it, and go through it diligently, revisiting the probiotics with the enzyme and everything that’s laid out in Step Two, and then consider escalating the antimicrobials in Step Three. Then two things you may want to add in to that would either be our intestinal support formula to reduce immune system reactivity or our gut rebuild nutrients to help provide some of the nutrients needed for intestinal cell repair and regeneration. The goal is to help you get to a point where you’re less food reactive and you don’t have to worry about organizing your diet around keto, histamines and salicylate allowing you to broaden your diet and not have to be hindered by these different dietary camps you’re trying to eat within.
DrMR: Well, thank you everyone for your questions. Keep them coming. Again, thank you … in light of what I said earlier, thank you everyone who has read the book, who follows the podcast, to all of my patients. It’s just so fantastic to have people such as yourself who care enough about your health to actually do the things that allow you to not need medication, to not need surgery. I know on some days it feels hard and arduous, especially if you’re taking steps to improve your health and you feel like your health isn’t getting any better or is even getting worse. I know that is a drag, I know it’s challenging. But stick with it. We don’t always get the answers that we need right out of the gate. I suffered for six months terribly and then probably a year after that to fully get back to a point where I felt at least somewhat normal, so I know how frustrating it can be and I’m sure there are some people who are listening to this who are on year five or ten of their journey.
Thank you for caring enough about your health to take these steps. I just can’t say how important I think it is to have people like those in our audience, because we really need a healthier country. I’m sure you’ve all heard the stats about how we will eventually not be able to afford the healthcare costs of this country, because they’re just spiraling out of control. I don’t propose to have a great solution for that, but certainly one great way to stop that from snowballing is to improve our health one person at a time. Being proactive and listening to a podcast like this is an example of exactly what we need people to be doing to help stop that snowball from spiraling out of control.
I am irrelevant without you, so thank you for your readership, your patronage, and please keep the questions coming. I’ll talk to you next time.
I care about answering your questions and sharing my knowledge with you. Leave a comment or connect with me on social media asking any health question you may have and I just might incorporate it into our next listener questions podcast episode just for you!
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