Listener Questions – Smart Phone App to Fine Tune Your Diet, Iodine & Goitrogens, SIBO & H. Pylori, T3 Levels, Gluten Avoidance, and More….

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Episode Intro

Dr. Michael Ruscio: Hey, everyone. Welcome to Dr. Ruscio Radio. This is Dr. Ruscio. Let’s do some listener questions over the past several weeks.

And before we jump into listener questions, just a couple of things. I misspoke about iodine in a previous podcast. Some of our listeners were nice enough to bring that to my attention, so thank you for doing that. I should also mention that I noticed that for a few weeks, I was a little mentally slower than I normally am.

I had actually been experimenting with an antiviral protocol, and I noticed during the protocol I actually felt worse. I was a little more fatigued, and definitely a little more mentally slow. In going back and listening to some of the podcasts and some of the interviews during that time, I was more prone to some of those small misspeaks. It was interesting for me to reflect on that, where I don’t think I gained anything from it and I actually think I felt a little worse during the time, probably because of a reaction I was having to something in the protocol.

So I just bring that up to emphasize that sometimes things that are meaning to help us can actually make us feel worse. So whether you’re a patient or a provider, it’s important to keep in mind that negative reactions are an important part of the clinical process. You want to be on the lookout for those. And yes, things that we think are sometimes helping us can actually make us worse. It’s important that we’re objective and okay with the fact that something that might be incredibly healing actually may make a small subset of people sick. And just to be open to that, and to adjust accordingly if you notice that.

Book Update

The book. What the heck is going on with the book? I thought it was going to be published in March. That’s what I thought. I’m learning that there’s a lot I have to learn regarding book publishing. I think the book itself is pretty great, if I don’t say so from a biased perspective. But gosh. Long story short, I was looking into using a certain publisher, and the further I got down that road the more I learned that that was probably not going to be the right fit. And I actually learned a lot about the publishing game and some of the things that happened in the space as part of the process.

And it was definitely really irritating, getting to a point where I thought I had put some time and energy into one avenue, and then that avenue ended up not being something that looked like it was worth pursuing. And I definitely hit a point for a few weeks where I just stepped away from all book-related stuff, because I was getting to a point where I was ready to say just screw it. Because it’s many years of work of my life, and I’m not willing to just hand that over to someone willy-nilly. So when you get to the point where you think you’re almost at that point where you can partner with someone and get some help with bringing this book from 10 yards out to over the finish line, and then that ends up looking like a terrible idea the closer you get to it. It was definitely a bit defeating.

So, it looks like I will be self-publishing now, instead. Which I think will be a better fit. And if anyone listening to this is a self-publishing consultant that considers themselves to be sharp and well experienced, then please reach out. Because I’m in the process right now of vetting some self-publishing consultants, and I could definitely use one, need one, and so feel free to reach out or send recommendations if you have any.

I also wanted to apologize for the Glenn Taylor interview. Glenn Taylor is the gentleman in the UK who does the fecal microbiota transplants. And if you heard a bunch of this {sniffs} during that interview it was because me, like an idiot, thought I was on mute. And I was just getting over a cold, and so I was sniffling and using these menthol cough drops and doing some deep breathing and deep sniffles to try to keep myself from not getting congested and sounding all nasally. And I’m not sure what happened. I don’t know if the mute button wasn’t working on my microphone that day, or if I was just completely out of it. But I really thought I was on mute. And poor Glenn Taylor must have thought I was just totally disinterested or just really rude. So I apologize for that.

I also bought a, you can’t hear it, but I bought a silent mouse. My old mouse, you can really hear it clicking, and so as I’m going through my notes trying to look at what questions I want to ask next, or taking notes for you guys and I’m clicking around, you can hear it in the background, it’s kind of annoying. So I bought a shush mouse that does not have any click sounds. So hopefully that will help a little bit with the quality.

New Phone Device for Digestion

All right, let’s jump into some of the questions. Jodi Iochi asks, “Have you seen this? Just curious to hear your thoughts on this new device.” It’s at www.foodmarble.com. And what this is is essentially, from what I see from a brief examination, essentially it’s a home breath test unit that plugs into a smart phone and can help you personalize your diet to avoid carbs that you may have an intolerance to.

So essentially, this takes breath testing for fructose and lactose intolerance, and it compats it with a home device and a smart phone to allow you to predict if you need to avoid certain carbs that are high in fructose or high in lactose, and that may help you with the FODMAP diet or personalization of the FODMAP diet, or just personalization of your diet in general, to avoid carbohydrate malabsorption or carbohydrate intolerance.

Definitely seems interesting. There’s a couple of things that I would comment on this. One, if someone is having IBS-like symptoms, according to the North American breath testing consensus, which we reviewed in a recent podcast, it’s a good idea to test for SIBO first before testing for fructose and lactose malabsorption because SIBO can give you a false positive on these tests. So I’m definitely open to this test. I like the potential utility of it, helping people to personalize their diet. And because it doesn’t require someone going back to a doctor’s office and paying an office visit fee and paying repeat testing fees, and is hopefully making this economical—I don’t know how much the device costs, but assuming this isn’t something that’s very expensive—then I like the utility of potentially helping people to personalize their diet.

That being said, some things that may be good to do before jumping into this home testing and monitoring from www.foodmarble.com would be, again, looking into SIBO. Testing for SIBO, treating for SIBO, and then getting that under wraps. Also, we do know that when people avoid FODMAPs, they can later reintroduce them with more tolerance. So repeat testing may not be highly necessary. And we know that when people’s intestines heal, the brush border enzymes, the tips of the villi, secrete lactose-digesting enzymes as lactase, and people with lactose tolerance can improve as their gut heals. So if you do some of the foundational work correctly, you may not need this device, but it may be helpful. If you’re someone that really loves all this quantified self-type stuff, and you enjoy this, I’d say go ahead. If you’re someone that feels daunted by this, I would not say you’re going to need this to become healthier.

Blending vs. Juicing

Next question; “Dr. Ruscio, I really enjoy your podcast and appreciate your straightforward and open way of discussing these issues. May I pose a question/topic suggestion for the podcast, please? I saw you were juicing a few months ago; 80% veg, 20% fruit. But mainly because of the time to clean it down, etc. And being uneasy about throwing away all the fiber.” Let me just summarize this because it gets a bit wordy.

So essentially, she’s asking, she started juicing because she thought it would be a little easier to juice. But instead of juicing, she switched over to just blending her vegetables, because she was concerned that she was going to be throwing out all the fiber when she juiced. So instead of juicing, which removes the fiber, she just blended vegetables. She’s wondering, can you still get the same health benefits?

And here’s where her question kind of comes down to. “My question is, do you think your intestines are typically capable of extracting maximum nutrient value from a blender-made solution or do you believe the only way to get the maximum nutritional value is to consume them after they’ve been juiced?”

So this is a good question. The more damaged someone’s intestines are, the harder it may be to absorb nutrients as a general rule. So juicing can be a way of making the nutrient a little bit more accessible. And it’s not in my opinion that the fiber blocks the nutrients from being absorbed per se, but fiber can irritate the intestines, and then it can cause these reactions sometimes, known as a peristaltic rush, where the intestines just push food through quickly, because the food is irritating. And when that happens, of course, you’re not going to have good absorption because things are moving through at too rapid of a transit.

So because fiber can be a little bit irritating, and if someone has compromised intestinal health to begin with, fiber can exacerbate an already irritated gut. That may not do any favors for absorption. So I see some plausibility to juicing when people don’t have good intestinal health. And this is kind of what we see with some of the elemental diet formulas. There is no fiber, and all the nutrients are somewhat predigested to make it easier to absorb and digest. So yeah, I think there is some utility in this for those with compromised gastrointestinal health. The healthier one gets, then the less of an issue this should be.

So juicing, I think, could have some more utility for those with compromised gut health. And then as their health improves, you can expand and hopefully not need to rely on juicing. The other side of juicing is the sugars. Because you remove fiber, you will accelerate the ease of which these carbohydrates can absorb through the intestinal tract, which can be helpful in some cases if you have really impaired absorption. But that can also turn or just make more ready available all the carbohydrate in what you’re juicing, and there’s no fiber to kind of slow it down. So you have to be careful with juicing, because you can run the risk of over consuming carbohydrates. And that may be problematic, especially if you’re someone who doesn’t tend to process carbs well. Meaning, you have a predilection metabolically to things like diabetes and prediabetes.

So with juicing, I’m definitely open to it. There may be some applications where people need a lot of nutrient density to help with healing, and/or have compromised intestinal health. So this is a way of making the nutrients available in fruits and vegetables a little bit easier on the intestines, because there’s lower fiber content.

So I’m certainly open to it, don’t have strong feelings, pro or con, juicing. Or pro or anti juicing. But I would say as you get healthier, try to move to a more natural diet that doesn’t require lots of juicing, because I think the less adulterated foods are, probably the better it will be for you in the long-term.

Goitrogenic Foods & Hypothyroidism

Next question. “What is the effect of goitrogenic foods on subclinical hypothyroidism? You covered goitrogenic foods with respect to thyroid autoimmunity in your last podcast, but what about the run-of-the-mill variety? How much of a decreasing effect does cooking have? How relevant is it with the scope of iodine sufficiency? And how much iodine classifies as sufficient? Vicky.”

Ok. So I don’t think that goitrogens are very relevant in my opinion. There’s a few reasons why I say this. Iodine sufficiency is pretty common. Iodine insufficiency is pretty rare. So firstly, we should just get on the same page with that. Now, some may say that they’ve heard, and there are a few very strong iodine advocates who recommend the iodine excretion test.

And essentially the iodine excretion test is, you take a bolus of iodine before collecting urine, and then you monitor how much iodine is excreted in the urine. But, when looking into this test, it became pretty apparent that this test has not been validated. And the values that are used were essentially created by the gentleman who put together the test.

So it was kind of done arbitrarily, meaning there wasn’t scientific consensus on this. There wasn’t clinical consensus on this. There was one, maybe two gentlemen who were, I think, really pro-iodine advocates, and they wanted a different sort of test, and what I’m thinking they thought was a better test. But the challenge I have with that is, it’s not been used or validated in the scientific literature, and the testing that has been used in the scientific literature, which is usually either a spot urine or a 24-hour urine analysis, does not document iodine sufficiency in most westernized countries.

So iodine deficiency I don’t think is very common. So I don’t think we have to be very concerned about goitrogenic foods, which are foods that block iodine absorption. Now, if you live in an area with documented iodine insufficiency, it would probably just be easier to add some iodized salt to your diet than it would to try to eat a diet devoid of goitrogens. Especially when you consider a lot of these are fairly healthy vegetables.

So again, I think the goitrogenic piece is interesting, but it’s only interesting when you’re looking at thyroid health through the perspective of ‘we all need more iodine.’ Therefore, don’t eat the goitrogenic foods that block iodine absorption, because iodine is so important. When you have a bit more of a contemporary view on iodine, and you realize that most are iodine sufficient, and the greater risk is actually overconsumption of iodine, and that has been overwhelmingly correlated to Hashimoto’s thyroiditis, then you see the potential lure or draw of an iodine restriction diet fade away, because you don’t really need to be worried about lowering the iodine content of your diet. Or, I’m sorry, you don’t need to be worried about maximizing the iodine content of your diet.

So, I don’t think it’s very relevant for all those reasons. I believe cooking does decrease the goitrogenicity of certain foods, but I haven’t fact checked that. So that may not stand up to scientific scrutiny. It may just be a theory that kind of gained some legs on the internet. And in terms of dietary intake, 450 mcg, make sure I get this right this time, of iodine seems to be potentially the sweet spot where you don’t run the risk of frank iodine insufficiency but you also don’t run the risk of potentially provocating Hashimoto’s.

And we did a whole review of the literature on this, and I go into the whole rationale of 450 in that review, if you type iodine in the search box you’ll see this episode come up from, gosh, now maybe almost 2 years ago. And I wouldn’t go much above 1100 to 1200 mcg a day from a dietary intake perspective. Because remember that too low of iodine intake and too high of iodine intake can cause some of the same problems. So in short, I’m not really concerned about goitrogens at all, from an iodine perspective.

H Pylori & SIBO Symptoms

This comes from, I believe Angela, unless we got the name wrong. “It was about the study that correlates H. pylori and SIBO, and says that SIBO can occur after eradication/treatment of H. pylori. Is this something worth exploring? I treated my H. pylori infection a little less than a year before my SIBO symptoms started. I’m wondering if treating my H. pylori brought on my SIBO issues. I had no symptoms and wonder if the infection was somehow protective in my body. Certainly a topic that I think many of your readers would love to hear more about.”

Ok. So essentially, wanting to know more about the SIBO/H. pylori connection. And this was, again, I believe this was from Angela. So, Angela, it’s possible that the antibiotic treatment for the H. pylori is what provocates the SIBO. Certainly, antibiotics can create dysbiosis, and potentially create bacterial dysbiosis. So it could be that the antibiotics were the reason for the SIBO increasing after H. pylori treatment. Perhaps it’s the acid lowering medications that are used as part of the H. pylori treatment. But this is a little more speculative, because usually the treatment for H. pylori is a couple of weeks, so being on an acid lowering medication for a couple of weeks, even a month or so, probably not enough to cause a measurable impact in the risk of SIBO.

And also, perhaps either SIBO or H. pylori indicates someone has a non-robust immune response in the intestines. It doesn’t mean that’s a bad thing, but we know, for example, people with celiac may have a lower incidence of gastrointestinal infections, because they may be prone to have a stronger immune response in the gut. So people with SIBO and H. pylori may be the opposite. They may genetically have a softer or a less strong immune response in the gut, leaving them more prone to both of these infections.

So people with genetics that are prone toward potentially celiac and maybe even IBD may be shown to have less gut infections, because of a strong immune response in the gut. And then what this may be showing is that the SIBO and the H. pylori, perhaps they’re not driving one another specifically, but they both are indicators of an immune system that generally does not have a very robust response. So these people are more prone to infections in general.

We have a lot of research about H. pylori, and a lot of research about SIBO, so maybe we’re seeing the associations because they’re two of the infections/imbalances in the gut we know the most about. Perhaps if we did another study looking at the incidence of SIFO, then we would see small intestinal fungal overgrowth was also increased in prevalence if the cause is not one of these imbalances driving the other, but rather these all are more prone to occur when someone does not have a very strong immune system response in the gut. And that may not be a bad thing. That may decrease your chances of gut autoimmunity, but it may also increase your chance of gut infection. So, I’m speculating a little bit there, but that’s kind of what I think.

Here’s a question actually from me, for the audience. I had someone who is a member of our Future of Functional Medicine Review monthly clinical newsletter ask if we would be able to put out a simple summary version of the research studies that could be used as sort of a monthly patient education pamphlet or handout or what have you. I would be willing to have that put together if a lot of people thought that would be beneficial.

So if you’re subscribed to our Future of Functional Medicine Review, and you’re getting the monthly newsletter, and you’d like to have the research section which contains 3-5 research study summaries, if you’d like to have a PDF handout available that was converted into layperson language that you could use for your patients or your clients as like a monthly handout, an educational handout, I would be willing to do that if there were a lot of people that expressed interest. So if you do, just let us know in the comment section or on Facebook or what have you. And if enough people chime in on that, then that’s something I’ll take action on.

Free T3 Testing

This comes from Regina. And she’s asking, “With how important essentially hormones are, why do I think so many practitioners do not test for the metabolically active form of thyroid hormone? I.e. free T3, and/or dismiss low levels of free T3?” Good question, Regina. I see both sides of this argument. So I think there’s a few practical takeaways from this question. Which is, why don’t some providers agree with testing or looking at T3? I think an easy way to evaluate the utility of T3 would just be a trial of a T3 containing hormone.

So in some of the studies that have shown, that have done comparative evaluations of if patients prefer a T4 only medication, like levothyroxine; or a combination like Nature-Throid of T4 and T3. They haven’t used pre-lab values, lab values to dictate who they give what to. They just simply tried a different medication. And what they’ve shown in one study in particular was about 48% of the patients preferred a T4/T3 combination, whereas only 18% preferred a T4 only prescription.

So we may not need to make it that complicated, where we may just want to try someone on a combination formula and see how they do. That may be a good way to start. You can get more precise with this when you start separating out the T4 from the T3, and you give someone levothyroxine and you also give them cytomel. That’s another approach, but it may not be that complicated. Looking at some of these studies, simply giving them a combination formula with a fixed ratio yielded pretty nice results for some, and for others it didn’t. So that’s one thing. And bringing this back to the most practical method of assessment or use.

Some data does suggest that those in the upper half of the reference range for T3 do feel better. So again, you could use testing to help guide that, and I would be open to that. But there’s not a lot of data there, so I see why some are a bit more apprehensive about that. It’s not something that I think has been very robustly studied. And there are risks of T3, most namely would be the symptoms of overdose. Some patients will feel worse on T3. I think it’s really important to actually understand that. And if you’re going on message boards, and reading the confirmation bias reaffirming lore on how great T3 is, you’re probably not going to hear much about how some people go on T3, either T3 added onto their levothyroxine or a T4/T3 combination formula like Westhroid, and they feel worse. They feel jittery, they have a hard time sleeping. They may even feel more fatigued. It’s not to say that T3 is this miracle cure-all. There are risks. There are those that do not tolerate T3.

Now, the question is in my mind, what is causing a lower T3? And I think if we did some additional studies on this, we could break it down into two groups. Those who respond well to the addition of T3, and those who do not respond well to the addition of T3. And those who respond well, I would guess are just genetically kind of sluggish converters, and they could use a bit of additional support, for those that respond well.

For those that do not respond well, my guess would be they have some sort of issue impairing their conversion. Like a gut infection, or stress, or what have you. And they’re not responding because the issue is not needing more hormone, the issue is needing to address the underlying imbalance that’s driving potentially the low fraction of T3. So I would say, try one or two T4/T3 formulas, and if after some tinkering with your dose you don’t feel well, look into something that might be driving a lack of responsiveness.

And in more direct answer to your question, “why don’t more people prescribe to the T3 theory?” I think because there’s not robust data there. There is some data, but if you’re super-data driven and if maybe you’re evidence based, but evidence limited, then you may not be comfortable stepping outside of that box. So I can see where that comes from, but I don’t agree with it.

Hypertension & Gluten

From Susan Mitchell. “I have Hashimoto’s thyroiditis, and I would like your opinion with how strict to be with gluten? I’m not sure who else to ask. One doc says don’t worry about a small amount. Another says a trace amount ruins everything. Enterolab says strict and permanent avoidance. It doesn’t seem to bother me, though. But when I suddenly ate a bunch in preparation for gluten testing, I got nerve pain on my face and a headache. It was short lived, and I’m not sure if gluten was a culprit, as I kept eating gluten for a few weeks and did not have any other symptoms.”

So I think there are a few important takeaways for this. I would avoid gluten to the level that you notice you have reactions to it. And this is simple, but I think it’s profound. Because in my opinion, allergies are not like a light switch. They’re not either on or off. There’s a gradient of tolerance.

And I spoke about this, and I talk about this in the book also briefly. We could look at this spectrum; the most severe would be celiac disease. Then not as severe would be celiac-light, which is this new clinical entity that’s not quite celiac, but looks like celiac upon further testing. Then there could be non-celiac gluten sensitive, and then there could be no reaction at all.

So there’s a spectrum of intolerance, and therefore there’s going to be a spectrum of reactivity. And I think it’s a pretty reasonable statement to say you should avoid a food in correspondence with your level of reactivity. So if you’re not sure, do some experimentation and see if you can figure out what your level of reactivity is, and then avoid in correspondence with that.

Now, the argument to this oftentimes is: what if someone has this smoldering autoimmunity underneath the surface that causes no symptoms, and antibodies are the only way to assess? The antibody problems could be raging for years before it produces any kind of appreciable symptoms.

I don’t know if I agree with that, because in my experience, the worse someone’s reaction to a food is, the worse they’re going to feel. It’s not to say someone who has a raging thyroid autoimmune response to gluten can have gluten, fuel that raging response, and feel no different. Because it’s not all about their thyroid hormone levels. The activity of Hashimoto’s thyroid autoimmunity has been shown to correlate with psychological wellbeing.

So we could draw, I think, a pretty reasonable inference that while, yes, it may take years of unchecked autoimmunity to cause overt hypothyroidism, in the short-term, acutely if someone is feeling a strong autoimmune reaction to gluten, there are likely going to be some other types of symptoms that someone sees. And this may be an acute change in how someone feels in terms of their mood, which has been documented. And those things don’t necessarily take years to manifest. Because some of these inflammatory cytokines can very quickly change brain chemistry and how one is feeling.

So, simple things like your energy, your mental clarity, your mood, your joints, your sleep. And I would definitely change my opinion on this should there be new data or better data to counter this, but I think it’s pretty reasonable to say that if you’re going to have an appreciable immune reaction to a food, there would be some type of symptom that you could correlate to that. So I don’t buy into the, “you’re going to provoke autoimmunity that’s silent and underneath the surface and you won’t know about it for years and years until you’ve accrued significant damage in the gland.” Because I think there will be other indicators that this does not work well for you that will show up almost immediately, and you won’t need to wait until a full-blown autoimmune organ level dysfunction is present.

Now, to be objective. You could run the antibodies that are well-established that correlate with your disease. I’d be wary of some of these non-validated antibodies or experimental antibodies, and I’d look at, for example, TPO. TPO antibodies have been pretty well indicated to correlate with Hashimoto’s, and be predictive of Hashimoto’s. Thyroglobulin, not so much. So even something like thyroglobulin that we have a lot of data on, we’re not seeing maybe a great predictor. But then you get even further out of the box with some of these other antibodies that are newer and interesting, but may not really be highly validated in terms of clinical meaning, then I think you have to be careful.

But look at your TPO, and be gluten-free for a few months, and run your TPO a few times. See if you can get a general sense of where your TPO generally is. Maybe you oscillate between 175 and 325. Ok, so once you have that pattern established, then spend a month having gluten, whatever you think you’d like to do. Maybe you’d like to have gluten once a week. Maybe you want to have gluten twice a week.

But run the experiment of having gluten at whatever frequency that you would feel good about in terms of it would satisfy whatever it is you’re looking to do, and then retest your antibodies. And unless you see a substantial spike in your antibodies, then I don’t think you necessarily need to worry about it. Again, I could be wrong. There’s more here to learn. But I think that’s a pretty reasonable way of approaching this.

High Fiber vs Supplemental Fiber

Ok. So, I’m going to shift over now to some cue card questions. I was at the NANP, National Association of Nutritional Professionals, a week ago, and I lectured there. And we got a bunch of questions via cue cards, and I didn’t have time to answer them all. So I thought I’d answer these kind of rapid-fire here.

“Fiber studies using diet with high fiber, or supplemental fiber, nonfood.” So I guess they’re asking what do the studies show using high fiber diets compared to supplemental fiber? And I go into a lot of detail about this in the book. Essentially, neither show tremendous benefit. You can find an equivalent number of studies showing that high fiber diets are helpful as you can find a number of studies showing that high fiber diets have no positive impact on health. I think that’s really important to mention.

And same thing for supplemental fiber, although supplemental fiber probably shows less benefit. And because of that, it makes me a little more cautious with supplemental fiber. And the population that probably does best with supplemental fiber are those with constipation. And those who should be at most caution with supplemental fiber are those with more diarrheal-type IBS, and potentially those with IBD, because diarrhea is another main symptom of IBD.

Probiotics Supplements

“With prebiotics, would you recommend pill form versus whole food sources for the reintroduction phase?” I would always recommend reintroducing with foods first. Because you want to get people on foods before you want to get people on pills. You could make the argument that you could be more precise with the dosing of prebiotics in terms of the dose and the type, yes.

But there are other, of course, important compounds in foods that are more important to obtain than just getting the prebiotic that you would get in a capsule. So I would always recommend starting with food, reintroducing with foods before you do prebiotic supplements. Because there are many other positive and healthy compounds in foods that are high in prebiotics, besides the prebiotics themselves.

Issues with Swallowing

“Have you treated anyone with swallowing problems? Suggestions for treatment?” I’m assuming when they say swallowing problems, they mean that people feel like they get things stuck in their throat. There are a couple of things here. So swallowing problems could be eosinophilic esophagitis, where people feel like things get stuck in their throat.

And it’s actually not that something is getting stuck in your throat in this case, but you have this immune response in the throat, and these immune cells are causing some esophagitis, some irritation in the esophagus that feels like something is stuck there.

So the best treatment for eosinophilic esophagitis is avoidance of food allergies. And there have been pretty compelling studies done using 6-food elimination diets, or 8-food elimination diets, which look very much like the paleo and autoimmune paleo diet. And also using elemental diets. So reducing the offender, the immune offender in this case, can be very important. So that’s eosinophilic esophagitis.

There is also—if someone has thyroid autoimmunity, and if they’re having some swelling in the thyroid gland, then that can cause the feeling of pressure on the throat and a hard time swallowing. So that could be another cause of issues with swallowing. And the treatment there, of course, is going to be to manage the thyroid autoimmunity and try to dampen the swelling as much as possible. And sometimes what may be called for here is a TSH suppressive dose of thyroid medication. At least in the short-term. So there are definitely some options there for that, yes.

And then thirdly, someone could have an esophageal stricture, which is essentially inflammation in the esophagus which can form kind of this scab, I guess you could say, or this scar tissue. And that can start to occlude the lumen, or the opening in the throat. And there is a balloon angioplasty that can be used to open up the esophagus and help with that, and then I think coming back to some of the same issues that we discussed earlier about food allergen avoidance can be very important. And then also looking into if someone has silent reflux or reflux that may be provocating that. So yes, there are definitely options for when someone has a symptom of problems swallowing.

Dysbiosis

“Dysbiosis protocol?” That is more than I think I can answer here aptly. But start with diet and lifestyle, because dysbiosis can be fueled, quite simply, by diet and lifestyle. Sleep, stress, exercise. Try paleo, try low FODMAP. That’s a good place to start. Try some probiotics and enzymes after that, see how that goes. Try antimicrobial therapy after that. And then if after that someone is still not doing well, a trial of either medications or elemental diets may be helpful. Those are some of the broad strokes in terms of things you can do to manage dysbiosis.

Type of Probiotics

Next question. “Enterotypes. What do you think of the idea that the type of probiotic depends on your enterotype?” I think that is a garbagé statement. I think the enterotypes tell us nothing about who is going to respond to what probiotic, because it’s not telling you how the probiotic is going to impact the disease state or the host.

So it’s actually a good example of something that’s super speculative, and that you want to be careful about, because I’ve seen a few patients who have gone to doctors that have been trying to, I think, be more integrative. And they’re trying to treat their lab values, in terms of their Lactobacilli species, their Bifidobacterium species.

And so the doctors are treating the lab values, giving the probiotics they’re deficient in, and giving prebiotics to help with spawning the growth of the probiotics. And these patients have come in after doing that for several months, and saying, “I feel worse than when I first went there.” Yes, because when you treat lab values and you don’t treat a patient, oftentimes you don’t get good results. Especially when the treatment has not been validated clinically, meaning that this has not been done before, and we don’t even know if this works.

So enterotypes to predict probiotic response: I’m open to it, but there’s no evidence that I’ve seen that suggests it can be helpful, so I would not do it. And also treating based upon what the labs show in terms of bacteria species or ratios, again, hasn’t really been shown to be a valid clinical concept. We’ve got great correlation and observation data with some of these things, but we haven’t treated people yet to see if these things actually help. So you’re better off looking at “does this person have IBS, yes or no?” Then let’s go through the treatments that are helpful for IBS, and not be overly concerned about what the microbiota is doing along the way. And this is something I talk a lot about in the book.

Low FODMAP & IBS

“What might cause a negative response to Saccharomyces for IBS while on a low FODMAP diet for two weeks?” Well, I mean quite simply, not everyone is going to respond positively to Saccharomyces boulardii. I’m assuming that’s the Saccharomyces you’re talking about. So, it’s not necessarily more complicated than that in my opinion. Not everyone responds to all probiotics, and some people even respond negatively to certain probiotics.

So what might cause it may just be a non-compatibility with that strain and with the host immune system, or with the host microbiota. I’m not so concerned about reverse extrapolating a meaning of that, but I’m rather just going to make a note of that and try to build a plan for someone that seems to be the most beneficial for their gut as I’m reading their symptoms and any salient lab work. Like a SIBO breath test improving would be salient. An enterotype reading would not be salient, in my opinion.

Diet for…

And the second part of this question, “What diet would you start a 30-plus-year-old ulcerative colitis client on who has had a year of antibiotics and the Standard American Diet?” Well, that depends on—the first thing I’d recommend is you want to treat them to get them out of a flare if they’re in a flare. And sometimes that requires medication, which I’m totally fine with because you want to get them out of the flare as quickly as possible.

And then from there, low FODMAP has been shown to be very effective, and/or SCD has been shown to be very effective, so I’d start there. Along with some probiotics and also some of the anti-inflammatory herbs that have been shown to be helpful. And just kind of personalized to them. And you can also use these herbs and probiotics at the same time as medications like mesalazine; they’ve been used together in trials and shown to have a synergistic effect.

So you may want to use them together, kind of co-managed with your GI, and then in time have them try weaning off the medication and see if they’re able to maintain the improvements with a less or eliminated dose of the medications. But also loop their GI in on what’s going on. He may not be thrilled about it, but I think it’s always good to have your communication.

Zinc & Histamine

“Can adequate zinc improve histamine tolerance since histamine is zinc dependent? Any studies or observations?” Great question. I haven’t looked very deeply. It’s something on my list, into vitamin or other cofactors that can aid with histamine degradation. But I don’t know how effective they would be.

There are some natural histamine lowering agents that I’ve been experimenting with, and I can’t say I’ve see amazing results with those. I think the more important factor with the histamine intolerance is going to be improving the overall health of one’s gut, which may involve reducing inflammatory foods, finding a diet that either feeds or starves bacteria to the right extent for that particular person, addressing things like bacterial overgrowths, using probiotics as needed.

So I think it’s tempting, but I’m not inclined to think that for someone that has pretty raging histamine intolerance that zinc supplementation is going to be like a godsend. But it’s probably going to be you’re going to see a small amount of improvement from a number of things, and those used together is what will really achieve a noticeable result. They may need to be on paleo or low-FODMAP along with some probiotics, and also treating any kind of bacterial overgrowth, reducing inflammatory foods. And there was one other thing I wanted to mention, it just escaped my mind. Oh, yeah. Of course. Also potentially using a low-histamine diet on that person, also, and I think you have the highest probability for success there.

For more severe cases, then you may need to get a little bit deeper into other things. But I don’t think for most people zinc is going to be huge. You could always try it, and a simple way to assess this is keep the person doing whatever they’ve been doing. Keep everything constant. Have them going on supplemental zinc for two to three weeks, and see if they notice an appreciable improvement. And tell them that you want to test this, and it may work or it may not work. Don’t tell them, “Histamine degradation is zinc dependent so I’m going to give you zinc. I’ll see you back in three weeks; I’m curious to see how improved you are.” Don’t implant in them the bias, because then you’re going to most likely get a placebo-effect answer back, and that’s not what you want.

I try to always let patients know with different experiments that we’re running as a course of their treatment. I do not tell them, “I expect this to be amazing,” and really kind of imbed in them a bias. I tell them, “I’m curious to see what kind of effect this is going to have. It could be really helpful, it could actually even flare you a little bit. But make a note of how you feel over the next few weeks, and then when we follow up I’ll be curious to get your report back.” That way, you’re not biasing them one way or the other, and you’re much more likely to get a true representation of that therapy.

And if you do that with patients over months and months and months, you’ll start to get a very honed sense as to what works and what doesn’t work. Unfortunately, all too often, we imbed a bias in a patient when we have them do something and all we hear back from them is a very placebo influenced answer, and that does not make us any better as clinicians.

Blood Test for Histamine Intolerance

“Isn’t there a blood test for histamine?” Yes, there is. You can look at the level of DAO, diamine oxidase, I believe. And the challenge is that that’s not available through any of the big box labs, so I haven’t been using it. Also one of the papers that really looked at this didn’t use a blood test alone as a way of labeling someone as histamine intolerant.

They used a blood test, they used the blood test having a certain reading. And the specifics of this will go in an edition of the Functional Medicine Review, the study this references and the lab ranges. But they used lab positive for high DAO activity in the blood, but they also used improvement in symptoms when someone underwent a histamine avoidance diet. So even in the research literature, it’s not only using the blood levels.

There are other markers available for this through LabCorp and Quest, but they’re not reliable. Histamine plasma, histamine urine, and those haven’t been shown to be super impactful clinically. So yes, there is a blood test, but I think you’re much easier just having someone do a week or so experiment on the histamine diet and seeing how they respond.

Preferred Probiotics

“Which probiotic product do you prefer?” Well, there’s not necessarily a specific product that I prefer. I like to use the different classes of probiotics and see how well someone does with each class. Lactobacillus Bifidobacterium blends. Saccharomyces boulardii as another class. A third class would be soil-based probiotic. And then a fourth class would be the E. coli nissle 1917 in select cases, because you can’t get it in the US, so it’s a little bit of rigmarole to obtain it.

I think it’s important to think about the probiotic classes, and not think about them as products, because there are so many products that you can drive yourself crazy trying the different products.

Saccharomyces

“Did the positive results on S. boulardii also have antibody…” Okay, so this is a question that’s asking about—I used to believe the people with positive anti-Saccharomyces cerevisiae antibodies should not use Saccharomyces boulardii probiotic. Saccharomyces cerevisiae antibodies are antibodies that can be elevated in ulcerative colitis, and I was advised by a lab director a few years ago, before I learned that you have to really question everything and double check everything, that those with Saccharomyces cerevisiae antibodies should not take Saccharomyces boulardii probiotic. And then when I looked into some of the literature on this, I found one of the most efficacious, one of the most successful probiotics for ulcerative colitis was actually Saccharomyces boulardii.

So this lab advisor had a good theory, meaning if you’re reacting to one Saccharomyces species, maybe you shouldn’t take the other. But you’re probably used to hearing me say that theory and clinical practice are two different things. And we should be careful how much theory we let creep into the clinical practice when we have clinical trial data to answer the theoretical questions. In this case, we did. I just didn’t know it at the time. So I don’t know if perhaps people with positive Saccharomyces cerevisiae antibodies are more prone to have a negative reaction to S. boulardii. But knowing that that antibody is pretty indicative of ulcerative colitis and the clinical trials show that Saccharomyces boulardii is one of the most successful probiotics for ulcerative colitis, then I’d be inclined to think it’s not that big of a deal.

Healthy Diet to Gain Weight

“Dr. R; what fast would you recommend for someone who is active, physically fit, who is borderline underweight, but otherwise healthy? Any simple cleanse for the gut?” Well, this person may just do well with a simple intermittent fast. And what that would look like is skipping breakfast and then eating lunch and/or dinner and making those meals bigger.

So that may be helpful for someone in that position. If they need a longer term fast, then using a semi-elemental diet may be the best approach, because semi-elemental diets have been shown to actually help with weight regain in Crohn’s populations. So, a semi-elemental diet may be a good option there. That would probably be composed of a partially hydrolyzed whey protein along with something like maltodextrin as a carb source, and then fats you could potentially add externally to it. So something like that could be helpful.

Importance of Strict Dieting

“Sometimes it takes my clients a few weeks to get compliant with a diet. If someone is on one of the diets for two weeks, but had a few cheats during that two weeks, we don’t really know if the diet works, right? How do you discuss with a client the importance of not cheating at all if they may have gluten sensitivity or gluten allergy?”

Ok, so this is a good question. And we kind of spoke to some of this already, but essentially what this person, I think, is asking about is I recommend with diet giving a diet a few weeks, and then if you’re not seeing some improvement moving on to a different diet. With the exception of, this is someone’s first go onto a healthy diet. Meaning they’ve been eating the Standard American Diet, a really unhealthy diet for a while, and now they’re going onto a healthy diet for the first time, then I think maybe giving someone up to a month can be helpful. Because when you’re coming off processed foods and added sugars and all these things, there may be a little bit of an adjustment process that takes a little over a week.

So if it’s someone’s first change of a diet, three maybe four weeks I think is an ample time window. If someone is on a generally healthy diet, but you’re making small derivations in the plan, like you’re going from paleo to low-FODMAP or what have you, then I really think 2 weeks is ample time to at least get a preliminary sense of, “Is this diet moving us in the right direction?”

And then with cheats, it’s a double-edged sword. Because if you create rules for someone that are so strict that they can be impossible to follow, then you can make someone very easily feel defeated. So, that’s the other side of this coin. I tell people to do their best to follow the diet as much as they can, but if they have a couple of slip ups, it’s not a huge deal, it’s not the end of the world, it’s not going to throw everything off. And use those slip ups as opportunities to listen to your body and to gauge what the effectiveness of the diet is.

I do not think that if someone has gluten sensitivity, and they go two weeks with no gluten, and then one night they have two slices of pizza, that the whole diet is off. Right? This person is probably going to notice if they have pronounced gluten sensitivity, they feel a lot better leading up to that two slices of pizza, and they felt kind of bad after it. And if that’s the case, that’s fine. They’ve learned from it. And you haven’t painted them into a corner where now they feel like they’re a failure and they’re going to beat themselves up. So I really think this strict avoidance, we have to be really careful with it. Because I think it inadvertently does more harm than it does good for a lot of people.

Now, if someone enjoys being type A and being 100%, then fine. Say go for it. Sometimes when I let people know they have a little bit of leeway with their diet, they say, “Nope doc, I’m all or none. I want to do this full in.” Okay, I’m not going to talk you out of it, if that’s the way you want to do it. But I want to let you know that if you’re not perfect, that’s okay. It’s not how I live. I wouldn’t ask anyone to live at a higher standard than I’d ask myself to live.

Prebiotics Usage

“Thoughts on using prebiotics during SIBO treatment?” Some evidence supports that probiotics may act synergistically. I’m fine with using some prebiotics as long as someone doesn’t have a known aversion to prebiotics, and I think that the clinical utility of prebiotics may be a little bit overstated. After all, there is only one study that has shown benefit. I think using probiotics would probably be a better idea. Because there have been, I think now 6 studies showing a benefit of probiotics as a treatment.

So I would rather see probiotics along with antibiotics or antimicrobials than I would prebiotics. I am open to it; I recently heard Dr. Pimentel speculate that the reason it’s more important to use prebiotics while using antibiotics, because antibiotics require bacterial activity whereas the herbal microbials may not require bacterial activity, so they use different mechanisms. Again, I think that’s a little bit speculative. I understand the premise of it. Again, I’m really open on this, but if someone has a known aversion to prebiotics or FODMAPs, I don’t know if it’s a great idea to have them eat lots of those in order to feed the bacteria during SIBO treatment.

Episode Wrap Up

I’m going to save the rest for a next episode because we’re already at about 55 minutes. So those are some listener questions. Thanks for sending those in, guys. And thank you everyone at the NANP. I got really nice feedback on the lecture. So I really appreciate that, and we will talk to you guys next time. Thanks. Bye.

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