Listener Questions On Leaky Gut, SIBO, and Taking NMN for IBS

Episode Intro:

Welcome to Dr. Ruscio Radio, providing practical and science-based solutions to feeling your best. To stay up to date on the latest topics, as well as all of our prior episodes, make sure to subscribe in your podcast player. For weekly updates, visit DrRuscio.com. The following discussion is for educational purposes only and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking with your doctor. Now, let’s head to the show.

Erin Ryan:

Hey everyone. This is Erin Ryan from Dr. Ruscio Radio. Today on the show, Dr. Ruscio answers your questions. In this week’s episode, you asked: Are the terms leaky gut and inflammation of the gut theoretical or proven? Without functioning thyroid glands, can healing gut issues make a difference in my medication needs? Could the prep diet for SIBO test provoke a false positive? Do your probiotics absorb well in the small intestine? Could NMN be helpful for IBS? Are thyroid supplements safe to take with thyroid medication? Any advice on how to treat Lyme and co-infections? I had great results with some probiotics, but they were short lived – why? I want to say thank you to everyone who submitted your questions. If you would like to submit a question, visit drruscio.com/podcast-episodes and click ‘Send us a Voicemail’ at the top of the page. Please speak loud and clear and keep it as concise as you can. Enjoy the show.

Dr. Michael Ruscio:

Hey everyone. Welcome back to Dr. Ruscio Radio. This is Dr. Ruscio here again with Erin Ryan. Into listener questions again we go, Erin.

ER:

Alright. Let’s jump right in with a question from Devin.

Question 1: Leaky Gut & Inflammation – Theory vs. Proof

Devin:

Hi there. First, I’ve really been enjoying your podcast so thank you very much for doing it. Second, I’ve had gut issues for many years now, and over the past two years, I really started diving into finding a solution. I recently read your book and I’m happy to discover that I’m (essentially, by mistake) following your protocol and things are going a lot better. I do have two burning questions though that I haven’t found an answer to. Number one is: Is leaky gut proven… I mean really proven… or is it just a concept or a theory based on evidence? If so, what kind of evidence? Is it purely anecdotal? My second question is about the term inflammation. It seems to mean different things to different healthcare practitioners. Similar to my first question. When you use the term inflammation, are you basing it on a theory? Or is there proven inflammation of the gut? (Similar to how a joint or skin can show physical signs of inflammation.) Those are my two questions and once again, thanks very much.

DrMR:

Alright. Great question. And as I’m listening to this, I’m going into our FFMR database because we do have a table of all of the research on zonulin or leaky gut. There may be a few studies that we’ve missed here, but it’s an ongoing table that we update as research comes in. Zonulin is a marker for leaky gut. In short answer to your question – yes, leaky gut has been proven. I’ll cover the strength of that proof, so to speak, in a second. Inflammation has also been found in a number of models of gut disease. I shouldn’t say models, as that implies an animal study. IBS, IBD, reflux… inflammation is often found in these conditions.

DrMR:

It’s not always found. I was even reading a study earlier today that found disease activity in Crohn’s disease improved after a given intervention, but it didn’t necessarily correlate with inflammatory markers improving. The connection between symptoms, disease, and inflammation — it’s not 100%, but it’s definitely a significant trend. So yes, the inflammation in leaky gut has been fairly well established. If you want to go really deep, you can subscribe to our FFMR — that is our Future of Functional Medicine Review database — and access the table here. If you go to the master index and type zonulin, you’ll find this pretty quickly. There’s a section called ‘Dr. Ruscio’s Review of Zonulin Testing for Leaky Gut.’ But, in short, leaky gut is a legitimate thing. It’s challenging because sometimes people throw that term around loosely and this can lead some people to think it’s quackery.

DrMR:

The correct term is really intestinal permeability, but oftentimes clinicians will translate things into a lay parlance that’s easier for people to understand. The main marker that’s been used for leaky gut is actually serum or blood zonulin. Older testing used a couple different measures, but probably the most popularized was a lactulose:mannitol. That has fallen out of favor due to it being inaccurate in certain cohorts (like those who have SIBO.) You may actually get a false negative because bacteria will metabolize the lactulose. The more contemporary is blood testing for zonulin. The functional medicine labs are oftentimes using stool for zonulin, which is likely less accurate, but still gives you some indication. However, it’s not a perfect marker. I think this is important to acknowledge. Yes, there’s a clear trendline toward various disease or symptom or syndrome cohorts having higher levels of zonulin.

DrMR:

But there are violations that are observation. Again, it’s important to remember that there is almost never a case that has zero evidence refuting it. If you look at 10 studies on zonulin, you’ll see perhaps seven or eight that support zonulin and leaky gut underlie X, Y, Z condition, but there will be two or three that do not. This is why I say it’s important to look at the trend because you could cherry pick the three or the seven, right? That’s why it can be so misleading when you cherry pick. You want to highlight the trend. The trend is definitely there for zonulin supporting it is at least associated to various conditions.

DrMR:

Namely, there is this one study using the Nordic diet, which is a heavier fish/paleo diet. And interestingly, the individuals got healthier by every measure in the study, yet their zonulin got worse. There’s another study using either a fiber or prebiotic intervention and symptoms improved, yet zonulin got worse. So, it’s not a perfect marker. Does it make much of a difference in a clinical setting? I look at leaky gut to whatever degree it’s present as an intermediary between the underlying cause and the symptoms that you’re having, but not necessarily something that tells us that we should treat you in any different way. There are some that will say, “Oh my God. What do you mean? You’ve got to treat the leaky gut.” But my argument is that by doing everything that we advocate for in the gut healing algorithm, you’re going to address the root cause of leaky gut.

DrMR:

It’s not to say we’re discounting it, we’re just not treating the lab. We’re treating the person and we’re personalizing the care to them based upon what the biostats tell us are the most likely to improve their health; to be most likely to improve them, their symptoms, and their zonulin. The same thing applies for inflammation. You’ll see it in many different studies. Again, it’s not a 100% correlation, but it’s definitely there. And interestingly, while the low FODMAP diet is sometimes criticized as “Oh my God, you’re going to starve that bacteria,” I think it’s taken out of context and this is why mechanism gets us in trouble. I was just reading a study today — and there have been many studies that have found the same thing — that a low FODMAP diet can actually reduce inflammation. The study today was novel in that it actually found an improvement in dysbiosis. Sorry if this is getting a little bit detailed, but essentially yes – inflammation has shown to correlate.

DrMR:

What’s interesting is some people will criticize a diet like the low FODMAP diet because it isn’t strongly encouraging a bacterial growth, which in of itself shouldn’t be a good thing or a bad thing. What does that correlate with? We should look at the correlation with reduced inflammation in a number of studies. Even a recent study found that dysbiosis improved when going on a low FODMAP diet. This ties into one of the posits I advance in Healthy Gut, Healthy You — you can’t micromanage an ecosystem, but you can create the healthiest environment possible… one that will be encouraging of eubiosis (or a healthy microbiota.) So, if an intervention that doesn’t feed bacteria — like low FODMAP — reduces inflammation and improves the milieu (or the health in the gut), theoretically you should then see healthier bacteria grow. And now we’re seeing the science catch up to that statement.

DrMR:

So, both of these are legitimate. Are they sometimes used loosely as proxies by clinicians? Yes. Is it a problem having a rough heuristic to help patients wrap their mind around these things? No. It is problematic when we try to use inflammation and leaky gut get to fear people into compliance or try to get them to take X, Y, Z supplements. So, we want to be careful with how we’re leveraging these things, but both have general legitimacy and are things to factor in, but they’re probably intermediary mechanisms and not necessarily things that we treat directly.

Question 2: Graves’ Disease & Thyroid Issues

ER:

Awesome. Well, I think that’s good for patients to ask questions like that and not just take everybody’s word for it. So, that’s cool. Our next question is from Heidi. She says, “I developed Graves’ disease at age six. I took Tapazole until I was 18, and then treated with radioactive iodine. My thyroid no longer functions. I’m addressing my gut health with the AIP protocol, which has given me very positive results in my brain clarity, mood, sleep, and weight management. Without functioning thyroid glands, can healing gut issues make a difference in my medication needs?”

DrMR:

Yes. This is one of the things that I’m actually most excited about. There have been a few studies over the past (maybe five or so) years and I have a video coming. It’s actually a short video, but I think it tells the story in a fairly entertaining way that’ll probably be shared in the podcast here just in audio form, but I would highly recommend watching the video because of the visual reference overlays. But the bottom line here is that there is ample evidence at this point showing that if someone has an ongoing issue in the gut, that can interfere with their absorption of thyroid hormone medication. I’m assuming that if you had radioactive ablation of your thyroid gland, then you’re on thyroid medication now. And what’s exciting is studies are finding that when people improve their gut health, they’ll actually need a lower dose — let’s say, of levothyroxine — of whatever thyroid hormone replacement medication they’re on, while simultaneously having improved symptoms and stabilization of their thyroid hormone blood levels.

DrMR:

There was just recently a study that looked at 60 individuals who were on thyroid medication and still had fatigue andTSH levels that weren’t quite normal. The researchers took 30 of these patients and gave them placebo. With the other 30, they gave them a probiotic. And after eight weeks, the probiotic group saw a reduction in their TSH (meaning it improved) and improved fatigue, all while needing less of their levothyroxine medication. This did not occur in the placebo group. And this is most likely because the probiotics improved their gut health, improved their absorption, and they needed less medication. And to whatever extent their gut and potentially some of the gut inflammation was leading to fatigue, as we know it does, they also resolved the fatigue. Whether it was due to the thyroid medication absorption and their gut health – either both or one or the other – doesn’t really matter.

DrMR:

There have been other studies finding similar things. For example, when giving people treatment for H. pylori, that can improve absorption. Or even when someone has inflammatory bowel disease that’s as managed as it’s going to get, but there’s still some ongoing malabsorption — When switching the individual to a more absorbable form of thyroid hormone, their symptoms improve and their levels stabilize. Now, if you’re not on medication for some reason, that scenario changes a little bit. However, it’s still possible that by improving your gut health, you’re going to potentially improve even further, as you’ve already seen by the gut-friendly AIP diet improvements in brain clarity, mood, sleep, and weight. This is really exciting and it’s something that I’m happy to be trying to bring more to the forefront of the conversation; that before we go into meticulous tinkering with the thyroid medication, the ratio of T4 to T3, and what have you, we want to make sure someone’s gut health is in good working order. So, definitely keep on the track that you’re on because it’s a very fruitful path in terms of the benefits that you should receive as you continue to take care of yourself and your gut health.

Question 3: The Prep Diet & SIBO

ER:

Well, that was a timely question. Awesome. Our next question is from Amanda. She’s a health coach.

Amanda:

Hi Dr. Ruscio. My name is Amanda. I’m a functional nutrition health coach and I also have chronic digestive challenges, including SIBO diagnosed by a breath test. My question is about the Prep Diet that’s recommended before SIBO testing. I know the intention of the Prep Diet is to reduce noise in the results from food in the regular diet, but I’ve wondered if in some cases the Prep Diet may provoke a false positive or a higher level of gases. For example, I struggle with slow gut motility and the Prep Diet, even for one day, slows things down even further due to a lack of fiber. So I’m wondering, are you aware of any research that confirms or contradicts the usefulness of the 24 hour Prep Diet pre-SIBO test? And since the test is only measuring 180 minutes after the challenge solution, isn’t it possible that a 12 hour overnight fast is sufficient to clear out enough residue and provide a good baseline gas level before testing? Thank you.

DrMR:

In short, yes. It is possible that if you’re noticing you feel worse when you’re doing the Prep Diet, then that worst could go either direction — more constipated or more toward diarrhea. That could either slow down the speed at which the substrate makes it through the intestinal tract and therefore skew the results of the test in a false positive or a false negative direction. This is probably why you don’t see — coming back to the earlier point — a 100% correlation between gold standard evaluations. For example, taking a jejunal sample and culturing that as compared to a SIBO breath test… or a 100% agreement between SIBO breath testing and symptoms. So, the answer to your question is yes. You could maybe try doing a shorter prep. You could try doing a different prep. You could also go into this different paradigm that I advocate for, which is treating the people, not treating the numbers.

DrMR:

And this is important to underscore because if the hypothesis here is that you need an accurate test to know how to treat the individual, I would argue that you’re really looking at this in a very reductionistic lab-centric fashion, and you’ll get far better results with this client if you start personalizing the therapies that we know help SIBO and help IBS to them. Try to transition away from the paradigm of just treating the number that they have (or maybe don’t have) or trying to make sure you get a better number for them. And the more I practice… the more we at the clinic practice… the more we scour the research literature… you see that there are limitations with testing. And as I say all the time, testing is really only 1/4 of the data you need to make a decision.

DrMR:

History, symptoms, response to treatment, and lab testing — those four are the pillars. So, if you’re doing these things the right way and looking at the history of the individual, their symptoms, and perhaps most importantly, how their symptoms respond to various interventions, then you have 75% of the data right there. And it makes the value of that 25% of the data lab testing have the appropriate weigh-in in the appropriate context. Your questions are great. They’re very insightful, but as it pertains to what do you do for this person clinically, they’re getting a bit into the weeds and they’re potentially pigeonholing the person into thinking that you must have lab data in order to figure out what to do for them. I’d invite you to free yourself from the lab test and just go to work on personalizing the interventions that we know work for individuals who have the symptoms that you have, and that should really lead you to the best outcome.

Dr. Ruscio Resources:

Hi everyone. Just a quick announcement regarding the clinic. I am happy to say that I, and we at the clinic, are now offering a free monthly support call to all current patients. This applies to any patient at the clinic, even if you’re not working with me directly. This is an opportunity to ask me and our team questions, share feedback, and get support with any challenges you may have. I will be accompanied by Dr. Joe Mather, our medical director, and Morgan Molidor, our clinical health coach. We have emailed details to all of our patients, so check your inboxes. Hope to speak with you there. And here is Erin with the date and time of our next call: The next call will be on Friday, February 11th @ 1:45 PM central.

Question 4: Absorption of Probiotics

ER:

Alright. Our next question is about probiotics: “Do your probiotics absorb well in the small intestine? I am having an ileostomy surgery soon and having the entire colon removed, and would like to know if I should take your probiotics and open the caps into a shake or juice. I don’t want any of the caps to get caught in the intestine and cause blockage.”

DrMR:

Well, this is a challenging question to answer because I don’t know everything here. And on the one hand, I want to tell you to refer to your GI on this. You should definitely ask your GI, and/or your surgeon, what their perspective is. Sadly, I’ve also observed that some in conventional medicine really aren’t staying on top of the probiotic literature. And because they don’t know the body of evidence, they revert to a reflexive, cautious, “don’t do that.” And what’s challenging about that – and I think needing better acknowledgement of – is that on the surface that that may seem like it’s well intentioned (and it is well intentioned), but if you’re reverting to an ultra cautious recommendation to not do something, and that thing could help the individual, then you may do an inadvertent harm. So, in this exact scenario, I’m going to make an assumption that probiotics would be helpful.

DrMR:

And if you’re worried about the capsules, then you could use a powder form — most namely, our ‘Triple Therapy Probiotic Powder Sticks.’ The other question about the small intestine is a really important one. I was just having this conversation with a friend the other day, and they were asking – “Aren’t enteric-coated probiotics the best?” And I don’t think so. The reason I don’t think so is we likely want to have the impact in the small intestine with the probiotics because this is the most immunoactive… it’s the most prone to leaky gut… it’s where 90% of caloric absorption occurs. This is really where we want to try to have the anti-SIBO, anti-dysbiotic, anti-inflammatory, anti-leaky gut impact. Something that only gets into the colon is missing this really important region of the small intestine.

DrMR:

So, I would do a little bit of checking in with your doctor. If you don’t feel you get a good answer, be your own health advocate and do your own health research. Capsules can be broken open or you can use one that comes in a powder form. It doesn’t really matter. You can take it with, or without, food. You can take it with juice or water. And that should steer you down the path. I’m sorry that you’re having to go through the surgery, but there are some helpful therapies — I’m assuming this might be IBD related — and probiotics are one, elemental dieting is another. If you need anything else, just reach out. We’d be happy to help you along your path.

Question 5: Probiotic Dosing for Children

ER:

Yeah. That sounds like a tough surgery to go through. We wish you luck. Side note on the probiotic sticks. I’m loving those for my son. He’s little and he goes to preschool. He comes home sick just about every other week and I am so thankful for these probiotic sticks. I don’t put the whole thing in there just because I actually don’t know if I should, so I put about 25% or 30% of it in his milk or whatever daily. I can sneak it in and he can’t taste it, which is awesome. He doesn’t want to take a whole lot of his other vitamins because of the way they taste and stuff like that. So, I just wanted to say shout out to the probiotic sticks because his colds aren’t lasting as long. I’m pretty sure it’s related to that because he’s just got a better immune system going, but anyway, we’re loving this.

DrMR:

There’s actually a systematic review +/- a meta-analysis published recently that found that probiotics reduce the incidence and severity of upper respiratory tract infection in children. It’s not the first clinical trial. That’s why we’re seeing it now appear as a summary of the clinical trials as either a systematic review or a meta-analysis. So, you wouldn’t be alone in that observation. I will admit I’m really enjoying the sticks also. They’re just way more convenient. And for people listening to this, we get a question every once in a while of – Why is it more expensive? It’s not more expensive. It’s just that you’re literally getting the same as if you bought three different bottles in this one box of sticks.

DrMR:

So, take three capsules out of the Lacto-Bifido Blend probiotic bottle, take two capsules out of the Sacchromyces Boulardii bottle, and take two capsules out of the Soil-Based bottle. Open them up, put them in a single serving stick — that’s what the Triple Therapy Probiotic Powder Sticks are. And they net out to be the same exact cost. But because a bottle is roughly $35 each, when you look at the cost of the Triple Therapy being about $90 – $120 (depending on whether you get the 30 or 60 count), it may look more expensive. However, it’s actually the same when you factor in that the Triple Therapy box is literally three bottles in one. So, just to clarify for people, it’s the same cost. It’s just far more convenient.

ER:

It sure is. And then if I can submit my own question — What do you think about dosing for a little guy? Do you think I should give him half or just go with like 30% of it?

DrMR:

How old is he?

ER:

Two.

DrMR:

Two? You could do a pack per day. If there was something really acute, you may even want to go a little bit higher. The range that’s been used in the research studies is somewhat broad. So, half a pack… one pack… seems to be a decent range to use. Could you go higher if there was something like a bout of acute gastroenteritis or being sick? Sure. And for adults, even though the equivalent dose is two to three sticks per day, there are some studies that use whoppingly high doses — especially with VSL#3 (the Rx form) — and they’ve shown benefit. It’s not to say you need to do that all the time, but there could be scenarios where you want to use a higher dose. And the drawbacks of that, especially when used sparingly, seem to be non-existent other than maybe some gastrointestinal upset if you go too high. But if you’re using it to combat something like traveler’s diarrhea or stomach flu, you’re likely going to have the opposite of that effect.

Question 6: The NMN Trend

ER:

Okay, cool. Well, I’ll do that. I’m anxious to see what that will do. So, our next question is about NMN.

Caller:

Hello. My question is about NMN. There’s been a lot of news on this anti-aging molecule. I wondered if you had any knowledge about how that might affect IBS or, in fact, if you had any information about it at all? I really trust your podcasts. Thank you very much.

DrMR:

Great question. NMN is something that I’ve used. There are a few different forms. This is Nicotinamide Mononucleotide. There are a few different forms of this, but essentially NMN is, as you said, an anti-aging molecule. It was popularized, especially on a Joe Rogan podcast with David Sinclair from Harvard, and I appreciated the conversation. Although, this is one example where I was a little bit disappointed in the sense that — and I want to give David Sinclair every benefit of the doubt — it didn’t seem like it was fully disclosed that there is no human interventional data with this compound. Now, perhaps there’s been something published in the last six months, but at last check (unless I missed something), there were no interventional trials with humans. It was all pre-clinical (meaning animals) and this is what Sinclair mentioned in the podcast.

DrMR:

He talked at length about the research he was doing in his lab with rats; that the rats were able to run on the treadmill longer or tread water longer. It’s this cruel experiment I believe they do. It’s having these animals tread water until they die. And I believe they were able to tread tread water for longer when they were using the NMN. It’s really interesting, but what I find disheartening is when you have a scientist who is providing you with a very interesting story about an interesting compound, but not doing an adequate job of saying, “Oh by the way, this hasn’t been used in humans yet.”

DrMR:

I was a little disappointed in that podcast in the sense that he was telling people about all this cool stuff in rats and talking about some of the mechanisms and about how he would take it with yogurt. Joe Rogan, who I feel typically does a pretty good job at ferreting out weaknesses in people’s arguments, seemed to be really satisfied with the fact that it was all animal research. So again, maybe I’ve missed a trial here, but at last check there was zero interventional data with humans. And so my thinking is that this is one of the many things that are kind of a fad. And who knows – maybe at some point in the future it’ll have adequate evidence, but some of these ideas just take wind, right? And when they do, people hear about them and it becomes a razzmatazz for a little while. The therapies that are effective stay in circulation and the therapies that aren’t tend to fade away.

DrMR:

I think the jury is still out on this one. If you want to try it, go ahead. I tried it. I didn’t notice anything. And my n-of-1 experiment was quite controlled in the fact that I’m doing timed mile runs on a weekly basis and I’m doing timed 5k rows on a weekly basis, and I have pretty consistent performance. And so I’m thinking, “Okay. Great. If this is going to lead to the improvements that I heard about for two hours on a podcast in rats, then I should shave off five seconds… 10 seconds… whatever.” I saw zero change. That’s my n-of-1, but this is why I recommend caution. Visibility does not have a direct translation to efficacy, right? So, things that are popular do not necessarily mean they’re helpful.

DrMR:

I am not using NMN in the clinic nor am I using it any longer personally. I may actually try an IV. There’s a spot here I go to in Austin where they offer that. I’ve gotten friendly with some of the people who work there and they’re like, “Oh, you gotta come try the IV.” And so maybe I’ll try the IV just to see if I do notice a benefit. I’ve heard some people using this as a patch or as an IV, although I’m pretty suspicious that the impact is either nonexistent or so small as to be imperceptible. It’s interesting, but I would hold off on that for the moment. Until some evidence is produced that is helpful, it’s one of many a thing that I would just sit out on the sidelines and not necessarily jump into the game… unless you are at the point in your journey where you don’t really have any complaints, you have some time, you have some money, and you want to experiment.

DrMR:

But if you’re complaining about IBS, I’m assuming you’re still struggling with stuff. And this is when I would not recommend any of these theoretical therapies. We have therapies that have the requisite evidence and can help people. And I would just go to work on personalizing those to your system, and that’s the highest likelihood you’re going to see the results you want to see. If you’re in the other camp of optimization — maybe like myself trying to run that mile a little bit faster — and you don’t mind spending some money that may be a waste, then I would try it. Or at least consider trying it.

ER:

I have to say I had a similar experience where I didn’t notice anything either. I was just running an experiment because I was feeling really good. And I was like, “Let me just see if this helps with gains in terms of working out and stuff like that.” But I really didn’t notice more energy or anything special, but I gave it a try. I know it’s a huge conversation in the biohacking world. And also just to be mindful of the fact that it’s a huge conversation in the skincare and anti-aging world right now, too. And if there’s not any human studies for an overall effect, I would really question an effect on the skin or the infrastructure under the skin (or whatever they’re selling it as.) But there’s a lot of NAD in skincare products and they’re charging $100 a bottle for them. So, maybe just wait it out a little bit until those people can show you studies in that.

DrMR:

And there are things that have been documented to improve skin; that have clinical trial evidence. And this is really what I’m trying to bring people’s attention to. I’m not trying to be a wet towel on the party here, but when it’s an area like IBS and there are a dozen therapeutics that we know work, maybe then you’d want to personalize those to your system and that’s usually what helps people… whereas the new thing that’s all the buzz is sadly a lot of times fad or profit driven. How do you get so much buzz about something that doesn’t even have an interventional trial in humans? It’s hard to see. I think it’s just a byproduct of — some things are cool and people want to talk about cool stuff and you just have to be careful that you don’t jump on that bandwagon (again, unless you’re in a position where you can do that.)

DrMR:

Unless you’re at, “Okay. I’m good. I’m trying to optimize. Let’s experiment with some stuff. I’ve got a little bit of money and I don’t mind potentially wasting it,” then that’s great. But when you’re someone who is trying to improve their health — like the drugs that people put in the uBiome test — and you just waste your money, that’s when it gets sad. Now you’re trying to help improve your situation, resurrect your health, and you’re putting your effort and money into things that aren’t going to help.

Question 7: Integrative & Adjunctive Care for Hyperthyroidism

ER:

Okay. Let’s go onto the next question: “I was diagnosed as hyperthyroid and don’t want to take medication forever, though my doctor wants me to try some medication. I read your recommendations and purchased the supplements that you recommended, but my doctor said not to take them while I’m taking the medication she prescribed, so I guess I’ll wait a few weeks. My main question is — Is it okay to take all of the supplements that you recommended at once?”

DrMR:

I’m assuming that she’s referring to the article that we wrote where we discussed the treatment options for Graves’. There are some dietary changes that have been shown helpful for thyroid autoimmunity — selenium… l-carnitine… as some of the most meritful. I’m assuming she’s referring to that, as opposed to Healthy Gut, Healthy You, which is more gut-directed. So, it partially depends. I’d refer you to the article and the guidelines laid out in that article. But yes, you can use multiple supplements at once. Something like selenium + l-carnitine + dietary changes can be used. I’d have the conversation with your doctor. There are a few things here that are important to take into account. The severity of the hyperthyroidism matters. The more mild you are, the more likely (no matter what you do) you’re going to see remission in the future and there’s not going to be a lot to worry about.

DrMR:

The more severe you are, then the more robust of a support/care plan you’ll likely need. Now, how do you know if you’re mild, moderate, or severe? Well, there are a few things that can be used. The severity of your symptoms is one. For example, was your blood pressure through the roof? Was your heart rate through the roof? Were you having anxiety, panic attacks, and sweating all the time? Or was your heart rate kind of elevated? Did you feel only a little bit hot? A little bit sweaty? Maybe you didn’t feel good, but it wasn’t too crazy? That would be severe versus mild. Another factor would be your response to treatment. The easier and more quickly you respond to treatment, the more mild your case is. The interventions that we discuss regarding nutrient replacement — like selenium — are supportive.

DrMR:

And I don’t know of any evidence that you can’t take, let’s say, selenium with methimazole (which is one of the main medications used for hyperthyroid.) But again, I don’t have all the information here and this is certainly not a consult. So, check in with your doctor on this. I know of no evidence that l-carnitine can’t be taken with methimazole, or that you couldn’t do something like a paleo diet along with methimazole. And we’ve had patients in the clinic do that with good results. This is an adjunctive/supportive model where you’re using both medications and natural agents together. They can be used together in the majority of cases (with some exceptions), but more often than not, can be used in a complementary way (hence complementary and alternative medicine.) However, it does depend on the paradigm of your doctor. And like I said earlier, some doctors, if they don’t know, revert to a ‘Do not do.’ So, you may want to find a doctor — get a second opinion — who seems to be more open-minded.

DrMR:

You just want to be careful you’re not going to work with someone who only acknowledges conventional treatments and is discouraging of alternative treatments. And a lot of that is just reading in between the lines. How was this received? Did they scoff? Or were they supportive and curious? All those things help you interpret if your doctor is someone who just has their paradigm and is unwilling to work integratively or not. Those are a few thoughts for you. Definitely keep on the path of trying to support your body because hyperthyroidism, in some cases, will lead to either surgery (although that’s being done much less) or radioactive ablation. Those are permanent, so if we can prevent that, that’s obviously a huge win. There is not a ton of research on the natural therapies, but there is research showing benefit.

DrMR:

And since these therapies are safe — things like selenium and dietary changes and l-carnitine — and they may actually reduce your need for permanent interventions, I think it’s reasonable to start with those. Make sure you’re seeing results, and to whatever degree you’re not seeing results, that’s when integration of more of the conventional therapies makes sense. That’s the paradigm that I look at it through, and starting more with natural and cause-based therapeutics. And if those don’t help you at all/don’t help you completely, then you escalate to conventional therapies, hopefully needing less of them or none of them; using them in this integrative fashion and approach. And I think that’s really the best way to approach this. But again, if you’re not feeling like your provider is endorsing of that, I would consider a second opinion because it has a big impact on the way this is going to play out.

DrMR:

If your doctor is fighting you regarding doing anything alternative, then they may just be a little bit jaded. And I get it. Some doctors in the alternative camps are nuts. They are kooks. Some in the conventional camp are also. I think what happens is — If you, as a doctor, have seen a few horror stories of patients who came in from natural medicine, you may be biased against natural medicine, but you don’t want to have to deal with someone’s baggage, right? It’s almost like a partner. If they had bad prior relationships and they bring the baggage from that to your current relationship, that’s not your problem. And it’s not fair to make you have to deal with that problem. Pardon if it’s a weird analogy, but make sure you’re getting good competent care, someone who doesn’t seem to be biased, and is open-minded and willing to work with you.

ER:

I just had a visual of someone bringing a duffle bag full of supplements into a doctor’s office, and them being like, “Oh, I don’t have time for this.” What I also wanted to say about that is I wish more practitioners would somehow on their websites put like a pop up — “I’m open-minded!” When you’re sick, it’s really hard to find another doctor and there’s no guarantee this one’s going to be any different or better. I just wish there was some kind of flashing sign that we could find on people’s websites. So, if you’re listening and you’re a doctor, make that a talking point on your website because we’re looking for it.

DrMR:

That’s a great point.

DrMR:

Hi everyone. If you are in need of help, we have a number of resources for you. Healthy Gut, Healthy You — my book and your complete self-help guide to healing your gut. If you’re not a do-it-yourselfer, there is the clinic — The Ruscio Institute for Functional Medicine — and our growing clinical and supporting research team will be happy to help you. We do offer monthly support calls for our patients where I answer questions and help them along their path. Health coaching support calls every other week. We also offer health coaching independent of the clinic, for those perhaps reading the book and/or looking for guidance with diet, supplementation, et cetera. There’s also the store that has our elemental diet line, our probiotics, and other gut health and health supportive supplements. And for clinicians, there is our FFMR – The Future of Functional Medicine Review database – which contains case studies from our clinic, research reviews, and practice guidelines. Visit drruscio.com/resources to learn more.

Question 8: Lyme Disease & Trunk Therapeutics

ER:

Next question…

Grace:

Hi. My name is Grace and I was diagnosed with chronic Lyme disease three months ago. I chose to go to Envita, as they specialize in Lyme disease. I also have co-infections with the Lyme disease, which are the EBV virus and the CMV virus. They were all elevated. I was treated with seven weeks of antibiotics, ozone, resveratrol, and a high dose of vitamin C. In spite of all that, my virus panel still came high. I don’t know about my Lyme because we just sent in another urine test for the Lyme. I’m very much concerned because it’s causing me to have MS like symptoms as well because I have an MS marker. Apparently I have HLA genes. If you’re exposed to Lyme, your nervous system has the same antigens so your immune system attacks your nervous system. It’s quite debilitating. I just want to know how you can help me. I’ll be looking forward for your answers. Thank you.

DrMR:

Well Erin, you’re probably guessing what I’m going to say here, which is my spider sense here is going off a little bit. I want to give every provider, first thing if I may say so here, the benefit of the doubt. We are all on the same team. We are all trying to help people. That said, I’ve noticed that there’s a fair amount of fictitious malarkey in the field — labs that aren’t validated… supplements (like we talked about) that are en vogue, but don’t have the requisite support… So, it’s important to be able to call attention to these things. Lyme is certainly possible, right? Viruses less so. I did both Lyme and virology panels in practice for a few years. With the viruses, I can never make heads or tails of it, and the response to antiviral treatment was very minimal. The fact that many of the natural antivirals are also antihistamine or antimicrobials made me think that the small signal of potential benefit I was seeing regarding antiviral therapy was likely due to the antihistamine impact or the antimicrobial impact probably having an impact on the gut.

DrMR:

That’s where the perceived or potential symptomatic improvements were coming from. Lyme is challenging because the integrative panels — the validity of them and/or what we call a positive, what we call a negative, and where we draw that cutoff line — seems to be blurred. Treatment for Lyme is probably more of a mid-to-end phase treatment. Addressing Lyme in general should be done once you’ve cultivated good diet, lifestyle, and gut health. Starting off with Lyme, in my opinion, is not the right move. Now, there are questions we can ask to try to shade some of this in. Is there any signal of symptomatic improvement from the treatment that you’ve done thus far? If you’re two, maybe three, months in now – are you improving? It’s not to say you’re always going to see improvement out of the gate.

DrMR:

It’s important to disclose that, but the hypothesis is Lyme, so you’re being treated for Lyme. Are you seeing any improvement? This is one important indicator and you start weaving these indicators together. Did your doctor seem dogmatic/hard driving? Was your lab bill $2,000 or $3,000 +? Are they still hammering hard with the same things even though you’re noticing nothing is improving? Or are they pivoting and personalizing the care to you? Picture in your mind a tree. I’m going to use this analogy a lot in the podcast, so I apologize if it gets trite. I think it’s just really important to give people some guideposts. Flip the tree upside down. So you have a trunk and as you come down from the trunk, you then have a number of branches. The trunk is — from a biostatistics perspective — the underlying causes of most disease.

DrMR:

So, we start with things like sleep, exercise, diet, lifestyle, and gut health. And we personalize those therapeutics because they’re going to help the highest number of people. As we progress through those trunk therapeutics, we look for how the person’s symptoms evolve. And in some cases, all the symptoms are gone. In other cases, you’re seeing a cluster of symptoms that is more suggestive of X, Y, Z thing. Lyme could be one of them. Limbic imbalances could be another. Female hormone imbalances could be a third. This approach would do a few things. One – It would make sure that you’re not jumping to Lyme before you’ve worked through the core or the trunk of the tree. It would also improve the resiliency and health of your system so that if Lyme treatment did need to be vectored, you’d be in better position to do this. And this is something that’s been somewhat agreed upon.

DrMR:

We had Dr. Rahbar (https://drruscio.com/lyme-disease-causing-chronic-sibo-dr-rahbar-episode-33/) on the podcast a while back and he had echoed the thinking that you should start with gut care before going to Lyme care, as someone who treats both. Is Lyme possible? Of course, yes. Is it more probable than a gut condition? Definitely not. Is testing perfect for diagnosing either one of those – Lyme or a gut problem? No. So, what do you do? You go to the biostatistics. Functional gastrointestinal disorders — 40% of the population. IBS — 15% of the population. Hypothyroid — 1% of the population. Lyme, I’m assuming, is probably going to be less than 1%. Can problems in the gut cause neurological problems? Yeah. I’m one of those people, right? Brain fog… depression. I hope this helps you see that we can’t hang our hat fully on the testing. Again, it’s 1/4 of the data that you need.

DrMR:

Knowing just this snippet, I would be much more comfortable with you working through this process of going through that inverted tree model, or the appropriate order of operations, as dictated by the biostatistics. Let’s start with the things that are most common. We can use testing, but we’re going to have a healthy respect for testing and realize that testing isn’t perfect. And this is usually how we’re able to help someone get there more quickly. We go through the numbingly practical exercise of starting with the things that are the most problematic for the highest percentage of people in our population. Then using their history, their symptoms, and how their symptoms evolve and respond to treatment, we progress, personalize, and dictate care. Because of all that, my spider senses do go off a little bit. I hear a little flicker of emotionality in your voice, which makes me even further confident that potentially this sort of clinic is going to be like pouring gas on an emotional fire. Because you’re likely going to get a whole bunch of (if I’m being really candid here) bogus tests that have questionable validity, you’re going to assign a high emotional charge to every one of those results.

DrMR:

And you’re probably going to make yourself feel worse because of the nocebo effect associated with that, all the while perhaps not understanding that a lot of those tests are kind of bunk. Those tests take your money, they take your emotional well-being, and they don’t help you improve your health. Again, there may be something here that I’m not understanding, but this is a fairly common scenario that we see in the clinic. A lot there for you to chew on. If you’re not sure, get a second opinion. If you want a second opinion from our office, reach out and we’d be more than happy to help you navigate through this.

ER:

Great. I hope you hear this podcast, Grace. I’m not sure how long ago you submitted this question, but I really hope you hear this because the emotional sound of almost giving up is very familiar to me. And I feel you on that. But as Dr. Ruscio said, it’s this tree trunk model. The cool thing about it is like, “It can’t hurt, right?” I’d rather go through that first than start with seven weeks of antibiotics. That can actually hurt you. It can help you too, but that could actually hurt you. It’s just thinking of it in a really simplistic way of “that could only help you.” In general, I think that’s such a better way to go. Also, the first thing she said was this practice specializes in Lyme. I’ve heard you talk about this so many times that when you go to a practice that sort of “specializes” in something, that’s most likely all they’re going to try and treat.

DrMR:

Yeah. Sadly. I can see that being challenging for the clinic because you need to have a filter in place where you say, “Well, if you haven’t done X, Y, and Z, you really should do X, Y, and Z.” But if you want to be the Lyme specialist, it’s incumbent upon you to make sure you’re not over treating people. Just like for us, we have referrals we make for limbic retraining or myofunctional therapy, so I understand the challenge associated with that, but it’s not an excuse. You don’t get to play that card as an excuse. You don’t get to just take someone who is not in need of your care or not a good candidate and force it upon them. Just like we can’t be trying to be the specialist in myofunctional therapy, pelvic floor, and limbic retraining. But yeah, you make great points, especially the fact that the harsh antibiotic therapy is not without potential side effects.

Question 9: Short-Term Results from Probiotics

ER:

Yeah. Okay. We’ve got time for one last question and I think this will be a quick one. It says: “I had amazing results with the first formula of Prescript-Assist. My constipation and acid reflux went away and my gut seemed to be working great. They changed their formula and when I tried the new formula, I did not have the same result. What should I take instead?”

DrMR:

They did change their formula.

ER:

I remember that. Was that a couple years ago?

DrMR:

Yeah. It was a few years ago. It’s an interesting formula and it got a lot of exposure early on. However, I believe out of the 28 species in that formula, only four had interventional evidence. I do think that’s important. Some people go too down the rabbit hole with probiotics. They go overly fastidious and they try to make the argument that you need a very specific strain for a specific condition. That’s probably going in this evidence limited direction where you’re not able to think past the reductionistic science. I think going too far in the other direction would be the Prescript-Assist formula that doesn’t have interventional data for the majority of the species in their formula. Now, to your question, what should you use instead? The way that we organize this is if you look at the probiotic formulas on the market (the ones that have been used in the research), there’s a clear and general trend that they break down into one of three categorical types.

DrMR:

Saccharomyces boulardii, or Florastor is one of the big name brands — there’s a whole boatload of studies that have used this probiotic just as Saccharomyces boulardii. And like you’re referencing, there are these soil-based probiotics. There are a few different formulas of these soil-based probiotics using one or two or three or four different species. And then there’s your traditional Lactobacillus and Bifidobacterium blend probiotics. They all have the requisite evidence to show their safety and utility. What should you use? If you’re someone who is sensitive, you can trial one at a time. If you had results with a soil-based probiotic in the past, use a soil-based probiotic. We make one called ‘Soil-Based Probiotic’ and there are others out there in the market that are also good. Obviously just make sure you do some fact checking and you use a quality company. Now, if you’re not sensitive, you may want to try our ‘Triple Therapy Probiotic Powder Sticks’ because that takes the three formulas – the soil-based probiotic + the Saccharomyces boulardii probiotic + the Lactobacillus and Bifidobacterium blend probiotic (the three different categorical types) – and our hypothesis is it seems to be more effective because you’re going to have a clinical dose of three different formulas in one. And that may be all you need. It’s not uncommon for people to see some response to a probiotic, and then maybe they only see that in a fleeting or short-term way. In fact, that’s not an uncommon response in functional gastrointestinal disorders at large. And that likely means you just haven’t found the right combination of supports yet to hold your system in balance. I wouldn’t be disconcerned by that. I’m not insinuating that you are, but just to put the perspective out there that you wouldn’t be alone in trying something, seeing a result, and then losing some of that result. Was it because of the formula change? Maybe. Or it may be that you just need a more comprehensive probiotic and/or a more comprehensive holistic approach where you’re going to integrate in lifestyle, dietary interventions, and other supportive gut interventions.

ER:

Yeah. That’s very familiar. I can’t tell you how many times I’ve seen questions come through like “I took rifaximin for SIBO and I felt great while I was taking it and now it doesn’t work anymore.” Or “The second time I took it, I didn’t feel it.” So yeah, it’s pretty common.

DrMR:

And just as a quick anecdote here — I’ll probably reference this study a bunch of times because it’s a somewhat pivotal finding. There was a paper published recently. I believe this was from World Journal of Meta-Analysis. When they were looking at the impact of the clinical trials and what impact probiotic supplementation had on SIBO, it averaged out to (I believe) 52%. Now, if you then added rifaximin on top of probiotics, it went from 52% to 85%. It articulates that if you combined therapies, you get better outcomes. This is exactly what we’ve been doing at the clinic. At the clinic, we’re getting that clinical signal. We really try to vector our care in these series of guided experiments where we’re isolating variables and reducing noise. And this is why I wrote about this in Healthy Gut, Healthy You and I’ve advocated for this stepwise approach.

DrMR:

One of the branches, when you you’re coming down that trunk, is antimicrobial therapy (whether that be antimicrobials or rifaximin.) These recommendations that may seem prescient are what a good clinician will discover if they’re really listening to their patients. This is exactly why we recommend not jumping right to antimicrobial therapy; to instead start with probiotic therapy, see your response, and then the next branch you may want to consider is something like either herbal antimicrobials or rifaximin. I just want to echo that because it fits here. In your case, level one might be just one probiotic. Level two could be probiotic triple therapy. And if that’s still not enough, you’ve now really qualified yourself and can move onto step three, which would be probiotic triple therapy + either antibiotic or antimicrobial therapy.

DrMR:

And it’s these differences that seem to be – to your point, Erin – the common observation that people try something and regress. It’s these changes in thinking and these differences in how we set up the order of operations, that tends to lead to the best outcomes and the long-term outcomes. It’s not that complicated. It just takes the right paradigm – a little bit of wisdom through a lot of clinical observation. I just want to try to echo that these things aren’t that hard once you have a model and you get all this other stuff out of the way. You don’t chase Lyme when it’s maybe not the causative factor. You don’t spend a few months on NMN therapy because you think that may help IBS. I’m not trying to poke fun at anyone.

DrMR:

I’m just trying to say these are all the things that have to be filtered out so they don’t get in your way. And when we share the finding as this one on the podcast, hopefully it’s insightful. But that insight is able to be appreciated when you have a filter that prevents you – again – from chasing down Lyme or the new anti-aging compound or what have you. These things typically are not as hard in practice. We just have to filter out the stuff that’s not ready to be brought into the clinical model and then have a good organizational structure for that clinical model that’s guided by biostatistics; that works you through the trunk of therapies, observes how you respond, and then picks whatever branches may be viable based upon the evolution of your symptoms.

ER:

Well said. Well, that’s all we have time for today.

DrMR:

Sweet. Well, thanks all. Thanks Erin, for letting me monologue there a little bit at the end. I just wanted to tie that in and thanks everyone for the questions. Keep them coming and we will talk to you next time.

ER:

That was like an Oscar nominee level monologue right there.

DrMR:

Thanks. Appreciate it.

ER:

Great. See you next time.

DrMR:

See ya. Bye-Bye.

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