Listener Questions: Is Paleo Healthy? Is Fasting Good or Bad? What to Do When Gluten Free Doesn’t Work

I’m turning over a new leaf in 2017 to answer our listener questions monthly. Today I’ll answer some January questions, and here is what we will cover. Is paleo healthy? Fasting, good or bad? What to do when gluten free doesn’t work. Constipation being caused by prokinetics.

In This Episode

Episode Intro … 00:00:42
Is The Paleo Diet Unhealthy? … 00:03:31
Does Fasting Damage My Metabolism? … 00:11:18
Dr. Ruscio Resources … 00:17:22
Does Gluten-Free Diet Heal the Gut? … 00:18:18
Can Iberogast Cause Constipation? … 00:25:55
Episode Wrap Up … 00:32:14

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Episode Intro

Dr. Michael Ruscio: Hey, everyone. Welcome to Dr. Ruscio Radio. Today, we’re going to do something a little different, something I’ve been wanting to do for a while, which is get into some of the listener questions that have been admittedly accruing for a while now.

And part of the reason why I haven’t done admittedly a great job about answering listener questions is my own fault, I guess you could say. I don’t like to really answer a question unless I really know the answer, meaning it’s something I consider myself to be highly knowledgeable in both clinically and from a research perspective.

And so to answer a question, sometimes it would literally take hours and hours of research, reflection on that research, and then thought. And in operating under that pretense, it’s going to be very hard for me to answer a lot of questions.

So I changed my expectations a little bit to the expectation to be able to answer some questions without giving you an incredibly well-researched overview of what the medical literature says that takes a copious amount of time and, in some cases, rather give you more my opinion.

And I’ll let you know when my opinion is based upon an extensive review or when my opinion is based more upon a partial knowledge of the evidence and my own clinical reflections.

And I don’t think people are going to mind this. I think I was maybe holding myself to too high of a standard. So now that I’m not going to hold myself to the standard of giving you maybe the most evidence-based answer that one could give to every question, I think we’ll be able to get some headway here.

Sometimes, I have the evidence-based answer to a question available right in my notes. Sometimes, I don’t. And if I don’t, I’ll let you know.

And maybe one other thing here really quick. The reason why I’ve been hesitant to offer just my opinion is because I think this happens way too much in the healthcare space.

And it’s people who offer their opinion up too freely with, I think, the best intentions, but it’s when people are offering their opinion up too freely that we get all these conflicting opinions out there.

And I don’t want to be another voice contributing to the confusion, especially if I’m giving an answer based upon my opinion that’s not very accurate. So that’s the reason why I’ve been tenuous about answering questions more so based upon my opinions.

But I think if I frame this and I preface answers the right way, then we should avoid confusion and collectively, hopefully, move toward additional clarity.

Is The Paleo Diet Unhealthy?

So the first one isn’t actually one person’s question that I’m going to quote like I will for most of them. But a few people had asked me about—there was some nutritional body that essentially voted the Paleo Diet and the Whole30 as one of the most unhealthy diets. So I’m sure you guys have probably heard defenses of this elsewhere.

But I just wanted to speak to this briefly. From a more foundational perspective, I think this is really sad. It’s sad when—and this is one of the things that admittedly gets me the most aggravated. So if we were ever having a glass of wine or a beer together, you’d get the really unfiltered version of this which can be quite graphic because it really upsets me.

But when people who have academic credentials hide behind a veil of being an expert when they don’t actually have the expert level knowledge, meaning they haven’t performed, for example, a comprehensive review of the literature, but they’re hiding behind their perceived expertise that is in accordance with their credentials or whatever it is.

The reason why that irritates me is it’s a direct violation of your trust. If you’re looking to someone, expecting them to be an expert, but they haven’t put in the hard work to become the expert, then that’s a violation of your trust.

And it also is a violation of your trust if that person put in the work to become an expert nine years ago, got a degree, but hasn’t stayed up to date with the expert level of knowledge since then. It makes me very mad.

So I think this is one of the key causes of the fact that some nutritionists still call the Paleo diet one of the most unhealthy diets. Now, I don’t think we need to say it’s the healthiest diet. But certainly, to say it’s one of the most unhealthy diets is way off the mark.

So let’s go into a few supports for this. And the way that I think we can answer this question most directly is when we look at any trials that compare a more standard “healthy” diet, which tends to be higher carb, lower fat, oftentimes higher grain. That’s your standard nutritional advice.

When we compare that in a head-to-head trial to a Paleo diet or to a lower carb diet, which are both fairly different than the standard nutritional advice but also tend to have quite a bit of similarities.

So this is the best way, when we compare one healthy diet to another healthy diet. So we would be considering standard nutritional advice to be a “healthy” diet, the Paleo diet to be a “healthy” diet, a lower carb diet to be a “healthy” diet.

And we’re going to compare those and see which one is the best. This is one of the most direct and logical ways to assess what diet is better.

So the clinical trial [1] comparing a low carb diet to more traditional dietary advice found a low carb diet worked better for type 2 diabetes. This was reflected in yet another randomized control trial [2]. And a Paleo diet has been shown to work better than conventional low fat, higher grain type diets for type 2 diabetes also.

So two randomized control trials looking at low carb versus standard advice found low carb was better for type 2 diabetes. And a Paleo diet compared to conventional dietary advice was better for type 2 diabetes also [3].

Now, I’ll put those links in the transcript. Also, I’ll put in a number of links showing there are many studies—and this is important for us to recognize on the other side of this argument—showing that traditional, low fat, high carb diets are actually helpful for heart disease and obesity. Those trials are out there. [4, 5, 6, 7, 8, 9]

So we can’t say that these are unhealthy diets if we’re truly going to be objective. But let’s continue the conversation here and look at what happens, again, when we compare a Paleo or a lower carb type of diet to those more traditional type diets because they can all work. But the question is which one might work better.

So a recent trial [10] found that the Paleo diet improves cholesterol levels to a greater extent than traditional dietary advice. Another comparative trial [11] found that the Paleo diet for only two weeks was able to improve cardiovascular risk factors more so compared to a traditional healthy diet in a group of patients with metabolic syndrome.

Another study [12] found that the Paleo diet caused better improvements to blood sugar and cardiovascular risk factors compared to traditional dietary advice. And this is in a group of patients with type 2 diabetes.

And very importantly, a systematic review with meta-analysis—so this is going to give us the summary of most of the available clinical trials—showed the Paleo diet is more effective for metabolic syndrome than standard nutritional recommendations, which are typically lower in fat and higher in carb—very important study there [13].

And for weight loss, another systematic review with meta-analysis of 53 studies found that lower carb diets are better for weight loss than lower fat diets [14].

So when we look at these studies and we’re objective about this, I think this is the only conclusion you can arrive at. Traditional dietary advice can be beneficial for people. However, there are some very compelling trials that have shown that while, yes, traditional dietary advice can be helpful, the Paleo diet, when compared directly to those, seems to have a slight edge.

So how a person at a nutritional university or with nutritional credentials can come off saying that the Paleo diet is one of the most unhealthy diets I think is really an admonition of dogma—dogma in this case being, “My traditional nutritional training told me that protein is bad and fat is bad because of older research that lumped in the Western diet that had higher fat and protein consumption along with sugar, trans fat, and other processed foods.”

Now, when we fast forward into the new millennium here and we look at contemporary literature, we see that when we parse out and take away those unhealthy aspects of a higher protein and higher fat diet and also include healthy amounts of vegetables, as the Paleo diet recommends, we see it actually performs better.

So that is my conclusion there. And that is based upon a fairly extensive review of the literature. A lot of this was done for the book. And you’ll get a nice narrative on this in the book. But there is some fodder for your argument.

And if you do have this argument with people, I would not attack them. I would put it just the way I put it because we don’t want to make them wrong in order to make us right. That just creates a polarized conversation that goes nowhere.

But rather, let’s acknowledge that, yes, the higher carb, lower fat diet does have utility when compared to a standard American diet. However, again, the head-to-head trials show a slight edge for lower carb and/or for Paleo.

Does Fasting Damage My Metabolism?

Okay, moving on. Caroline Hillseth-Liu on, I think this was Facebook, had this question. I’m going to read it here.

“Hi, Dr. Ruscio. I heard your last video about fasting this morning. I qualify under the set of those who would benefit the most according to what you said. I am a post-menopausal and—” so the English here isn’t always proper.

So, “I am post-menopausal and I suspect very insulin resistant because I have not lost weight at all in 18 years since I had my first child. And now, I am 75 pounds overweight and desperate to find something that might work well.

“Way before that, 25 years ago when my metabolism actually worked, I was a bit overweight and decided to lose weight. I had no plan but decided to eat every other day and see how well that went.

“Well, I lost 30 pounds. Of course, I did Jazzercise every other day, too. So that helped a lot. Still, I was doing that before my diet habit changed mattered. Back then, if I told someone what I was doing, all they said was I was stupid because I didn’t eat like five times a day with small meals and that my metabolism would shut down because it would think I was starving.

“Although it did make sense, it did not explain why I was still able to lose weight at that time from fasting. So people still give me this argument. What do you think?”

So I’ll put a link to the video that she’s referencing in the notes [15]. And when I look at fasting, I look at people who fall into a camp of having a high likelihood of success with fasting and the other camp, people who might want to be most cautious with fasting.

So the people who will likely do the best with fasting—those who are overweight, have metabolic syndrome, high blood sugar, high insulin, high cholesterol, or diabetics—this kind of metabolic excess and also those with gut issues. Many people with gut issues tend to do well with fasting.

Those who should be cautious are those who are underweight, fatigued, burnt out, with chronic stress, not sleeping well, are prone toward hypoglycemia, or feeling like they don’t do well when they miss meals.

So that can help you determine if you’re more likely to do well or more likely not to do well. And I’m working toward the other aspect of your answer here also.

Now, a modified fast or intermittent fasting might be the happy medium. A modified fast is not a true fast, but you have some sort of liquid nutrition to get something in your system, like bone broth or the Master’s Cleanse which is a lemonade/maple syrup type of solution, or even using an elemental diet.

And intermittent fasting is just skipping several hours in the day and then eating potentially lunch and definitely dinner.

And I just read a study—I do not have the link for this, so I’m sorry. I won’t be putting this in the show notes. But I was reading a study where they put two groups of people on essentially the same diet. But all they changed between the groups was one group partitioned their meals into only, I think, a six-hour window during the day. And the other group was able to eat the same amount of food in a more expanded window.

And they actually showed favor for the group that was eating their meals in a shorter window, which is essentially intermittent fast. So essentially, what they did was they skipped breakfast. And their only meals were a lunch and a dinner and maybe an evening snack. Instead, the other group had more of your typical expanded window where they ate at breakfast, at lunch, and at dinner.

So we do see some evidence here, theories aside, that intermittent fasting can be helpful. And I should maybe say that my answer here is not based upon an extensive review of the literature. But there’s just some common sense that I’m applying here. So I should make that caveat.

Coming to the question of damaging your metabolism, I always wonder what exactly does that mean because it’s kind of a vague concept. You can make an argument, or one could say that your thyroid hormones may shift. This is true. But this is non-pathogenic.

And again, I don’t have the link handy for this. But if you go to the search box on our homepage and type in “thyroid and carbs” or “carbs and thyroid,” some combination of those two terms, you should find the episode where we reviewed low carb diets and their impact on thyroid hormone.

And essentially, it’s a non-pathogenic shift that’s usually short-lived. There are a few other details there, but that’s the essential summary of it.

Now, fasting is also part of the evolutionary pressure that shaped our metabolism. So the feeding and fasting cycle, fasting being part of that cycle, is a natural part of our metabolism. So I don’t really agree with the premise that fasting is universally bad.

And there has been quite a bit of research and even entire books written about the positive effect, a fasting effect. It’s funny that you had the plan, Caroline, to eat every other day. One book on fasting, I believe, is called The Every Other Day Diet. So you’re onto something with that.

So what does this all come down to? In my opinion, here, learn to listen to your body to find your own truth regarding fasting. There are some people who will not do well with fasting—someone, for example, who tends to gravitate or be more prone to hypoglycemia.

Someone who is overweight and type 2 diabetic is likely to do very well. So learn to listen to your own body. You may want to see that video for some other tips and guidelines that I provide. But I think it can be quite beneficial for some people but not for everyone.

Dr. Ruscio Resources

Hey, everyone. In case you’re someone who is in need of help or would like to learn more, I just wanted to take a moment to let you know what resources are available. For those who would like to become a patient, you can find all that information at DrRuscio.com/GetHelp.

For those who are looking for more of a self-help approach and/or to learn more about the gut and the microbiota, you can request to be notified when my print book becomes available at DrRuscio.com/GutBook. You can also get a copy of my free 25-page gut health e-book there.

And finally, if you’re a healthcare practitioner looking to learn more about my functional medicine approach, you can visit DrRuscio.com/Review. All of these pages are at the DrRuscio.com URL, which is D-R-R-U-S-C-I-O.com, then slash either “GetHelp,” “GutBook,” or “Review.” Okay? Back to the show.

Does Gluten-Free Diet Heal The Gut?

Okay. The final question here, depending on time—Ah, I didn’t put the person’s name in here. Sorry. So to whoever posted this, sorry. I accidentally didn’t include your name. But the comment was, “Dr. Ruscio, could you comment on this article by Dr. Fasano? It’s concerning. Thanks.”

And then, if you go to the article—I’ll put the link to the article in here, “Prolonged Gluten-Free Diets Don’t Heal Guts, New Study Finds.” So let’s dig into this [16].

Essentially, what the study they’re referencing here found was persistent intestinal damage in 19% of subjects was still there after one year on a gluten-free diet. So 19% of people still had intestinal damage after being gluten-free for one year.

So what does this mean? And when I see this, I can immediately see this as being a leverage point for the people who want to be crazy in their approach to health, to diet, to functional medicine.

And this is going to be a study [17], I’m sure, that will be referenced to sell a whole bunch of food allergy testing and leaky gut testing and trying to coerce or scare people into needing to do more restrictive diets than they need to do.

So this is an area I know quite well. And this answer is based upon quite an extensive review of the literature. It’s not to say that more shouldn’t be done. And I’ll get to some specific recommendations in a moment.

But philosophically, theoretically, let’s be careful about not using a piece of information like this to scare people to fear people. And already, this person is expressing their concern after reading it.

So I think it’s something that, if you’re a healthcare provider, you have to be very tactful in how you communicate this sort of information with your patients. If your patients bring this to you, you want to be very tactful in how you address this.

And if you’re a patient reading this, speaking with your friends or family, what have you, not using this as a leverage point to try to scare people into a heretical type of diet.

So there have been some very well-defined factors that are known to be present in people who are what’s known as non-responsive celiac patients or those who are non-responsive to a gluten-free diet.

So this isn’t a mystery. This has been fairly well documented. And I’ll link to two, I believe they’re systematic reviews, that cover this. So this is definitely based upon pretty conventional, conservative, medical evidence.

But here are the factors that are known to cause people not to respond to a gluten-free diet: other food allergies, small intestinal bacterial overgrowth, poor secretion of digestive enzymes and acid, H. pylori bacterial infections, use of NSAIDs (non-steroidal anti-inflammatories like Advil, Motrin, and Tylenol). [18, 19]

So based upon this, what should you do? Try a few other diets. Try Paleo. Try low FODMAP. Do you need to live in fear of food? Do you need to never have a glass of wine? Do you need to stop going out with your friends because you’re in fear of one small amount of FODMAP in the dinner you’re going to get? No, don’t go to that place.

But what you should do is be strict Paleo for two to three weeks. Or if you want to go the extra mile, try Autoimmune Paleo for two to three weeks. If you notice an improvement, you’re on the right track. If you don’t, move on.

The next diet I would try would be low FODMAP. Give that a two to three week strict trial. Then open up your boundaries.

For all these diets, be strict for a couple weeks. If it’s needed, if it’s getting to the cause of the issue, you should notice pretty noticeable and pretty swift improvement. And then after a period of time, at least a month, you can go into reintroduction so you can have a normal life and not have to be on this highly restrictive diet forever. And in the book, we go into some guidelines to helping people walk through this.

So if that doesn’t work, you can try an enzyme. Based upon what the research shows, you can try enzymes. Pancreatic enzymes, bile, and acid are the three things that you want to look for in an enzyme.

And not in here, not listed directly in what’s been published, is trying a probiotic, because probiotics can help with food allergies, with SIBO. They can also help with H. pylori and with gut healing. So try a probiotic also.

Now, should those things fail, screen for SIBO, H. pylori, and other infections or dysbiosis.

And finally, get off any non-steroidal anti-inflammatory drugs. If you’re using lots of Advil or ibuprofen or what have you, try to figure out what’s causing the need for those things and work to reduce or eliminate the amount of those that you’re using.

Now, there are natural anti-inflammatories as alternatives. Or it might be some sort of structural imbalance that you have. We had Dr. Jeff Johnson on talking about the therapy that he uses to help with chronic muscle aches and pulls and imbalances that cause pain and what have you. So investigate the factors that are leading you to need these NSAIDs chronically.

What you should not do, and unfortunately, this is probably as important as what you should do—food allergy testing. I don’t think you need to go spend $300, $500, $900, $1200 to get an extensive array of food allergy tests.

Try Paleo. Try Autoimmune Paleo. Try low FODMAP. You are going to cover most of your bases regarding other food allergies or intolerances just by doing those. And those are free.

Leaky gut testing is not going to tell you where the problem is coming from. Save yourself a few hundred bucks.

Gut autoimmunity testing is not going to tell you where the problem is coming from for the most part. Maybe something end-phased with a skilled clinician who is conservative, yes.

Should you go out and do gut autoimmunity testing on your own because you think it’s going to give you this Holy Grail, magic answer to your problems? No. See the list that I just went through. That’s where you are most likely to find the cause of the problem.

Fancy, non-clinical microbiota assays—do you need to map your microbiota? No, because it tells you nothing about how to fix this problem. It’s very interesting to see Fusobacter high, Proteobactor low. Oh my goodness!

But what that tells us in terms of what you should do clinically? Nothing. And what those actually mean actually tells very little. So those are not things that you need to do. Save your money.

This is relevant and important because doing the should-do’s and not doing the don’t-do’s is how you will save yourself hundreds to thousands of dollars in recouping your health.

So I keep coming back to this cost effective model of functional medicine. It’s decisions like this that will dictate thousands of dollars spent or thousands of dollars saved.

So that’s really the brunt of those questions there. I’m just going to look at my list to see if I can do one more of these questions because we have a little more time.

Can Iberogast Cause Constipation?

Okay. This is a Twitter question. And I didn’t really take a moment to prep for this one. So it’ll be a little bit on the fly. But Yanni Wolf asks, “Could Iberogast somehow cause constipation? I have hydrogen SIBO and Crohn’s, currently on anti-microbials for SIBO.”

So this is a good question. Now, Iberogast is a prokinetic. Prokinetics are just agents that help to ensure that the food contents in the intestines are essentially moving stuff through and down because stuff should flow in a downward direction from your mouth to your esophagus, to your small intestine, to your large intestine, out your rectum, and gone.

So flowing food is good, stagnant food is bad, just like flowing water does not foster bacteria growth, and stagnant pond water does. So it’s important to keep things moving from the perspective of general health, from preventing overgrowths of bacteria and fungus like SIBO and SIFO. And also, prokinetics can help people who have constipation.

Now, the prucalopride—I always have a hard time saying that medication, it’s also known as Resolor—is probably the best studied and documented prokinetic prescription for constipation. The literature is pretty clear on that.

Now, Iberogast has also been studied. It has more literature looking at its function as a prokinetic for the upper gastrointestinal tract—so stomach, small intestine. That’s where we see the majority of the benefit.

If I could record one podcast without an ambulance or a cop car going by, that’d be great! You’d think I live in the Bronx or something.

So Iberogast has some impressive studies as an upper GI prokinetic. It’d be weird, paradoxical, for something that’s supposed to improve constipation to cause constipation. In the clinic, I certainly see some people, not a ton of people, who immediately notice when they go on Iberogast that their constipation improves.

So the question here is “Could Iberogast actually cause constipation?” Well, anything is possible. Sometimes there are what’s known as paradoxical responders, where you give something that should do X but it actually causes the opposite of X. So melatonin is a common sleep aid. Some people take melatonin, and they get wired from it.

So you could be a paradoxical responder, where Iberogast should help with your constipation, but instead of helping with your constipation, it actually makes it worse. So you may simply be a paradoxical responder.

You could sort that out by discontinuing, going back on, and seeing if the constipation gets better and then comes back as you go off and on. And if you see that relationship consistent after a couple re-trials or trials in general, then it tells you that you’re probably just a paradoxical responder to Iberogast and it’s causing your constipation.

Now, the other interesting thing here is the Crohn’s. Now, one has to be a little cautious with Crohn’s. And exactly where I fall on this in terms of my clinical opinion, I’m still making up my mind. But one of the things that can be contraindicated in any type of inflammatory bowel disease, including Crohn’s, ulcerative colitis, collagenous colitis, indeterminate colitis, what have you, lymphocytic colitis—one of the things that can be contraindicated in those conditions is prokinetics.

Why is this? Well, simply put, when people have IBD, a common symptom is diarrhea. So giving an agent that helps you move things more quickly is contraindicated.

Part of this may have to do because of serotonin receptor sensitivity or serotonin signaling in the gut. There is some evidence that suggests that people with Crohn’s, ulcerative colitis, IBD in general may be overly sensitive to serotonin signaling. Or they may have very sensitive serotonin receptors that essentially is part of the reason why they have this predilection toward diarrhea.

So of course, giving something like a prokinetic that usually works via the serotonin receptors in the gut could be contraindicated because you’re turning up what already might be too highly turned up, so to speak.

So that’s something to be aware of. It sounds like you’re having the opposite problem. But you have to think about these things more broadly. And here’s what I mean. Yanni has SIBO. And she has IBD. Now, she really may not need to be on a prokinetic because a prokinetic may make her Crohn’s and the symptoms of diarrhea worse.

Now, I’m not sure if she, at baseline, has constipation or diarrhea. But really, in my opinion, the better evidence for using a prokinetic is in people that have constipation-type SIBO and/or have SIBO in general but do not have IBD.

You have to be a little more careful with prokinetics in people with IBD because you may exacerbate one of the main symptoms of IBD, which is diarrhea.

Again, in Yanni’s case, it may even be working in a highly beneficial way because if you’re going from +5 bowel movements a day, now down to one or two, if that’s how you’re defining constipation, then Iberogast may be working beautifully for you.

This is a very difficult question to give you a specific answer to because the clinical context here is far more important than any of the specific data pieces that contribute to this answer. So ultimately, find a good clinician. Follow that clinician’s lead.

And in short answer to your question, it is possible that it could be causing constipation through the paradoxical response. Also, be on the lookout for if this seems to eventually start to cause your gut to go the other way, because that’s something to be cognizant of in people with IBD. So that’s the answer to that question.

Episode Wrap Up

And hopefully, this Q & A forum has been helpful for you guys. I’m curious to get your feedback on how much you liked it. So feel free to leave me a note in the comments section.

And also, I’m going to do a much better job about answering questions. My goal is to do one episode a month that reviews questions that have come in.

So I know that there were a few questions that I’ve been sitting on for a while. So I’m working my way around to those for the people who’ve submitted those probably a year and a half ago and are saying, “What the heck, Dr. Ruscio! You never answered my question.” I’ll work my way around to those, turning over a new leaf here now that the book is done and I have a little bit of my life back.

So once a month is what I’m shooting for to answer some of these questions. I like this format because it gives me a chance to just give you a little more of an opinion on some things and not have to go into such a detailed review of the literature. But let me know what you think. Keep your questions coming in.

I’ll do my best to keep answering them. And as always, thank you, guys, for your continued support of the podcast. Alright, we’ll talk to you next time. Bye-bye.