Listener Questions on Thyroid, Diabetes, Keto, COVID Vaccine

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.

DrMichaelRuscio:

Hey, everyone. Welcome back to another episode of Dr. Ruscio Radio. This is Dr. Ruscio back again with Erin Ryan and more listener questions. Shall we attempt to answer? Hey, Erin.

ErinRyan:

Hey. Yes, we have more listener questions. Thank you everybody for submitting your audio questions and written questions. We’ve got a lot to get through today. So, let’s get started. This first question is from Mary.

Listener Question #1: Diabetes & Blood Sugar Dysregulation

Mary:

Hi, Dr. Ruscio. I have yet another question for you about the relationship between the gut and the thyroid, but I’ve not been able to find any great answers on the details of my particular situation. Essentially, my question is – Can diabetes or blood sugar dysregulation affect thyroid function? The very short version of my situation is that it looks like I’ve recently become pre-diabetic because of a genetic condition I have that does progressive damage to the pancreas. I’ve also been having hypothyroid symptoms, and my thyroid labs showed slowed thyroid function compared to a couple of years ago, (but not full blown hypothyroidism.) So, while I work on stabilizing my blood sugar, I’m trying to parse whether the slowed thyroid is a separate issue or not; whether those symptoms could likely be resolved by stabilizing blood sugar, or if I need to work on this separately. Brief background – I’ve also been dealing with severe intestinal permeability and histamine intolerance for over a year at this point. That is because of a medication I’m taking that has affected my GI tract, but which I have to keep taking because of its benefits in other ways. So, I also assume that it’s possible that maybe just the overall inflammation and stress from that has affected my thyroid separately from the blood sugar issues, but I would be interested to hear your thoughts on that, as well. I know that’s a lot, but thank you so much.

DrMR:

Yeah, a few things there to unpack, but definitely always happy to field these questions on thyroid because it is quite disturbing how often patients are given very damaging advice regarding their thyroid. Again, I always try to catch myself here and parse out the fact that I see people, as I’ve said many times before, break down crying in the office because they’ve been given wrong advice. Separate that from the fact that those who might be giving sub-optimal advice are doing the best they can. I think a decent causative reason for some of this is just problems in the educational system. So, to answer your question, it is potential that blood sugar is affecting thyroid, but the really important thing to keep in mind here is that it is almost for certain not having any clinically relevant impact. I’m sure if we looked hard enough, we might find some sort of analysis that found that patients with probably frank diabetes is what we could find in the research literature. This correlates with some sort of perturbation in thyroid hormone levels, but it’s not a perturbation that’s clinically significant. We may see a clustering of those diabetes where they have slightly higher free T4 or slightly lower free T4, but they’re still within the normal range. This is interesting academic, but not anything that’s clinically relevant. It sounds like what’s much more relevant for you are the issues in the gut with the histamine and the permeability. Those are definitely things that will likely be the most important for you to address and to pursue.

DrMR:

Regarding the diabetes, I’m not sure if you’re referring to latent autoimmune diabetes in adults (LADA) where people essentially have this delayed onset type 1 autoimmune diabetes. That may be what you’re referring to. If that’s the case, then that’s something to definitely look into. It sounds like the big factor here is gut related. The slow thyroid – I think that needs to start being called out as something that does not help patients. It’s incorrect in its framing in the sense that there doesn’t really seem to be a thing – I think a slow thyroid thing is incorrect. It’s telling someone who is fine, that they have a thing. This has been fairly well bore out by the fact that subclinical hypothyroidism – a more accurate way of identifying what some call slow thyroid – has been shown to have no correlation for the most part to symptoms. The most definitive and compelling data is that these patients do not benefit from any kind of thyroid hormone replacement therapy. Most of these patients will see their thyroid go right back squarely into the normal range with time and with no intervention. This nitpicking reading of thyroid labs, according to our very comprehensive and repeat reviews of the published literature combined with our own clinical analysis and reflection on this, shows that “slow thyroid” is not a thing.

DrMR:

If you’re seeing a slight creep up of your TSH to 3 or 4 or 5… it doesn’t really seem to matter. If your free T4 is getting close to that cutoff of 0.8 and it’s maybe 9 or 1.0, this does not seem to matter. I don’t think we should be calling it slow thyroid. It’s almost like saying, “Well, you’re almost SIBO.” That’s not really helpful. In fact, even those who are technically SIBO, but just barely over the cusp, I’ll often say, “It’s technically positive.” If I were a robot and I had to pick a binary yes or no, then I’d be forced to spit out a positive, but the fact that you’re three points over the cutoff is not something that’s likely clinically relevant. I think it’s really important to understand this slow thyroid is something that I see do far more harm to individuals than good. Delineated from frank hypothyroidism – this is a legit thing that has been shown, of course, to require and benefit from medication.

DrMR:

In your case, the most important thing to focus on would be whatever’s going on in the gut and with histamine. Putting on my clinician’s hat on for a moment, what you are saying raises some alarm bells in my mind. There have been enough times where I’ve heard this sort of explanation from patients as they’re going through the intake. Then, I look at the labs that underlie this or the evidence supporting some of these syndromes that you’re describing. I’m getting that spider sense go off that some of what you’ve been told, I would question. Now, take that with a massive grain of salt, because this is just one small snippet, but I just want to kind of cue you into what my intuitive read there is. You may want to get another opinion. Some of this flags for me as this super theoretical realm of integrative healthcare, which is trying to help people, but unfortunately has some stuff wrong and ends up harming people.

The Dangers of Overdiagnosis

ER:

Well said. It sounds like when you leave a doctor’s office or clinician’s office with a grab bag of diagnoses, you’re like, “Well, which one do I start on?”

DrMR:

Yes. That’s actually well said. I just want to echo that. I think the more theoretical you become in functional medicine, the more quickly you have diagnosed a handout. This hearkens back to something that Nick Hedberg sent me. It was a hand drawn image, just as a joke, but he called it the Hedberg-Ruscio effect. He drew out on the one access – the amount of supplements and tests used and on the other access – practitioner competency. He was trying to show us there’s an inverse relationship between the amount of tests and supplements you use and the competency of the practitioner. Of course, the more tests you use, the more diagnoses you come up with. That is admittedly a little bit of a dig, but I think there’s definitely some truth to that.

ER:

Well, I was probably way too embarrassed to ever say this out loud to anyone or on this podcast, but there was a point when I was searching for what was going on with me. It was the classic story of all the very extreme SIBO type symptoms and no one could really name it. I went into this health store one time who had this practitioner of some kind – I don’t even know what his title was – but, he was like, “I can help you. I can help you.” He sat me down and looked at my tongue, my eyes and my nail beds, and then sold me – are you ready for this? – $385 worth of supplements.

ER:

So, with my health history, I’m so embarrassed to admit this, but I was a year and a half in. I would have done anything. I can’t even describe to you how many of these scenarios I’ve been in in my life until thankfully, I found you. I went back two days later because, of course, a handful of supplements made me extremely sick. Anyway, I went back. My dad went with me just because I didn’t have the energy to go back and be like, “You gotta make this right. I think you totally just sold me a bunch of supplements because you knew I was desperate.” My own dad went with me and was like, “I oughta sue you!” It was so sad and so embarrassing. I don’t think I’ve ever told anyone that before – not that this is her scenario – but, I’m just saying how easily you can put your faith and trust into someone that you think can help you. They tell you that you have all these things wrong based on your nail beds.

DrMR:

Right. I think there is some legitimacy to some of that because it sounds like a traditional Chinese medical assessment. However, it doesn’t mean that it was being applied the right way. It was probably overkill and this clearly wasn’t working in a clinical setting. So, it could be someone who either was ripping off TCM or maybe knew enough about it to be dangerous. So, I don’t want to throw that baby out with the bath water. Your example is still a great one, which is essentially over-diagnosis and definitely over-treatment. To your other point, which I think is phenomenal and ties in with this case… when people aren’t feeling well, they’re really amenable to theory.

DrMR:

This is why I try to always remind people that I’m not discrediting your symptoms. I’m just crediting the specious story that whatever educator is feeding you. “It’s thyroid… it’s this slow thyroid…” This whole story about that, which I myself was pulled into for years in clinical practice. I want people armed with other options and better knowledge in terms of, “Okay, I want to get better, but how can I go after what’s really the cause and not what is just sadly, the most appealing?” Therefore, it gains the most clicks on social media, visibility in the Google algorithm and on YouTube. It’s a real problem that healthcare has to contend with. The other side of the slippery slope, which I do not advocate at all, is censorship because then you get some of what we’ve seen where certain health platforms are getting shut down because they’re not following CDC recommendations or whatever it is. Then it’s like we’re going into a kind of health autocracy. So, I guess it’s buyer beware, do a good job educating yourself and hopefully avoid some of those pitfalls that – you and I both, Erin – have gotten sucked into.

ER:

Get multiple opinions, if you can.

DrMR:

Definitely.

Listener Question #2: Fasting Symptoms

ER:

Alright. So, our next question is – Are headaches, POTS (postural orthostatic tachycardia syndrome) reactions and heart racing common symptoms of fasting?

DrMR:

Great question. For our audience – POTS is essentially this postural orthostatic hypotension – or said more simply, people who get dizzy with standing and have heart racing. So, this headache, low blood pressure and dizziness when standing could be a symptom of fasting, but I think there’s a better way to look at this. Matthew Phillips – a Canadian neurologist who does a lot with fasting and was recently on the podcast – termed it really well. What I used to call low carb flu – or maybe fasting flu – he thinks should be renamed to ‘electrolyte insufficiency syndrome.’ Electrolytes are one of the main treatments for POTS. So, my assumption here – again, just having this one sliver – would be that you probably need more electrolytes. This is really where a salt forward electrolyte like the LMNT that Robb Wolf has put together can be quite helpful.

DrMR:

I would start there. The two big things I would look at are – Are you, as an individual, skewing toward underweight/underfed/highly food reactive/food avoidant? With fasting, we may want to be a little bit more careful if any of those things are present and/or you just need more electrolytes. With fasting, there’s a Goldilocks amount for everyone. Usually the more depleted someone is, the less of this healthy stress or a fast they can tolerate, but you can get the most out of their tolerance if they have sufficient electrolytes. So, check out those LMNT packs. You can do anywhere from two to three per day and see if that helps resolve some of this.

ER:

I think if you search LMNT – just put it into the search on your website – they are a sponsor. So, they have some kind of deal going on right now where you get a free starter pack and all you have to do is pay $5 for shipping. So, that’d be a good thing to try. I actually have a follow-up question – Does something like LMNT break the fast? I’ve actually been taking LMNT in the mornings and I try to fast food-wise until at least 10:30AM/11:00AM or so. That’s what works for me, but I do take it in the morning because it’s so hot here in Texas. If I don’t, I get a migraine by the end of the day. So I’m just curious – am I breaking my fast anyway?

DrMR:

No, not at all. Electrolytes are fine. Tea or coffee is fine. A little bit of cream – okay. I have myself been doing – and now I’ve been advising patients at the clinic – to use an LMNT pack plus a fresh squeezed lemon plus a little bit of protein powder (whey or pea protein) to help them take the edge off. Now, this is for when people are trying to do something like OMAD (one meal per day), and really push through that window. I try to do the one meal per day on one day per week. However, if it’s been a social Wednesday and you went out with some friends, had some food and dessert and a few drinks and you’re like, “Wow. I just ate a whole day’s worth of calories in that one evening,” I’ll usually do OMAD the next day. To get me through that window where I usually eat around 1:00PM and I’m trying to get to 5:00PM, I’ll have another LMNT packet plus a fresh squeezed lemon plus a whey protein. That will give me some satiation and get me through the rest of that window. So, no – it doesn’t break your fast.

ER:

Cool. I don’t know if I’d recommend whey protein with the LMNT. That’s a lot of flavor going on. Do you put it in with it?

DrMR:

Yeah. It depends on what you’re using, but I’ve used the raspberry LMNT with chocolate whey protein. That goes together nicely, or they have the chocolate LMNT and I’ll use that with chocolate protein and a little bit of lemon in there. It goes together nicely.

ER:

I’m still getting used to the punch of salt. So, I’m like, “Ugh, I wouldn’t mix that with anything.” But, okay – I like that.

DrMR:

Yeah, try it.

ER:

I will.

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Listener Question #3: COVID & Gut Issues

ER:

Let’s see. I think our next question is from Elizabeth.

Elizabeth:

Hi, Dr. Ruscio. My name is Elizabeth and I listen to your podcast regularly and I love it so much. I’ve learned a great deal. My question today is regarding gut health and the vaccination. I battled C. diff (Clostridium difficile) three times. I’ve since then been battling post-infectious IBS and SIBO. I have had multiple doctors that I trust recommend that I go ahead and get the vaccination because they’re seeing long haulers in this nightmare of the pandemic being those that have poor gut health. I’ve also had many of my naturopaths tell me absolutely not – and to stay away from the vaccination. I would love your take on the vaccination for COVID for people with gut health issues. Thank you for all you do and I look forward to hearing your answer.

DrMR:

Alright. Another question that seems to have implicit embedded in it – the admonition that there can be bias in both communities. In this case, it sounds more like the natural health community having this positional vaccine hesitancy. Now, I am not someone who’s been scouring the evidence on COVID-19. I’ve kept generally abreast. His moniker online is @ZDoggMD – Zubin Damania is how you say his proper name. I think he’s done a very good job of weighing the evidence here, and he’s been fairly impactful on my thinking. I don’t see the case for the vaccine hesitancy. I also don’t see the need to mandate or force this upon people. From what I’ve been able to gather, there’s a clear protective effect and a high level of tolerance and safety to the vaccines.

DrMR:

It seems reasonable for high risk individuals to more strongly consider the vaccine and those at lower risk to not need to worry about it so much. So, I come down in this alt middle approach where I see both sides. I don’t think there is evidence strong enough to make you want to tar and feather your unvaccinated neighbor. I also don’t think you get 5G internet reception after you’ve had the vaccine or Bill Gates is trying to track you and perform some sort of campaign to sterilize society. I would make this more pragmatic based upon your risk and consider the vaccine in that context. I got the Johnson & Johnson vaccine and I also had a breakthrough case. So, using my own N-of-1, the vaccine likely offered some protection and is why I had a very mild case.

DrMR:

I also wasn’t really sweating it. I kind of waited until I could work it into my schedule conveniently because I wasn’t in contact with unvaccinated high risk populations. Nor did I have much worry about it myself. So, kind of middle of the road. This may sound earth shatteringly, pragmatic and simple, but I’d use your own individual case and your risk to dictate what way you go on this. As it pertains to gut health, I haven’t had anyone report that they noticed their digestion flare or get worse from having the vaccination. I also haven’t been meticulously tracking this, but just in terms of day-to-day clinical operations and seeing patients, I haven’t seen that be something that’s reported.

DrMR:

I should also mention that there is evidence that probiotics reduce not only upper respiratory tract infections, but I believe there’s at least one trial now that found better outcomes with COVID-19 when people were using probiotics. I’m very careful in making that statement because one thing I would never want to do is draw an inference that supports something that I favor probiotics, leveraging the fact that people are scared of COVID-19 and using their fear as a lever to better position things that I’m an advocate for. I’ve been careful to state that up until recently, there was pretty good evidence that found that upper respiratory tract infection, incidence, severity and duration was reduced by probiotics. I didn’t want to go so far as to say this is an essential or a mainstay of COVID-19, or just be careful in disclosing that upper respiratory tract infections – while similar to COVID-19 – are different. We now have some of that data. Would that help someone who is 78, obese and diabetic? Would probiotics be the difference between hospitalization and not? I’m not sure. I don’t think the effect size or the magnitude of benefit from probiotics was that strong. I also didn’t look at the research closely enough to see if that was kind of sussed out. I wouldn’t hang my entire hat on that one hook. It is just one other evidence point to consider. I take a fairly middle of the road, pragmatic approach on this, and I hope that helps.

ER:

Can you give me the name of that researcher one more time? I want to put it in the show notes.

DrMR:

@ZDoggMD. He does certain parodies also. I think he got his start doing these medical parody music videos, but he’s also a very sharp guy and an objective thinker.

ER:

And creative, too.

DrMR:

Definitely.

Listener Question #4: Keto Dieting & Thyroid

ER:

Alright. Next question is – Is the keto diet detrimental for a functionally low thyroid? Oh, here we go again…

DrMR:

Yeah. So, it’s that same kind of specious diagnosis and it’s a canard. Low thyroid really does not seem to be a thing. Again, the low thyroid oftentimes is that someone’s TSH is not perfect – meaning it used to be 4.5 and then it became 2.5 and now I think it’s 2.0. Before we know it, you’re going to have a 0.3 variance in TSH, and if not, you’re going to be considered low thyroid. So, this TSH that’s not uber perfect combined with perhaps a free T4 that instead of being at the top end of the range (1.8) and not wanting to be below the low end of the range (0.8). Maybe you’re seeing someone with a TSH of 3.8 and a free T4 of 0.9. It’s like, “Ooh, it’s low thyroid.” It’s hard for me not to make some of those derogatory tones with my voice.

DrMR:

I really am trying to bridle myself from doing that because I used to give out that advice. I understand how compelling the argument can be and how there are people in positions of authority who are making the argument. So, let me again try to catch myself after the fact and roll back some of my poking fun. The reason that I do is because when you have the time and the resources to adequately fact-check this, as we have done numerous times, you see ample evidence that low thyroid is not really a thing. There are hormonal fluctuations in humans that is normal. No two people are going to have the same symptoms and the same hormones. Using a parallel analogy, you’ll see some men who have high normal testosterone, but many symptoms of testosterone insufficiency. This would be another example of that where people can have variations in thyroid. Some people who go on a lower carb diet, or maybe even a lower calorie diet, may see improvements in body composition, energy, but their thyroid hormones skew to this “low” or “low-normal.”

DrMR:

This is a metabolic adaptation. It’s because the body is starting to go into fasted state physiology. As it’s doing that, you’re losing weight, you’re getting energy – up until a point. (There is too low-carb and too low-calorie.) However, if this is something that’s benefiting the individual – they’re doing keto and they’re feeling well on it – then these perturbations in their thyroid hormone are a healthy metabolic adaptation. Now, could that same person continue keto for too long and perhaps burnout? Yes. Could they have the same level of thyroid that they did three months ago when they were feeling great? Yes. That would tell you that thyroid is not the driver of the problem. Could it also be that this person is simply experiencing this electrolyte insufficiency syndrome and their fatigue and insomnia is being driven by electrolytes? Yes.

DrMR:

Could that happen in someone with this “functional low thyroid?” Yes. Would that mean that the thyroid is a problem? No, it would not. So to answer your question – No. Keto is not going to cause any problem with the thyroid. It may cause skewing of the levels, but these will be normal adaptations that mean nothing regarding thyroid health. Rather, it’s the body shifting metabolically around the dietary changes that you’re making. I would not consider this any risk or any danger. I would use how you’re feeling as the primary barometer for steering your diet. If there’s someone who is overweight, then you may use your weight and how you’re feeling. If you’re someone who has chronically high total cholesterol, cholesterol ratios and triglycerides, then you may want to use those labs to steer how you’re eating; to not make these normal range fluctuations in the thyroid what you use to dictate how you modify your keto diet or any other dietary intervention that you’re going through.

ER:

Just being in this world of functional medicine that I’m in now – working with practitioners for the last four years -and your 10 or 12 years, it’s funny that the language there seems to always be a term that has its heyday – like adrenal fatigue. It sounds like low thyroid is the new term being thrown around, unless it’s been around for a while. I don’t think I’ve heard that as much as I have just in this last set of questions.

DrMR:

Right. Well, part of it might be…

ER:

It’s Google…

DrMR:

I’m hoping there’s been enough call out of people saying hypothyroid when they’re seeing low thyroid. I’m hoping there’s been enough blowback, that at least providers are using their words more carefully. I would actually consider that a win because that’s a step in the right direction.

ER:

It’s an actual diagnosis.

The Issues of Thyroid “Marketing”

DrMR:

Yep. One other thing I should just tack onto this. There are practice management groups that recommend you treat thyroid because it’s such a successful condition from a marketing perspective. I don’t think these are people saying, “Oh, how can we screw people over?” You’re a clinician, you want to help people and you don’t want to participate in the standard medical model. What are people looking for on the internet? A lot of this is just consultants reflecting back to clinicians what people are clicking on, right? Part of this – not to point a finger – is the patient’s fault, so to speak. Maybe there’s this natural human tendency to find thyroid as an attractive hypothesis for why they’re having symptoms. Maybe this is just something that’s in vogue. To put this together, this is something that consultants are teaching providers to market to because people seem to be motivated to solve their thyroid problems.

DrMR:

A lot of this has industry influence that underlies it. I think it’s understanding that additional layer that may help you understand why the doctor (or other healthcare consultant you went to) was so keen on thyroid. The provider – again, always giving people the benefit of the doubt – probably doesn’t understand that some of what they’re being educated on isn’t highly accurate. It looks accurate, right? If you’re a busy clinician, you don’t have time to fact-check every reference. In the clinician’s defense, when I say a fact-check, it’s not, “Ooh, I’m Dr. So-and-So. I go onto Google and in 30 seconds, I can unravel this fallacious thyroid paradigm.” No. It takes hours and hours and hours and hours of finding all the science, collating it, weighing it out and evaluating it to see if a paradigm is correct.

DrMR:

In the clinician’s defense, it’s not an easy exercise to fact-check, but that’s why we harp on this so much in the podcast. We’ve done the fact-checking. You see that a lot of the reason why thyroid seems to be so in vogue – even though only about 0.3% of the population are true hypothyroid – is because people seem to really be tickled by the prospect that thyroid is causing all their problems. This compounds… the more people click on this stuff, the more Google tells consultants that this is what people want… the more it tells the people who are trying to help doctors reach patients to truly help them that you should be marketing and speaking to thyroid… the more this stuff compounds. There are probably just a few different incentives here that aren’t necessarily malaligned, but, can you see how if everyone is seeing these different components, but no one is kind of tasked with the exercise of fact-checking, then the marketing consultants say people are really keen about thyroid. “Do you see fatigued patients?” “Yes, I do.” “Well, maybe you should start explaining to them how it could be their thyroid.” Right? Then, the doctor who wants to provide educational seminars and write books is saying, “Hmm, what should I try to teach providers about? It seems like everyone is really keen about thyroid…” Then, this whole thing snowballs. If no one is tasked with the exercise of doing the fact-checking and looking at what’s the most truthful, then this can get away from you really quickly, which is where I think we currently are.

ER:

That makes so much sense.

DrMR:

Hi everyone. This is Dr. Ruscio. In case you need help, I wanted to quickly make you aware of what resources are available to you. If you go to DrRuscio.com/resources, you will see a few links you can click through for more. Firstly, there is the clinic, which I’m immensely proud of the fact that we deliver cost-effective, simple, but highly efficacious functional medicine. There’s also my book, Healthy Gut, Healthy You, which has been proven to allow those who have been unable to improve their health – even after seeing numerous doctors – to be able to help them finally feel better. There’s also our store where there’s a number of products like our Elemental Heal line, our probiotic line and other gut supportive and health supportive supplements. Health coaching. We now offer health coaching – so if you’ve read the book, listened to a podcast like this one or are reading about a product and you need some help with how to use it or integrate it with diet, we now offer health coaching to help you along your way. Finally, if you’re a clinician, there is our clinician’s newsletter – The Future of Functional Medicine Review. I’m very proud to say that we’ve now had doctors who’ve read that newsletter find challenging cases in their practices, apply what we teach in the newsletter and be able to help those patients who were otherwise considered challenging cases. Everything for these resources can be accessed through DrRuscio.com/resources. Alrighty – back to the show.

Listener Question #5: Psychological Stress & Gut Issues

ER:

So, our next question is from Scott.

Scott:

Hey, Dr Ruscio. My name is Scott. I was curious – Let’s say you have a patient with IBS and they’re pretty clearly triggered in terms of having loose stool and other gut symptoms. They’re triggered by stress – let’s call it psychological stress. Where on your hierarchy of treatment modalities would something like a gut-directed psychotherapy or hypnotherapy be on there? My follow up to that would be – Is that gut-directed hypnotherapy similar to limbic retraining? Would you use limbic retraining instead of gut-directed hypnotherapy? That’s pretty much it. Looking forward to hearing your answer. Thank you so much.

DrMR:

Great question. I’m pretty open in terms of referring for cognitive behavioral therapy (CBT). Is it more limbic retraining? Is it EMDR? I’m fairly open on that. Is it hypnosis or gut-derived hypnosis? We’ve tended to use limbic retraining just because it’s a self-help program that we can vouch for. We know what someone’s going to get, whereas saying “See a local therapist.” It’s hard to say. Are they going to be a qualified therapist? Or, I should say – more skillful? Most people will likely have the credentials, but just like in gut care, not everyone is going to have the same level of competency. So, we’ve tended toward limbic retraining and EMDR because there are some self-help courses.

DrMR:

Especially with limbic retraining, there is some published evidence, and also anecdotal evidence, in cohorts that we tend to see – those who are very sensitive, supplement reactive and also very prone to stress, fear and worry. There’s published evidence for hypnotherapy in IBS. There’s definitely evidence there also. I’m pretty open on what we use. The ‘when’ is what’s a bit more up for interpretation. It’s a fairly straightforward exercise. The more you see upon intake and initial examination with an individual that raises the flag that stress intolerance, prior trauma, worry, stress and fear are permeating their entire life and their psyche, the earlier you make that recommendation. The other side of that coin is, how much of what you’re seeing – in terms of, let’s say, anxiety and reactivity – could be driven from the gut?

DrMR:

We know that probiotics are one example that can improve depression, as it can anxiety. We know that fatigue and food reactivity can be improved from a low FODMAP diet. So, it just depends on some of those nuances of the individual. Do you incorporate this early on… or do you wait and see? I know that’s not giving you a super definitive or direct answer. However, another thing that can shade that in would be – the more someone has done some of the therapies we use at the clinic on their own and done them in a quality manner (meaning a good trial on low FODMAP… or a good trial on paleo… or probiotic triple therapy… or they’ve worked with a naturopath and they’ve done antimicrobials…) The more that you’ve seen those boxes successfully checked and the less responsive they’ve been – and also the more indices that you see that you suspect limbic imbalances or these emotional issues present – then the earlier you’d want to make the recommendation of limbic retraining, CBT hypnosis, what have you. So, that’s one of the things in the hierarchy. Typically, it’s a wait and see, unless people have done a lot of the interventions and they have many indices indicating that this could be a frank driver for them.

Listener Question #6: Prebiotic Intolerance & SIBO

ER:

Alright. We have time for one more short question. So, I’m going to leave it up to you. Do you want to talk about the prebiotic intolerance and SIBO question, or do you want to answer the role of hunger and satiety?

DrMR:

Let’s do the prebiotic and SIBO

ER:

Okay. So, the question is – Does prebiotic intolerance mean SIBO?

DrMR:

Great question. Let’s say someone gets dizzy when standing, they have fatigue and they have prebiotic intolerance. They could diagnose themselves with POTS, adrenal fatigue and SIBO. Then, they could go read about all those 3 things… and how those 3 things cause 7 other things… and now they’re concerned about having 21 things. This is where the limbic patient comes in and you have to try to put some of the psychological fire out. I don’t mean to make fun of this, but it’s almost comical, and really actually unfortunate, how much of a tizzy people can work themselves into if they make diagnosis via inference. So, no – prebiotic intolerance does not mean someone has SIBO. They could have SIBO, but it’s certainly not diagnostic.

DrMR:

Actually, some who have SIBO do well on prebiotics. This is a hypothesis I put forward years ago on the podcast with Allison Siebecker. I termed this prebiotic responders and SIBO where some people with SIBO seem to do better when you move them on a higher FODMAP diet and/or use prebiotics. It seems to be a smaller subset, but they do exist. So, nope – I wouldn’t make that association. I would just remember that some people do better on lower FODMAP and prebiotics. Some people do worse on lower FODMAP and prebiotics. There’s a number of things that can be going on underneath the surface that may make someone intolerant to prebiotics. Some of this could do with inflammation. If someone has inflammation, they can become hypersensitive to normal gas pressure. Even a little bit of additional prebiotic makes them so sensitive to that little change in gas because the inflammation upregulates pain reception, that they could feel a negative reaction because of that. In their case, the inflammation may not be SIBO. It may be dysbiosis or something else like H. pylori. So, use that as something to help personalize your diet and your supplements, but be careful not to start diagnosing based upon just one observation like that. That tends to lead people more astray than it does in the direction they need to go in.

ER:

Yeah. I was one of those people that stayed far away from prebiotics when I had SIBO, but I also found out that after I felt much better and didn’t have SIBO anymore, I still don’t do well with prebiotics. I think it gives me a histamine reaction or something. So, I’m just like, “They’re not for me. No kombucha for me. That’s fine.”

DrMR:

Yeah. That’s some people and that’s just that last bit of dietary personalization.

ER:

Yeah. I’m not kidding myself to think that I can have any food or drink in the world that I want. For some people, it’s possible. For me, I’m good. I’m 90% living without things I’d like to have, but I’m fine because I feel 90%. I’m not going to throw that away for some sauerkraut or whatever.

Episode Wrap-Up

DrMR:

Yeah. That’s something that Melissa Hartwig says that I always really appreciated – the short, concise nature of ‘Worth it…? Or not worth it…?’ We all have things that we can do and we can’t do. Is it worth having this food and feeling bloated for a little while… or is it not? I just loved the way she framed that – worth it… not worth it… I’m not going to get caught up in the emotion of it. Right now, do I want to have ice cream or not? You know, sometimes it’s a yes and sometimes it’s no, but you’re in the driver’s seat.

ER:

Yeah. Well, that was awesome – so glad to have recorded another one of these with you. I can’t wait to do the next, but we’re out of time.

DrMR:

Alright. Well, thank you Erin. Thanks guys, and we will talk to you next time.

Outro:

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