Listener Questions: Vegetarian Diets, Cost-Effective Functional Medicine, the Best Stool Testing, Testing to Determine What Probiotics You Should Use, Low Vitamin D, and More…

Today let’s dig into the mail bag with listener questions.

Dr. R’s Fast Facts

Here is what we’ll cover:

  • The massive difference between saying “the evidence shows” versus “there is evidence showing”
  • Are vegetarian diets really best for rheumatoid arthritis?
  • Addressing criticism of my ‘cost effective functional medicine’ approach
  • Can your stool test results help you determine the probiotic for your gut?
  • Thoughts on the best stool testing
  • What to do for bad breath
  • What to do if your vitamin D levels are always low
  • Testing for nutrient deficiencies

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To be notified when my print book becomes available & get a free gut health eBook, click here.
If you are a healthcare provider looking to sharpen your clinical skills, click here.

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Episode Intro … 00:00:42
RA and a Vegetarian Diet … 00:00:50
Misleading with “Evidence” … 00:10:05
My Cost-Effective FM Approach … 00:15:45
Dr. Ruscio Resources … 00:23:43
Stool Tests and Probiotics … 00:24:42
Rationale Behind Testing Strategy … 00:30:35
Bad Breath … 00:33:59
Low Vitamin D Levels … 00:36:21
Nutrient Deficiencies … 00:40:39
Episode Wrap-up … 00:45:14

Download Episode  (Right click on link and ‘Save As’)


Listener Questions: Vegetarian Diets, Cost-Effective Functional Medicine, the Best Stool Testing, Testing to Determine What Probiotics You Should Use, Low Vitamin D, and More…

Episode Intro

Dr. Michael Ruscio: Hey, everyone. Welcome to Dr. Ruscio Radio. This is Dr. Ruscio. Let’s jump into another round of listener questions.

RA and a Vegetarian Diet

And the first item I wanted to discuss actually wasn’t a listener question, but it was something that came to me after reflecting upon the podcast interview between Dr. Susan Blum and myself. And I really appreciated the conversation. And I have a few afterthoughts. And I just want to be clear and saying on the front end, these are not criticisms at Dr. Blum. They are merely things that came to mind after reflecting on the conversation.

We had some slightly different opinions on a few different items, which is totally fine and understandable. I have no issue with that. However, I was reflecting on some of those disagreements, what may underlie some of those disagreements—or differences of opinion, I should say. And I wanted to speak to that. So just to be clear, none of these are in any way a criticism of her, her work, or her opinion.

However, if you caught the podcast, you probably heard her make the remark about the evidence showing that vegetarian and/or Mediterranean diets were the best for rheumatoid arthritis. And that struck me as odd—not to say that I’ve done an extensive review of the literature on RA specifically, but knowing what I know about gut health and the immense impact that has on autoimmune conditions—RA or rheumatoid arthritis, inflammatory autoimmune condition of the joints that causes joint pain and deterioration—knowing all I know about that, I was very suspect about that comment, especially when IBD (inflammatory bowel disease) and RA share a lot of therapeutic similarities.

So I thought on this. And the first thing I always do is reflect and ask myself, “Is this a knee jerk reaction that I’m having that’s more emotional than it is logical?” Because I think we’re all guilty of that. And we have a tendency to make decisions based upon emotion and then later justify that emotional decision based upon facts. So I really try to get that out of my thinking.

And so firstly, I reflect, “Am I trying to find a scientific rationale for what I believe rather than what is actually true?” And no, I don’t think that was the case. I think I’ve gotten pretty good at this where I’m not—I don’t have a dog in the fight on one side of the dietary fence, so to speak.

So then I did some digging. And admittedly, this was not a comprehensive review of the literature where I spent hours and hours and hours and hours. But I’m pretty good at this now, and I can pretty quickly pick apart something and at least get a cursory view that’s pretty accurate when looking into something. And when I did this, I found a few interesting things.

Essentially—and we’ll get into some more details here in a second—but essentially, the literature seems to reflect a limitation of available data that is mostly consolidated to studying a vegetarian diet and/or Mediterranean diet in rheumatoid arthritis. There’s not a lot of data in other studies. So looking at some of the high level science, we’ll elaborate on that comment.

So the first study, which is—well, the title gives it away—“Effectiveness and Safety of Dietary Interventions for Rheumatoid Arthritis: A Systematic Review of Randomized Control Trials.” Okay. So again, our high level science here as I’ve been harping on the systematic reviews. And of course, this is a systematic review of randomized control trials, which is excellent.

So to quote, “The effects of dietary manipulation including vegetarian, Mediterranean, and elemental eating plans and elimination diets on rheumatoid arthritis”—geez! I’m having a hard time with that today—“arthritis are still unclear due to the included studies being small, single trials with moderate to high risk of bias.” So right there, we see some limitations. First of all, they’re small, and there’s risk of bias. But we see vegetarian and Mediterranean. We do see elemental. And we see elimination diets.

So it doesn’t give us a ton of different dietary perspectives. And you see there that 50% of those dietary interventions—actually when you look at the actual breakdown of the control trials, it’s actually over 50%—the majority of the trials did look at vegetarian and Mediterranean-type diets. That’s important. And I’m going to come back to why that’s important in a second. Let’s look at a Cochran database review. Cochran database is essentially a database that will do a very diligent screening for bias in addition to performing systematic reviews.

So simply entitled, “Dietary Interventions for Rheumatoid Arthritis.” “The effects of dietary manipulation including vegetarian, Mediterranean, and elemental diets on rheumatoid arthritis are still uncertain due to the included studies being small, single trials with moderate to high risk of bias.” So essentially, what this tells us is A) the data here answering the question are not great, and they certainly are not conclusive. Also, we see that there is a favoring—or there’s more data available, looking at vegetarian and Mediterranean diets.

And again, if you read some of the specifics on some of these studies, you see there’s something like eight trials on either vegetarian and/or Mediterranean. There are only two on elemental diets. And I think there are only two or so on elimination diets. So we see a non-representative sample of data, meaning we don’t see the paleo diet here, we don’t see the low FODMAP diet here.

So this is a great example of when we want to be evidence based but not evidence limited. In my opinion, making a statement that vegetarian diets are the best or something along those lines, that’s a very evidence-limited statement because we don’t have evidence to really answer that question in full confidence. So we want to be evidence based. But when we don’t have evidence to adequately answer a question, we have to think a bit more laterally.

Now, thinking laterally here and being evidence based but not evidence limited—when we look at the one dietary trial that we have reviewed previously that showed that a low carb diet—a simple, low carb diet—was able to improve thyroid autoimmunity, well, that’s something that’s interesting and should be factored into our calculation.

When we look at the many studies showing that lower carb and/or paleo diets are better for cardiometabolic function—like cardiovascular disease markers, metabolic-syndrome-associated conditions like overweight and high blood pressure and blood sugar, and also weight loss trials—that’s something else to be factored in.

When we see the plethora of anecdotal evidence of people reporting that they feel better when they restrict gluten or go gluten free, that’s something else to be considered. And also the anecdotal evidence about nightshade vegetables and also some evidence I’ve come across lately—and there does seem to be some scientific backing for this—which involves low-sulfur diets in rheumatoid arthritis and knowing that many vegetables are high in sulfur, not a huge surprise.

Also, when we factor in the clinical experience that any halfway decent clinician should have when treating something like SIBO and seeing that that has been shown to be helpful for rheumatoid arthritis and knowing that a high FODMAP diet is not going to help SIBO and that many vegetarian-based diets inadvertently may gravitate toward a higher FODMAP diets—all these reasons combined make me very wary of that statement. And that’s why I come back to my original reaction, which was a bit concerned or skeptical of that remark. And this is why I feel that way.

So Susan and I were in agreement that in the long term, we should move toward the broadest diet possible. And at the end of the day, as long as we work to help someone heal and then move to the broadest diet, these little differences aren’t going to be a big deal.

So again, these are not criticisms of Susan at all. But I do think it’s important that, when we’re looking at some of the evidence here, we’re not limited in some of the dietary recommendations that we make being vegetarian-favored, because I don’t think the data really supports that.

Misleading With “Evidence”

And this brings me to a very, very important point which is, there is a massive difference between these two statements: “The evidence shows…” versus “There is evidence showing…”

This is incredibly important. And it’s also a pet peeve of mine. And not to be overly particular in language, but we actually should be overly particular in language here, because if we’re not then it’s very easy if you’re a healthcare provider to mislead the public that you’re educating or, if you’re a healthcare consumer, be very easily misled by what you’re reading.

When you say, “The evidence shows…,” I think most people interpret that as, “Okay, this person has—” They probably picture someone sitting in a medical library sifting through all the data, hours and hours and hours, up late at night drinking coffee, really sifting through all the evidence.

The expert opinion has now finally been garnered from all of this work. And you can say confidently, once you have looked at everything that the evidence shows… And that means there’s clearly evidence that shows X based upon a lot of work but, also equally as important, based upon data looking at both sides of an issue.

So for the vegetarian diet, regarding rheumatoid arthritis, there is evidence looking at all different types of diets. And when we look at all these different studies—vegetarian, Mediterranean, low carb, paleo, what have you—we see the clear trend in the data suggests that a vegetarian diet is best.

That’s what, “The evidence shows…” should mean. And I think most people interpret that as such when they hear that.

Unfortunately, what happens all too often—and this is a huge pet peeve of mine—and again, this does not involve Susan in any way. A huge pet peeve of mine is when the so-called expert makes this statement hiding behind their credentials. And they actually have not done the hard work in order to be able to qualify that statement.

It irritates me like nothing else, because I actually do the hard work. And it is hard work. And it’s really like someone’s cheating. It’s like we’re going to do a sprint contest, and I train my butt off for that sprint, and that other person didn’t train their butt off, and then they show up to the track with shoes that have little rockets on the heels. And they can just cheat their way and win the race because they’re cheating.

So it irritates me as someone who’s done the hard work and knows what goes into crafting that opinion, but it also irritates me because it misleads people. And it creates a lot of confusion.

So a better way to maybe phrase the vegetarian diet for rheumatoid arthritis is to say, “There is evidence showing that a vegetarian diet can improve rheumatoid arthritis. Now to be fair, we don’t really have data looking at some of these other diets, so we don’t know if it’s actually better or if it just helps compared to no diet at all.”

That is a much more reasonable statement. And importantly, that is a statement that is not going to make someone with rheumatoid arthritis who maybe has found good results on a different diet second guess themselves and change their diet and potentially make themselves worse.

And again, it’s not to say that a vegetarian diet is bad. I don’t care what diet it is. I care about being truthful in the information that we give people.

And so for all these reasons, I wanted to reflect on this conversation that we had. And I’m very thankful for the conversation that we did have because it made me think about some of these things. And I think it’s very important for us all to be aware of this.

So as I’ve said before, when people make very definitive statements, very confident statements, I’m usually very, very suspect, because it’s usually people who know more who actually are less confident in making a very definitive statement because they understand that there’s contradictory data.

And it’s hard to say one thing is better than the other, or it’s absolutely X, Y, or Z, because they’ve gone through all the data. They’ve seen these conflicting results. And they understand that it’s not as simple as good or bad. But rather, there may be a suggestion of a trend in a certain direction.

So “The evidence shows…” versus “There’s evidence showing…”—two massively different meanings. And we should be careful with the way we use these types of statements so as not to mislead people.

And hopefully, this little rant here on this issue will help you understand that it’s very easy, even to be well intentioned, to do a brief review of evidence and come away with an opinion that may be well intentioned but also misguided or may mislead people.

And really why all this matters is because we want to help people get to the recommendations that will help them feel the best as quickly as possible. But when we embed biases into opinions and recommendations, we actually can make it harder for people to get there. Whoo! All right. Moving on.

My Cost-Effective FM Approach

So here is a question or comment that came in. Okay. This came in from Ben. “Whites” I think is how you pronounce the last name. I’m terrible with pronunciations of last names. So I might be butchering that.

And this was actually a very interesting comment. And I thought we could talk through this one. So the comment goes, “Hi, Dr. Ruscio. I listened to your latest podcast this morning and heard you say that the growth in your podcast is due to your cost-control approach to functional medicine.

“As a functional medicine practitioner, I listen to your podcast because of your science-based approach and cringe when you go into your ‘other practitioners are bad for doing too much expensive testing and recommend too many supplements’ rant. This may be appealing for patients, but not likely for practitioners, in my humble opinion.

“Some of my patients give me a hard time if I ask them to get even two, reasonably costing, functional labs that maybe cost a total of $400-$500, such as a SIBO test and a stool test, and want to know if they go to their primary medical doctor, can they get them covered by insurance.

“I don’t really enjoy your attacking other functional medicine practitioners. We already have the conventional medical community to attack what we do. So this is why I have not signed up for your Review service.

“On the other hand, I appreciate your focus on the gut and loved your discussion of evolution and the importance of the small intestine in your latest podcast.”

Okay. So thank you for your feedback, Dr. Ben. And I am always open to listening to feedback whether it is good or bad. And actually, sometimes I enjoy the bad feedback or the criticisms more, because you need to have both types of feedback to stay balanced.

So let’s first get on the same page for how we define excessive testing, because I think we’re really missing each other here. $400-$500 is totally reasonable. And I think I’ve been pretty clear in saying that it’s when people leave a doctor’s office and they are asked to perform an initial lab testing bill that’s $2000, $3000, $4000, $5000, that that is problematic.

So I think it’s really important that we get on the same page with that point, because if you’re thinking that—or if anyone is thinking that I’m criticizing if someone is asking someone to spend a few hundred or even underneath $2000 of lab testing on the initial visit, depending on the case, then I want to make sure to be clear in saying that I’m not criticizing that camp at all.

It’s just—as I’ve discussed many a time—the thinking that more testing will produce better results has led many clinicians to routinely order $3000 and up in many cases. And sometimes, you’re looking at $5000, $6000, $7000, $8000. It can be pretty alarmingly excessive.

So there’s a big difference between asking someone to leave and spend $6500 on testing compared to maybe $1200. Big difference there.

Now, if you’re getting pushback from your patients for that amount, then that has nothing to do with me. That has to do with the patient’s perception of value and if they’re comfortable or they’ve wrapped their mind yet around the fact that not all healthcare can be provided in an insurance-coverage model.

Again, that doesn’t really have anything do to with me. What I’m trying to do—and the message here is trying to do—is trying to help providers make the care accessible financially for people, not cost prohibitive.

And I would be shocked to think that any patient that’s following my work would leave your office being asked to spend $500 and say that’s excessive, because my message has been pretty clear. It’s when we’re above a few thousand dollars, then you may want to be a little bit wary.

So I think it’s really important that we get on the same page with that, because I’m actually reinforcing what you’re doing. And I think you’re accidentally taking this as an attack.

Another couple points here are—these are not attacks. But these are rather citing what we need to improve. And if we become more cost effective, it’s better for you, Ben. It’s better for really all doctors, because now it opens doctors up to treating more patients, because we’re not only able to treat the elitist with a high level of disposable income.

It’s also better for patients because patients now are able to afford this care. And it’s better for the healthcare system because it’s less financially taxing on the system.

And it’s better for the acceptance of the movement, because when we’re more conservative and discerning in what we’re doing and less excessive, then other people, like conventional medical providers, are going to be less able to offer up criticisms, because we’ve cut a lot of the fat and a lot of the unsubstantiated pieces out of what we’re recommending.

So I really hope that you can see that. What I’m recommending here with this more cost effective approach really ultimately is better for everybody.

And also, when criticizing the camp of $2000, $3000, $4000, $5000, $6000, $7000, $8000 of lab testing on day one and just testing in excess, those are legit criticisms.

Again, it seems like these are not things that you’re doing. So these are not criticisms against you, but rather some of our peers that are doing this and maybe doing it in a well-intentioned way. But these are legitimate criticisms.

Think back to the review that we did about the lab that did the urinary neurotransmitter testing and actually plead guilty to fraud. So some of the conventional medical providers that criticize functional medicine have every right to do so.

However, if we get better at cutting the fat from our model, we are progressively taking bullets out of their gun to use in the fight against us from an argumentative perspective.

So again, it’s not about us versus them. It’s about us getting better. And the better we get, the broader our acceptance will be, because we are gradually removing every strong argument against what it is that we do.

So I hope you’ll get on board with everything, Ben. And I hope we’ve been able to establish that we all need to be able to be criticized in order to get better. Criticism is one of the best ways to figure out what’s not working. And it might be criticism in your office from a patient in terms of a customer service policy or what have you. It might be, for me, criticisms here on the website platform. But all these things help us to get better.

I truly love the quote, “Feedback is the breakfast of champions.” So if we can take these criticisms and use them constructively, then we’ll get better. If we ignore them, then we don’t get any better.

So I’ve definitely heard what you said. I hope you’re hearing what I’m saying. And hopefully, this speaking to your question will help get us on the same page, and you can get on board with everything here. But thank you again for your comments.

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 the 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 “Get help,” “Gut book,” or “Review.” Okay. Back to the show.

Stool Tests and Probiotics

Okay. Let’s go to Amy. Amy had a question. “Dr. Ruscio, I wanted a bit of clarification here. I tend to utilize Doctor’s Data three-day parasitology testing to assess for the presence of pathogenic bacteria, yeast, parasites, overgrowth, infection, which you discussed is a pretty well confirmed by the research for accuracy test and a sound basis for treatment. So that is pretty clear of me.

“In terms of looking at the microbiology assays, for example in the case of very low or no growth of considered important bugs like Bifidobacterium or Lactobacillus, are we to interpret this as meaning very little or still an understanding that the dysbiosis, or the dysbiotic environment, needs to be supported by general strategies to improve the growth of these potentially important floral types?”

So essentially what she’s asking is, “Do we look at some of the commensal bacteria reads on stool testing, like Bifidobacterium and Lactobacillus? Does that mean anything?” And I know of no study that has used some of those markers to predict response to treatment. So yes, I do not look at this data really, because we don’t know if it means anything. Rather, I focus on the clinical outcome. So to say this more clearly, I haven’t read—and there may be one out there, but I’ve gone through a pretty hefty amount of this literature and haven’t seen it—a study that did a stool test, showed low Bifidobacterium. And they showed that the custom-tailored probiotic outperformed the probiotic that was randomly given to a patient.

So we have two groups of patients. One group, all the stool tests, the probiotic is custom tailored based upon what’s found on the stool test. The other group is just given a standard mixture of probiotic. I know of no study that has shown that using stool testing to try to predict what type of probiotic intervention will work for them, or prebiotic, has been shown to enhance the clinical effect at all. In fact, I don’t even think that study has been done.

And I would be inclined to think that if that study were done, the results would probably show us that there was no benefit from doing so. Here are a few examples that support my thinking. The Hadza, for example, hunter/gatherers—or HadZA, as it may be more correctly pronounced—have virtually no Bifidobacterium, but also have virtually no IBS.

Other examples—people with IBS go on a low FODMAP diet. And signs and symptoms vastly improve. Yet Bifidobacterium counts go down. But also in IBS patients, one of the most effective probiotics has been shown to be Bifidobacterium.

So what I think this comes down to is when you introduce too many variables into the clinical process, you distract yourself. And these variables may seem appealing. “I’ve done a stool test that shows low Bifidobacterium. Okay, I’m going to give a Bifidobacterium probiotic. I’ve made a case. The test shows this. And I’m going to give that.” And that’s all fine and good.

But unless that test paired with a given treatment has been shown to mean something, all you’re doing is introducing a meaningless variable into a very variable-rich endeavor, which is the clinical process, which will just make your life and the clinical process more difficult.

In fact, I’d say maybe 10 to 20% of the patients I see are patients who’ve gone to other doctors, and their doctors have done testing like this. And they’ve tried to put together a custom-tailored, probiotic/prebiotic regimen to treat the labs. Yet they’re not really factoring in the patient’s symptoms. Example: Someone comes in with IBS or IBD. Their bacteria are off. So we’re going to give them those compendium probiotics along with prebiotics and a fiber supplement.

What happens? They get worse, because a lot of the moderate to severe cases of IBS and IBD have a higher chance of negatively reacting to prebiotics and to fiber than they do benefiting. One can clearly see that when they look at the clinical trials. So you want to be careful not to introduce variables into the clinical process that haven’t been shown to be truly meaningful, because they will distract you from good clinical observation and monitoring. So no, I don’t really look at those. But it’s funny how many people cite some of these tests.

And there are other labs that do even more robust microbiota assays that are also somewhat clinical. And it’s funny that people pay attention to these, because the methodology used there is not the same methodology that’s used in pretty much all of the research literature.

So it’s…I’m trying to think of an analogy. It’s a very different test. So just to say that Proteobacter is enriched or depleted because maybe you read a study about that that was done at a research center that had a vastly different testing methodology, you can’t compare one to the other. In fact, if you slightly change some of the methodology in the microbiota assays because they are so sensitive, you can have a vastly different reading on what’s high or low or positive or negative. So no, I don’t use these. Okay.

Rationale Behind Testing Strategy

“Hi, Dr. Ruscio. Thanks for all the great information you put out. I happily subscribed after following your podcast for two years.” I think he means to the clinical training newsletter, the Future of Functional Medicine Review. “I especially appreciate your dedication to evidence-based treatments as well as your concern for lowering the cost of functional medicine for patients.” So thank you, Joe. I think I needed that after one of the last comments. “In the last two case studies, you have mentioned several labs that you routinely use. I’m an M.D. just starting my functional medicine practice and would find it extremely helpful if you could elaborate on your thought process into which labs you select for your patients in the case reports.

“Looking into some labs that you’ve mentioned in your case studies, it looks like you like the 401H from BioHealth and also a GI panel from Diagnos-techs. Do you find one more sensitive in certain cases? Are the costs to the patients roughly the same?

“Do you routinely find enough parasites to justify one panel over the other? Or do you find the regular O&P is sufficient? Do you find these tests to be superior to Genova’s Comprehensive Digestive Stool Analysis?”

So Joe, thank you for your feedback. And I have started to elaborate more on my rationale behind the testing that I’ve chosen in the case studies. And I will answer that question in full in a subsequent edition of the Future of Functional Medicine Review. But briefly to give an answer in terms of testing, there’s a handful of tests that I like. In addition to BioHealth and Diagnos-techs, I also like Doctor’s Data and LabCorp and Quest. Those are some of my favorite labs.

There are subtle differences that will determine why I use one compared to the other. Cost is definitely one. Of course, I don’t use LabCorp or Genova if someone does not have insurance, because they’re ridiculously overpriced if you try to order them as a cash-paying patient.

And then the other panels are all fairly similar. There are a couple slight nuances. The one nice thing about the Doctor’s Data expanded profile, the Comprehensive Stool with Parasitology 3x, is that it also has lactoferrin and calprotectin. So if I’m looking to also get a preliminary assessment of IBD risk, I will include that. If I don’t suspect IBD, I do not order that expanded panel because it’s just not worth the money. And I wish more people understood this. Those functional markers mean little to nothing. And you can make an argument for them here and there. But on the whole, beginning phase, those markers mean little to nothing in terms of what you do clinically, especially because a lot of those markers will rectify themselves if you address inflammation, if you get them on a better diet, if you clear dysbiosis.

So for the extra—I don’t know—it’s $150, $200 to go from one level of that test to the other, it’s really not worth it. But we’ll elaborate on that a little bit more in a Practitioner Question of the Month in one of the future editions of the Future of Functional Medicine Review clinical newsletter. So thank you for your feedback, Joe, and more to come on that.

Bad Breath

Okay. Gosh, this name. I’m not even going to try to pronounce this one. “Doc, I need your help. I had a bad smell but brush my teeth every morning. What could be the problem? And what should I do to stop that? Thanks!”

All right. So there are a few things here that could be contributing. One of the first that comes to mind is dysbiosis. You could have a fungal overgrowth in the small intestine or the colon. Or you could have a bacterial overgrowth or just some sort of general bacterial or fungal imbalance or even infection that could be contributing.

Now, reflux is another potential causative factor. And diet can contribute to reflux, as can dysbiosis, as can acid level, so those are all things to consider. A few simple things from a starting perspective are trying the paleo diet. Give that a couple weeks. If that doesn’t work, try the low FODMAP diet. Those are two good places to start.

You also might want to try a probiotic. I would start with Lactobacillus/Bifidobacterium blend and also a Saccharomyces boulardii probiotic. And add in with that a digestive formula that contains an enzyme in it, also with some HCl, and also with some bile in one combined formula. Now, something else that maybe contributing to this might be oral dysbiosis. And oral dysbiosis can be caused by sleep disordered breathing. If you’re a mouth breather, that changes the pH in the mouth and allows pathogenic bacteria to grow, which can have odors.

And that also can cause things like increased amounts of dental caries, or cavities. And it can lead to receding gum lines, gingivitis, bad breath. And if you have things like oral lesions, bleeding gums, sore tongue, and/or poor sleep, then oral dysbiosis and/or sleep disordered breathing might be something to look into.

And if you need help with that, you can contact our office, of course. And we can try to provide you some guidance, especially with the gut piece of that and/or refer you to someone good for an evaluation of sleep disordered breathing or oral dysbiosis.

Low Vitamin D Levels

All right. Then our almost final question—two more. This is from Angie on Facebook. And she asks, “Can you discuss on your podcast what might be going on when vitamin D levels are low, a person supplements, and then they get test results like high, 125 vitamin D, aka calcitriol, and regular vitamin D that is low?” So high calcitriol, also known as 125, and regular vitamin D that is low. “I once heard it could be due to chronic infection such as a mycoplasma pneumonia. I am also wondering if it could be due to mutations in the vitamin D receptor, even only if heterozygous.”

Okay, so I’m not an expert in this area. But it could be both. It could be infection. It could be a vitamin D polymorphism. The infection piece can be tricky, because the family of some of these intracellular infections—it can be hard to get a definitive in terms of if it’s positive or not positive or what a true positive is, kind of like Epstein-Barr virus. Sometimes, low level positives don’t require any clinical action.

So I would start with the gut and getting as healthy as you can and working with a clinician and looking into the things that the clinician is thinking are the major impediments to your health. So focus on getting healthy first and your vitamin D level second. I wouldn’t focus on trying to fix your vitamin D level as a way to get healthier.

Now, you could also use parathyroid hormone as another way of gauging if your vitamin D levels were adequate or not. And Chris Masterjohn came on the podcast, and we discussed that in detail. So you could go to our search box, type in “Chris Masterjohn,” and then you should find that episode come up. I do give vitamin D to most of my patients in a conservative dose, usually around 2000 IUs a day, sometimes higher if someone is pretty low and they also have an autoimmune condition, but it’s not a huge focus of mine.

Some reasonable supplementation has been shown to be helpful for many people with autoimmunity in the clinical trials. And it seems, at least in some of the cases, to be irrespective of the level of vitamin D. There was one study in particular that gave, I believe it was women with Hashimoto’s and were normal vitamin D, vitamin D supplementation, and they saw a positive response in their autoimmunity. And I think they also compared them to another group in that same study that were deficient, and both groups experienced benefit. And I can’t recall if one group experienced more benefit than the other, but some simple supplementation was able to improve autoimmunity.

Now, if after some initial supplementation you’re still struggling, I would then look into what might be present that’s hindering your health. If you have a lot of digestive symptoms, I would look into that. Even if you don’t, I’d still have a good gut evaluation, because there might be something there that’s contributing. Potentially, there’s something going on with your thyroid. You might want to have that evaluated, a simple, standard thyroid evaluation and look at the fundamentals, not get wrapped into the crazy ratios and elaborate testing.

And there are other things that you may want to look into that are kind of in our tertiary buckets like mold, metals, and then some of these intracellular infections, which would be things to look as secondary and/or tertiary, even quaternary considerations. But I would focus on the clinical process first—getting healthy, working with a clinician to find known items that can detract from your health, and track the vitamin D along the way. Follow that first. And look at that secondary to your treatments for your general health and not try to manipulate the vitamin D as a way of getting healthier.

Nutrient Deficiencies

All right. Last question here. “Dr. Michael Ruscio, do you have a clinician’s perspective on SpectraCell testing for nutrient profiles, especially B vitamins? Or do you have a lab you recommend for detailed B vitamin concentration and deficiencies/sufficiencies? Thank you for your time. Love your work!”

Well, thank you. So I have ordered SpectraCell a handful of times. And for the most part, I haven’t really felt the need for it. Nothing against it. I just haven’t felt much of an overt need for it. As far as nutrient deficiency/sufficiency testing goes, I have heard good things about SpectraCell. And that’s the one I’ve used. I cannot say I’ve done a comprehensive review of the literature to vet out what the best one is.

I look more to foundational issues before I look at deficiencies. This is a question I have with my patients when they ask about deficiencies. And in my opinion, if we focus on getting someone healthy, which comes back to all the stuff habitually talk about—diet, lifestyle, gut health, thyroid evaluation, many of the fundamentals—and we work through those and get someone feeling better, the need for the deficiency testing usually goes away. We really can’t justify deficiency testing in someone that is predominantly asymptomatic.

So that’s why for me I haven’t really done much in the way of testing for nutrient deficiency/sufficiency, because I focus more on core issues, treat those. When you identify and treat those well, people usually see a very marked improved in their symptoms. And then the ability to justify for their testing becomes somewhat obsolete.

Now, there have been a few times wherein I’ve treated based upon results of a SpectraCell, but I haven’t noticed anything major. And it’s probably because, in my opinion anyway this is, that deficiencies for the most part aren’t a main driver of disease, because if people are eating a halfway decent diet then super frank deficiencies probably aren’t very common.

But rather deficiencies might be noise that’s you’re seeing due to altered metabolism or absorption. And those are probably being driven by underlying deeper issues that need to be investigated. So I look at deficiency testing like noise. Now, I do use a general screening for anemias through your standard CBC with differential. We always do a little bit deeper of a profile for iron and include ferritin and some of the associated iron markers. And sometimes, we’ll do a more detailed B vitamin assessment. But that’s getting a little outside of my area of expertise. So I don’t often do that, but also I haven’t often found it to be 100% needed.

So again, SpectraCell, I’m fine with it. But it is a test I use much? No, because I really think if you fix major problems and get people on a good diet, then this can take care of itself. If you’re someone that really wants to do this testing, I would strongly advise you not to do it at first but rather to focus on core fundamentals and then leave this as a kind of cherry on top. The reason I say this is because I’m really becoming progressively more of the belief that one of the major stumbling blocks for clinicians is doing too much testing, much of which doesn’t actually have any clinical utility. But the clinician is unaware of that.

And they are making their lives so much more difficult because they’re introducing testing into the clinical process that doesn’t have clinical meaning. And so they’re just flooding themselves with useless variables that make it much more difficult to get results. And this is one of the big things that I’ve been trying to always articulate in the Future of Functional Medicine Review clinical training newsletter. We don’t order a ton of tests, but we tend to get pretty darn good results, because more testing does not equal better results.

In fact, I think less testing probably equals better results because you can focus more on the lesser amount of things that you’re trying to manage and monitor. So that takes us through a bunch of questions. And hopefully, you guys got a lot out of that. Ben, thank you again for your question.

And Dr. Blum, I really appreciated our podcast. And again, just to preempt any confusion, none of that conversation was in any way a criticism of you. But it was rather reflecting on some of the things that came to mind after our conversation that have to do more with just the field in general and how we look at evidence and how we comment on that evidence.

Episode Wrap Up

So thank you, guys, for the comments. Keep them coming in. And please, keep the good and the bad comments coming in, because I do very much so listen to bad comments or more tactfully said criticisms or challenges or problems or concerns, because that is equally as important as the praise. So I appreciate them both. And please don’t ever feel afraid to make a criticism as long as it’s phrased politely, because those things are equally as valuable to me.

All right. Thanks, guys. Talk to you next time.


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What do you think? I would like to hear your thoughts or experience with this.

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

Discussion

I care about answering your questions and sharing my knowledge with you. Leave a comment or connect with me on social media asking any health question you may have and I just might incorporate it into our next listener questions podcast episode just for you!

10 thoughts on “Listener Questions: Vegetarian Diets, Cost-Effective Functional Medicine, the Best Stool Testing, Testing to Determine What Probiotics You Should Use, Low Vitamin D, and More…

    1. Thanks for sharing Roxana. I have not hear of it but we did have on Dr. Steven Gundry who advocated plant-based/low-lectin for various conditions which I believe included joint pain. It will release soon 🙂

    1. Thanks for sharing Roxana. I have not hear of it but we did have on Dr. Steven Gundry who advocated plant-based/low-lectin for various conditions which I believe included joint pain. It will release soon 🙂

  1. Hey Dr. Ruscio,

    Long time listener, first time caller. Love your work. Thanks for all that you do.

    I just wanted to share something in regards to the RA conversation. I have a background in nutrition, wellness and biochemistry, I read continuously on these matters, and I keep detailed journals regarding my diet and symptomatology, but I am no physician, nor clinical research scientist, so this is purely conjecture to consider.

    I had RA for 2 and a half years (Aug 2014 – Jan 2017). During this time it was clear that fat and protein were my biggest enemies. However, it did not matter whether this fat or protein came from animal or plant sources, the more I had the worse my symptoms. This fact was all uncovered by Mr. Paddison (referred to in the previous listener comment) during his development of RA. Therefore, drastically decreasing fat and protein intake also drastically improved symptoms. With this in mind, it may make sense that a vegetarian or vegan diet would benefit symptom relief of those with RA, as these diets tend to be naturally a bit lower in fat and protein. But, obviously, this does not mean that it is the animal products themselves that are the issue. In fact, in Paddison’s book and program, he admits he tried to address his symptoms while continuing an intake of various plant based oils, and it just didn’t work until he got rid of all fat and oils.

    Instead of being animal product related, I think it is possible that it is the lack of breakdown of these fats and proteins, along with gastro-endothelial permeability, with accompanying confusion by a adaptive immune system, that is at least the downstream factor causing RA joint symptoms (inflammation and degradation of synovial fluid/cartilage). – {In retrospect, before my RA symptoms really appeared, I had many consistent, significant signs of leaky gut followed by an attempt to go ketogenic which most likely pushed my adaptive immune system over the edge…} – Personally, I did follow a (for all intents and purposes, fat-free) very low fat, low protein, plant based diet while I tried to figure out my physiology to limit RA symptoms, and it helped immensely. But it wasn’t until I started to focus on gut permeability and stomach acid levels (Auto-immune paleo and Betain HCL with pepsin, with a few other things) that I noticed I was able to reintroduce larger and larger quantities of both fat and protein without RA symptoms.

    I could never digest fat before, had 6’s and 7’s all day on the Bristol scale, and now I can eat sardines and coconut butter until full and still poop like a champ. I used to have massive amounts of food sensitivities, name a food and it made me break out in hives, or itch, or cramp, or tingle, or get dry eyes, and now they have all basically gone away. And although my knuckles still turn a little red from time to time, I haven’t had joint pain for almost 6 months now.

    I want to be clear that this did not happen overnight, and I do stick to an auto-immune paleo diet very firmly, but it just seems unlikely that the issue here is animal product in general.

    Additionally, it might be prudent to caution folks that if you do choose to eat a high carb vegan diet to reduce RA symptoms, you should probably make your meals relatively small and just eat more frequently (like Clint Paddison did and suggests) because otherwise you could be staring down the barrel of a SIBO infestation. Bigger meals, mad up of lots of carbs and vegetable matter, along with the simultaneous suppression of stomach acid levels, may provide perfect opportunity for northern migration of bacteria.

    Anyways, I just thought I should share my thoughts as someone who has had the disease and put it into remission, more or less. My now crooked thumbs remind me to stay discipline with my AIP diet everyday.

    Hope this helps someone else out there. Thanks again, Dr. Ruscio.

  2. Hey Dr. Ruscio,

    Long time listener, first time caller. Love your work. Thanks for all that you do.

    I just wanted to share something in regards to the RA conversation. I have a background in nutrition, wellness and biochemistry, I read continuously on these matters, and I keep detailed journals regarding my diet and symptomatology, but I am no physician, nor clinical research scientist, so this is purely conjecture to consider.

    I had RA for 2 and a half years (Aug 2014 – Jan 2017). During this time it was clear that fat and protein were my biggest enemies. However, it did not matter whether this fat or protein came from animal or plant sources, the more I had the worse my symptoms. This fact was all uncovered by Mr. Paddison (referred to in the previous listener comment) during his development of RA. Therefore, drastically decreasing fat and protein intake also drastically improved symptoms. With this in mind, it may make sense that a vegetarian or vegan diet would benefit symptom relief of those with RA, as these diets tend to be naturally a bit lower in fat and protein. But, obviously, this does not mean that it is the animal products themselves that are the issue. In fact, in Paddison’s book and program, he admits he tried to address his symptoms while continuing an intake of various plant based oils, and it just didn’t work until he got rid of all fat and oils.

    Instead of being animal product related, I think it is possible that it is the lack of breakdown of these fats and proteins, along with gastro-endothelial permeability, with accompanying confusion by a adaptive immune system, that is at least the downstream factor causing RA joint symptoms (inflammation and degradation of synovial fluid/cartilage). – {In retrospect, before my RA symptoms really appeared, I had many consistent, significant signs of leaky gut followed by an attempt to go ketogenic which most likely pushed my adaptive immune system over the edge…} – Personally, I did follow a (for all intents and purposes, fat-free) very low fat, low protein, plant based diet while I tried to figure out my physiology to limit RA symptoms, and it helped immensely. But it wasn’t until I started to focus on gut permeability and stomach acid levels (Auto-immune paleo and Betain HCL with pepsin, with a few other things) that I noticed I was able to reintroduce larger and larger quantities of both fat and protein without RA symptoms.

    I could never digest fat before, had 6’s and 7’s all day on the Bristol scale, and now I can eat sardines and coconut butter until full and still poop like a champ. I used to have massive amounts of food sensitivities, name a food and it made me break out in hives, or itch, or cramp, or tingle, or get dry eyes, and now they have all basically gone away. And although my knuckles still turn a little red from time to time, I haven’t had joint pain for almost 6 months now.

    I want to be clear that this did not happen overnight, and I do stick to an auto-immune paleo diet very firmly, but it just seems unlikely that the issue here is animal product in general.

    Additionally, it might be prudent to caution folks that if you do choose to eat a high carb vegan diet to reduce RA symptoms, you should probably make your meals relatively small and just eat more frequently (like Clint Paddison did and suggests) because otherwise you could be staring down the barrel of a SIBO infestation. Bigger meals, mad up of lots of carbs and vegetable matter, along with the simultaneous suppression of stomach acid levels, may provide perfect opportunity for northern migration of bacteria.

    Anyways, I just thought I should share my thoughts as someone who has had the disease and put it into remission, more or less. My now crooked thumbs remind me to stay discipline with my AIP diet everyday.

    Hope this helps someone else out there. Thanks again, Dr. Ruscio.

  3. Hi, I have been having major digestive issues and am Hashimoto’s. From a Genova Comprehensive stool test, I have klebella and little good bacterial in my microbiome. My former doctor wanted to give me an antibiotic, and my current doctor won’t give antibiotics to kill it. The former doctor I am not going to anymore because he misdiagnosed me with diabetes based on a urine test not a blood test and wanted to put me on Metformin.My current doctor and an endocrinologist confirmed I didn’t have diabetes. I was in ketosis due to my Paleo, no dairy diet with low carbs. I am getting worse and having major diarrhea every morning. I had a vitamin C/glutathione IV with the current doctor, which didn’t make a difference. He said it would kill everything. I am on a probiotic by Natural Factors obtained at Whole Foods. I have calf pains which recently spread to the back of my thighs.

    1. Linda,

      It sounds like you may not be digesting all of that fat from the ketogenic diet very well. High fat intake can definitely have a laxative effect, especially if your not breaking it down very well. Additionally, I have personally had calf and hamstring pain and soreness from fat intake in the past. I’m not sure if it was from poor digestion, malabsorption, or large fat molecules leaking through the gut barrier, but the cause and effect was absolutely confirmed.

      Maybe consider getting some pancreatic enzyme tests for fat malabsorption, or maybe check you gastric HCL levels as that too can effect the enzyme release.

      I’m curious to know, have you seen significant improvements with your Thyroiditis through a ketogenic diet? I’ll admit I’m not very well read on Hashimoto’s and dietary protocols other than Autoimmune paleo. But, I do know that a ketogenic style diet doesn’t always jive with everyone. It seems to be a great tool for certain illnesses but may not be the best in all situations.

      Just some things to consider. Good luck!

  4. Hi, I have been having major digestive issues and am Hashimoto’s. From a Genova Comprehensive stool test, I have klebella and little good bacterial in my microbiome. My former doctor wanted to give me an antibiotic, and my current doctor won’t give antibiotics to kill it. The former doctor I am not going to anymore because he misdiagnosed me with diabetes based on a urine test not a blood test and wanted to put me on Metformin.My current doctor and an endocrinologist confirmed I didn’t have diabetes. I was in ketosis due to my Paleo, no dairy diet with low carbs. I am getting worse and having major diarrhea every morning. I had a vitamin C/glutathione IV with the current doctor, which didn’t make a difference. He said it would kill everything. I am on a probiotic by Natural Factors obtained at Whole Foods. I have calf pains which recently spread to the back of my thighs.

    1. Linda,

      It sounds like you may not be digesting all of that fat from the ketogenic diet very well. High fat intake can definitely have a laxative effect, especially if your not breaking it down very well. Additionally, I have personally had calf and hamstring pain and soreness from fat intake in the past. I’m not sure if it was from poor digestion, malabsorption, or large fat molecules leaking through the gut barrier, but the cause and effect was absolutely confirmed.

      Maybe consider getting some pancreatic enzyme tests for fat malabsorption, or maybe check you gastric HCL levels as that too can effect the enzyme release.

      I’m curious to know, have you seen significant improvements with your Thyroiditis through a ketogenic diet? I’ll admit I’m not very well read on Hashimoto’s and dietary protocols other than Autoimmune paleo. But, I do know that a ketogenic style diet doesn’t always jive with everyone. It seems to be a great tool for certain illnesses but may not be the best in all situations.

      Just some things to consider. Good luck!

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