Listener Questions: Healthy Gut, Healthy You – Supplements During Fasting, Elemental Diet If Underweight, Inulin, Probiotics, NAC
Today we will cover listener questions, including…
- Magnesium while fasting
- Is the elemental diet and fasting okay if you are underweight?
- Is the inulin in the probiotic okay?
- Noticing white tongue while on the elemental diet
- Dosing for NAC
Dr. Michael Ruscio, DC: Hey everyone, welcome to Dr. Ruscio Radio. This is Dr. Ruscio. Today I’m here with Erin Ryan and we’re going to go over some listener questions from our audience and go from there.
Erin Ryan: Cool. This week the focus is going to be on Healthy Gut, Healthy You. We’ve had a ton of questions come in, mainly through the internet and email. So we’re going to focus on those. We’ll do them in order of the phases of the book. There’s a step one, step two, and step three of the book, so we’ll sprinkle in a couple of questions from each.
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Dr. R’s Fast Facts Summary
Step 1 Questions
Can artemisia be substituted for artemisinin?
- Do your best to find the closest formula that is the most proximal to what is described in the book.
Can one take magnesium during the fasting stage?
- A bit of constipation during a fast is not highly concerning
- Aiding motility with magnesium during a fast is ok
- Constipation with prior abdominal and intestinal surgery may be caused by abdominal adhesions, scar tissue, etc.
- Look into the research about visceral abdominal massage by Larry and Belinda Wurn from Clear Passage
Is the elemental diet or fasting ok for those who struggle with being underweight?
- The predigested elemental diet formula has actually shown to help patients gain weight
- Aim for 2,000 – 2,500 calories (women) 2,500 – 3,000 (for men)
- A minimal amount of weight loss from the protocol may be ok especially if the ultimate result is better absorption
Step 2 Questions
Can you take Saccharomyces Boulardii with other probiotics?
- There is no evidence to support that taking different probiotics together is less effective
Does the small amount of inulin in the lacto-bifido probiotic blend cause symptoms?
- The amount of inulin in this probiotic is only a couple hundred milligrams which will not cause a problem
How to tell if a probiotic is causing die-off or a negative reaction?
- If a negative symptom pops up for 3-5 days then fades away that would be considered die-off
- If a negative symptom persists and never gets better, that type of probiotic is likely not for you
Step 3 Questions
Is there a substitute for Oregano oil?
- Step 3 in the book includes recommendations for different herbal protocols
What is the cause of white tongue while on the semi-elemental diet?
- It may be caused by a short term fungal overgrowth in the mouth aka thrush. This symptom subsides once the elemental diet protocol is completed and has not shown to cause any further symptoms
- Some find it helpful to gargle with oregano oil or natural mouthwash.
- Get help with gut health.
- Get your personalized plan for optimizing your gut health with my new book.
- Healthcare providers looking to sharpen their clinical skills, check out the Future of Functional Medicine Review Clinical Newsletter.
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Trust the Process
DrMR: Sweet. Let me lead by making one comment for anyone who is going through the book protocol and has questions. There’s always a challenge with wanting to personalize the care of the individual, but also realizing that the algorithm I put forth in the book will solve most problems for most patients. Oftentimes the answer to a question (the vast majority of the time) is: really continue through the protocol in the book. What I find—the same thing happens in the clinic—is more often than not, a patient needs reassurance. Insert question here, reply blah, blah, blah, reassure them, continue forward with the protocol. Then someone continues forward with the plan laid out in the book and they start to respond eventually.
I think the challenge is, if you’re working through, let’s say, the dietary step and you’re not improving (just as one example), you may say, “Well, could I have SIBO? Should I go right to step three, which are various antimicrobial therapies?” And the answer is definitely no. Because the algorithm and the process in the book are meant to build upon themselves to help move someone forward, laying the foundation of healthy inputs to the gut first. This is your diet—which is said flippantly sometimes, optimize your diet—that for some people can take six weeks or perhaps a little bit longer.
So there are those modifications. Also, getting some time outside, time in the sun, some exercise… all of those create healthy inputs to the gut and allow you to better respond to step two. And in step two, the supports—potentially adrenal support but definitely the probiotic protocol—are all another layer of support to the gut, moving you in a positive direction. There are many people when using the probiotic protocol in the book, who will not need to treat SIBO. We’ve published a number of case studies documenting this in our clinicians’ newsletter. Day one, someone performs a test. We tell them— after they send in their tests and we’re waiting for the results—start on this probiotic protocol and then we’ll follow up about three or four weeks later. There have been at least three cases with a documented form of dysbiosis, or SIBO, who no longer needed any treatment because the probiotic protocol ameliorated all of their symptoms.
So these things are meant to be done in this progressive fashion. If you don’t see huge improvements from step one or step two, remember that sometimes it’s more about gaining ten, twenty, or thirty percentage points of improvement with one step, moving on to the next, and building the protocol that works best for your gut. As tempting as it is to read something, hear something, think something, and want to jump to the one aspect of the plan in the book that works for you, remember that there is a lot of wisdom—mainly my almost 10 years of working with patients and an extensive review of literature on this—that has gone into that system and that algorithm.
I just want to lead with that to make sure people understand, yeah, it’s tempting to want to jump to whatever it is. And I wanted to do the same thing myself as a patient, when I was having brain fog that was non-responsive and I saw something about heavy metals causing brain fog. I wanted to jump into heavy metal detox. In fact, I did, and I saw no results from that. It was only when I figured out that I needed to optimize my gut health, which was a step-wise and gradual process, that I was able to really see the improvements I wanted.
So I get when you are not feeling well, you want to jump at whatever piques your curiosity. Take a deep breath, work through the system in the book. That is very important and cannot be overstated.
With that, let’s go into some of the questions that people are grappling with, in that context, to guide them through the book protocol.
Substituting Artemisinin with Artemisia
ER: Sure. So our first question is from Ian. He asks, “Can I substitute Artemisia for artemisinin? I can’t find artemisinin where I live. And would the dosage be different?”
DrMR: Good question. I don’t know offhand how the dose of artemisinin to Artemisia converts. And it also may not be an easy question to answer because you may have different concentrations in artemisinin supplements versus Artemisia. So that can be a challenging question to answer, short of me going and doing some direct research on that question. I would try to find whatever formula is the most proximal to what we recommend in the book (if you can’t access what we recommend in the book), and do your best to put together a dosing protocol that seems as close to the one that we’ve listed in the book as possible.
These questions are always challenging because conversions are, of course, challenging. There are multiple variables here: the concentration of the formula is one example. So I would do your best. As long as you’re doing the best-educated job that you can, I am not inclined to think that that will be the difference between success and failure, especially when examined in the broader protocol of the book, which is going to have many points of leverage. As an example, Saccharomyces boulardii probiotic also works in an antiprotozoal and anti-inflammatory manner. So do your best and that should be okay.
Remedying Constipation During a Fast
ER: Great. Next is from Rachel. “I had LIS surgery years ago. I’ve been on magnesium ever since for my bowels. When I have my surgeries for idiopathic subglottic stenosis, I get severely constipated even when fasting. Can I still take my magnesium during the fasting stage?”
DrMR: Well, to be a bit constipated during a fast, that’s not a highly concerning thing in my mind because there is less food and some slowing down of motility. Now, can you use something to aid with motility during a fast? Absolutely. Magnesium is fine. Some people will use Senna tea, that’s fine.
If you have constipation with a history of prior abdominal intestinal surgery, then you may want to consider an evaluation for abdominal or pelvic adhesions or scar tissue that could be leading to constipation. This is where the people at Clear Passage, Larry, and Belinda Wurn, who have been on the podcast previously, have done a fantastic job. They’ve published on a number of conditions aided by their visceral, abdominal, and pelvic massage technique. It breaks down the scar tissue that may be impeding on the intestinal tract, causing constipation or points of restriction that may lead to decreased motility and small intestinal bacterial overgrowth.
And it doesn’t appear that one always has to do the exact Wurn protocol. I’ve had a handful of patients who, for whatever reason, haven’t been able to do that full protocol (as great as it is), and have found a local visceral therapist. And that has worked well for them. Some people have even done YouTube tutorials on abdominal self-massage and seen benefit from that.
So, to the question: yes, you can use something like magnesium, vitamin C, or Senna to aid with constipation that may occur secondary to a fast. And a history of surgery or trauma to the abdomen or pelvic area is another factor to consider. In which case, consider an evaluation for, or visceral therapy massage to, that region in case there is adhesion and/or scar tissue impeding the intestinal tract.
ER: Great. I’ve heard that many people have success with that. Especially when people find that nothing else is working to get rid of their SIBO, when it keeps rearing its ugly head every six months or so, they’ll try that as a last-ditch effort and turns out that really helps the SIBO from coming back.
DrMR: Yeah, and great point there, Erin, which I want to touch on really briefly. Which is, I wouldn’t make that the first thing that you do.
DrMR: If you’re just waiting, tinkering with your diet, getting acclimated to the probiotic protocol, doing some fasting, and having constipation, then there’s still a world of therapy you haven’t employed that may resolve that problem completely. But as you’re saying, kind of as a last-ditch effort, if you’ve gone through the book protocol and you still feel like you’re having these recurring symptoms that are only minimally responsive—especially if there’s that history of trauma or surgery—then definitely consider some type of therapy for abdominal and/or pelvic adhesions.
Elemental Diet Safety if You’re Underweight
ER: Yeah. Okay, our next question is from Eileen. She wants to know if it’s still advised to do the elemental diet or fast while she already has struggles with being underweight.
DrMR: Yup. It’s a great question. Comes up.
ER: A lot.
DrMR: So we have some pretty good research to answer this question. Essentially what we see is that semi-elemental diets, like that of our Elemental Heal formula, actually have been shown to help underweight patients gain weight. Now, why is that? It’s likely because people with impaired absorption will absorb a predigested formula better (predigested proteins, carbohydrates, and fats). This may be why when you give something that’s predigested to people who are not able to gain weight, they are finally getting in at least a near full calorie count for the day… because they find it very easy to absorb.
Now, there’s another piece of this that’s important. That is, if you’re only consuming 1,100 calories of the Elemental Heal during a day, then the likelihood of gaining weight is pretty slim. You want to aim for at least around 2,000 to 2,500 calories for a woman and I’d say 2,500 to 3,000 for a male, as a general approximation. We have this outlined in more detail in some of our support materials for Elemental Heal. If you do that, the odds are in your favor that you will maintain a normal weight or gain some weight. So it’s really important to draw that distinction.
The other thing, from a broader perspective—and I do also discuss this in the book—is that a couple of pounds, a minimal amount of weight loss, during a process that heals your gut (and theoretically will then improve absorption), might be taking one step backward in order to take two or three steps forward. So it’s important to keep that in mind also.
Now, that doesn’t mean that you should follow a recommendation from someone who seems unreasonable and dogmatic, and watch your weight drop precipitously and just operate on blind faith. You want to be careful who you follow in terms of recommendations there. But if it’s something like using an Elemental Heal formula, and let’s say the first week you lose one or two pounds, I wouldn’t freak out. I’d push forward, I would try to make sure you get the adequate calorie count in. Of course, loop in your family practice or your GP just so they can keep tabs on anything.
There’s really no evidence to show any kind of deficiencies or concern when using the elemental diet, but I think it’s always good to be looping in a provider when doing something like that.
But with all that said… a short answer to your question is that for semi-elemental diets, the majority of the data shows they can actually help with weight gain. Even in Crohn’s children, they have shown that the children who used elemental shakes to replace one to two meals per day actually had better growth than Crohn’s patients who were eating all whole foods. So some pretty good evidence there that shows that the elemental diets are viable even for a low-weight population.
ER: Yeah, it’s so counterintuitive, except it makes so much sense at the same time when you break it down.
One thing that I’ve seen and heard a lot with gut health patients during the elemental diet or the semi-elemental diet is that it’s very tempting to under-consume the drink because it’s not amazing tasting. I mean, the semi-elemental diet is not bad, the one that you have. But most of them are pretty yucky and it’s really easy to underdose, and that’s I think when people get into trouble.
DrMR: And of course, it is a problem with people who are underweight. For people who are overweight to any significant measure, then that may not be a bad thing, because it may put them in a short-term hypocaloric state. Yeah, it’s definitely important to factor that in. If you’re underweight and you’re drinking 750 calories of the Elemental Heal per day, then you can’t expect to gain any weight from it. But yeah, it’s a great question.
Timing of Probiotics
ER: Great. So this next question is going to be in our step two realm. So this is from Lena: “Regarding the probiotics in step two, my chiropractor says that you shouldn’t take Saccharomyces boulardii at the same time as other probiotics (in other words, taking them both first thing in the morning) because it won’t be as effective. But I can’t seem to find any information to validate this. Your protocol doesn’t mention it, but I just wanted to double-check.”
DrMR: Yeah, there is a lot of lore circulating regarding probiotics. I was at a conference recently and one of the presenters there said that apparently, some probiotics can make leaky gut worse. I would’ve loved to have seen the evidence for that. I’m assuming what happened here was there was, one study looked at some type of mechanism that was interesting and different. And because it was different, and things that are different are more attractive than things that aren’t different, it was put in this presenter’s presentation, which I really do not appreciate. Because if you look at the totality of the data, you see overwhelmingly that probiotics can help with a litany of conditions that we at least tacitly assume have a connection to leaky gut, like IBS and inflammatory bowel disease.
Not to mention that there are a handful of studies actually documenting reduced leaky gut upon utilization of probiotics, in human beings. One is with a soil-based formula mainly and one is with a predominantly Bifidobacterium blend. I know specifically, those have been published in human outcome studies. So where does this opinion come from, which I’ve never even heard before (and I’ve read so much on probiotics in terms of the research)? I literally go through every meta-analysis, looking at the randomized control trials that compose the meta-analysis, looking for trends, looking for patterns, looking for adverse events, looking for the effect size. I’ve gone through the probiotic literature with a fine-toothed comb.
I’ve never seen that written anywhere, so I’m assuming that this is one of many a piece of superfluous and hyperbolic claims circulating in natural medicine, that has no basis in science. It’s probably a theory that someone cooked up. I have no idea where that comes from. I would not agree with it at all. What I would say is to simply work through the protocol in the book which uses the three different categories of probiotics, your Lacto-Bifido blend, your Saccharomyces boulardii, and your soil-based.
If you’re someone who is historically sensitive or reactive, start on them one at a time, in case one particular category of probiotic doesn’t sit well with your system. Then, if a probiotic is seeming to cause a negative reaction that persists longer than three to five days, stop that probiotic, because it means that it’s probably not a good fit for your microbiota.
But as to these highly meticulous rules around probiotics… another one from years ago was if you have inflammatory bowel disease you shouldn’t use Saccharomyces boulardii. Yet there have been a number of clinical trials showing that Saccharomyces boulardii can be helpful for inflammatory bowel disease. Now, this may have come from the observation that people with inflammatory bowel disease can have antibodies to Saccharomyces cerevisiae, and people said, “Well, Saccharomyces cerevisiae is kind of similar to Saccharomyces boulardii so theoretically you shouldn’t do this.” This is where we get in trouble when we just have a hypothesis, and we start making clinical recommendations from a hypothesis. We run a huge risk of error because a hypothesis is just a theory. Until we look at what happens when we treat humans and test a hypothesis, we shouldn’t really say much about the theory. We shouldn’t make a clinical recommendation. And as it turns out, as I just shared, when we have intervened with people with inflammatory bowel disease, they seem to generally do pretty darn well on Saccharomyces boulardii.
Another one of these highly specific meticulous claims is, don’t use probiotics if you have SIBO. Yet there are four clinical trials showing that probiotics can combat SIBO. I would be very circumspect with anyone who gives you these highly meticulous recommendations, because oftentimes it is, “Hey, here is something different than what everyone else is saying, and so this is what I’m going to put out there because I want to come across novel.”
And pardon my candor here… I don’t think anyone is doing this with malintent. But I think some people get so excited about something new that they can’t check their own bias. So if you’re not good at checking your own bias, then it’s easy to slip into sharing a recommendation that has no evidence to support it (as in this case). Squarely to your question, I would not worry about that at all. I have no idea where that comes from. If someone has a credible reference, I am happy to look at it. But I have not seen anything even hinting at that being the case.
ER: Yeah, and I love the recommendation—especially if you’re someone highly reactive as I was when I was having a lot of gut issues—to maybe try them one at a time. Because I was able to throw out a lot of different possibilities and also find the probiotic that worked really, really well for me. But I almost gave up on probiotics altogether and I’m glad that I stopped for a second and tried them individually. It made it very clear what was working and what was not working, so I love that.
DrMR: Good. Yeah, it is unbelievable, looking at some of the narratives regarding probiotics in the space. It’s no wonder practitioners are confused: I look at some of what the educators are saying and it absolutely baffles me. We have a lot of work to do here in functional medicine and integrative medicine, in terms of our stance on probiotics. Hopefully, with time we’ll see a more evidence-based narrative. The thing is, there is a bunch of evidence, so we don’t have to be making these theoretical posits. We can actually say, “Here is what the evidence shows.” So, good question articulating where to be careful and how the answer is quite simple in practice.
Concerns Over Inulin in Probiotics
ER: So next we heard from Miriam. She says, “I noticed that the Lacto-Bifido probiotic blend contains inulin. I’ve been doing paleo/low FODMAP and it’s helping, so I’m confused as to why I’d want to take a supplement with inulin.”
DrMR: Yep, great question. This comes back to reassurance, which is to follow the protocol in the book. Unless you think I don’t know what I’m talking about, then throw the book out. If you think I have any idea of what I’m talking about, take solace in the fact that know what I’m doing. I’m almost positive I speak to this specifically in the book, which is as long as the amount of inulin is only a couple hundred milligrams as ours contains (I believe it’s 450 milligrams)… Really anything below a thousand milligrams is almost guaranteed not to cause a problem.
For the audience, inulin is a prebiotic. And a low-FODMAP diet, which can be very helpful, is a low prebiotic diet. Many people with IBS and IBD and gut symptoms may not do well with prebiotics. But this is where thinking about things dichotomously and in extremes gets us into trouble. A low amount of prebiotic poses no problem.
Even in the literature, it has been concluded—as I discuss in Healthy Gut, Healthy You—three to five grams or 3,000 to 5,000 milligrams of probiotics tends to be the sweet spot where people see the benefit and there is a minimal risk of negative side effects. So even in the research, we see you can go quite a bit higher and will likely be okay, 10 times higher than the amount of inulin in our probiotic.
So it’s a good question, it’s one that you do want to be careful about. You want to make sure that you’re not using a probiotic-prebiotic combination, meaning you have five grams, 10 grams of prebiotic with your probiotic. In our case, the amount of prebiotic is infinitesimally small and nothing that I would be worried about.
Is It a Probiotics Die-Off Reaction?
ER: Okay. There’s a two-part question next from Cameron. He says, “I started step two and have been trying to implement the probiotics. Prior to the probiotics, I was taking betaine hydrochloride (HCL) and lipase. I was a little aggressive with the probiotic dosages and unfortunately started having bad acid reflux. Is this die-off reaction or is the probiotic helping my stomach produce more acid on its own and the addition of betaine HCL is now causing too much acid? Or could taking probiotics on an empty stomach be the cause?” That’s part one of the question.
DrMR: So it’s a great question. Now, timing here is really important. One of the ways that you can tell if a probiotic is causing a negative reaction, compared to if a probiotic is causing a kind of die-off or adjustment reaction, is the duration of the negative reaction. For most people, if a negative symptom pops up for three to five days and then starts fading away, that is a die-off or an adjustment reaction. So if you notice around day three, four, five, in this case, the reflux symptom is starting to abate, then see where you end up. And what you may notice is by a week or a week and a half in, reflux is completely gone and you’re actually feeling even better perhaps.
But if you notice that the reflux comes on and persists day after day after day, well beyond three to five days, and is showing no sign of getting better, then that tells you it’s more likely a negative reaction and that type of probiotic doesn’t work for your system. Now, for some people, certain probiotics can cause a net pro-histamine effect. And this may be because that certain probiotic may not jive well with your microbiota, that may cause stimulation of histamine, and histamine then triggers stomach acid release.
So, there are some patients for which probiotics will be vastly helpful for reflux, but that’s not a blanket statement. This is why we break the probiotics down into the three categories. And I recommend for sensitive people, trying them one at a time, because what you may notice is the Lacto-Bifido blend may trigger your reflux, but S. boulardii or our soil-based formula may improve your reflux. So you want to tinker a little bit and experiment to see what if any probiotics are helpful for you, and what if any probiotics trigger your reflux. And remember that the timing of a negative symptom, in this case, reflux, can help you determine if that’s an adjustment reaction and just some temporary turbulence or if that’s a negative reaction and that probiotic category is one that you should not be including in your gut-healing protocol.
Possible Causes of Reflux
ER: Cool. And is there anything there with betaine HCL and the combination of that and the probiotic? Just curious.
DrMR: I don’t know of any research showing that probiotics can help you better produce your own HCL. I suppose it’s theoretically possible if the probiotics help decrease inflammation and help with the repair of the gut lining. What I see more often is the mechanism I outlined a moment ago, which is, if a specific probiotic is negatively jiving with one’s system, you will likely have a pro-histamine, and therefore a pro-acid, effect (this is why we have to personalize it to the individual). So I don’t think we can assume this person needs HCL. That’s something you have to work through the book protocol to figure that out. But I would simply start with figuring out what probiotics you need while using the minimal dose of HCL that is contained in our digestive enzyme with HCL, because most people will not need high doses of HCL.
In fact, if you’re exhibiting reflux—and age here is also important, and again, I expand upon this in the book—the younger you are, the more likely you do not need acid. The older you are, the more likely you need acid. If you have a history of anemia or autoimmune conditions, that increases the probability that you may need stomach acid. But the need for it is grossly overstated in natural medicine. Some people do need it, but because there are other factors that can confound if you need or don’t need acid, we start with a minimal dose of acid while we go through this gut-healing protocol and then we reevaluate.
So the acid one is a little bit tricky. We have to get one’s gut healthier so that you can tell if the reflux is coming from leaky gut, food reactivity, histamine, or from the fact that you’re actually low in HCL. That takes a little bit of time. It’s not the first thing to tackle, which is why we give, again, a small dose of HCL with the digestive enzymes. But that’s not our focus initially, because most people will not need HCL in the long term when they heal their guts (unless you fit that criteria of predisposing factors I just outlined).
Can I Skip the Probiotics Step?
ER: So the second part to this question is sort of answered in the first part there. But if there’s anything you want to add I’ll go ahead and read it. “I’m 99 percent positive that my health issues are caused from SIBO or another gut imbalance. Could I start step three supplements without the probiotics, then add them back in about a week or so?”
DrMR: Yep. So based upon a flawed assumption, which is that the best way to address SIBO is with antimicrobials, and that’s not necessarily the case. In fact, this is one of the main reasons why probiotics come before antimicrobials: the probiotics may be enough to not only heal your gut but also combat SIBO, fungus, and any other type of dysbiosis. So my answer would absolutely be no. Start with the probiotics. Don’t let the fact that you’ve had a reaction to one completely throw you off the track. Continue forward exactly as we recommend in the book.
If you’re having a reaction to category one, the Lacto-Bifido blend, firstly give that a fair trial as I just outlined. Then move on to category two and category three and you’ll likely find at least one probiotic that works for you, that you want to carry forward. But you also want to give that formula a little bit of time. You may notice after you find a tolerable probiotic and you’re on it for a few weeks, your symptoms are gone and your SIBO could be gone. Again, there are four clinical trials showing this can be the case and we’ve written up a number of case studies supporting this also.
Substitute for Oregano Oil
ER: Okay. Laurie wants to know if there is a substitute for oregano oil. She seems to be reacting to it, experiencing knee pain and irritation at the corners of her mouth.
DrMR: Yep. There are alternate antimicrobials listed in the book and in our store, so I’ll just direct you to either the book protocol for that or the store page for the step three supports.
Cause of White Tongue On the Elemental Diet
ER: Yeah. You can get there really quickly on the website. So this one’s from Becky. “What is the cause of white tongue while I’m on the semi-elemental diet? And should I continue with this diet if my tongue has become white? Thank you for the great book.”
DrMR: Yeah, it’s a great question. So, unfortunately, this has made some people conclude that elemental diets can cause fungal overgrowth.
While I don’t know of anyone who’s taken a large group of people and tracked their fungal markers while on elemental diets, what I can tell you is, I am very suspicious that that is incorrect and propagated solely due to the observation that some people—likely because of the carbohydrate content in the elemental formulas—develop oral thrush. They develop a short-term and temporary bit of fungal overgrowth in the mouth while they’re using elemental formulas. In my experience, it goes away very quickly after someone finishes their course on the elemental diet, and has no negative ramifications. If you were to use something like a type of oral mouthwash, even a natural one, you will likely be able to keep that at bay. Some people gargle with oregano oil, that could also help. But again, I have no concern about fungus in the elemental diet. In fact, we have patients who will both have SIBO and fungus who do great on the elemental diet.
That being said, if there is any quality evidence showing that not to be the case, I will be one of the first people to revise my position on this. But remember that the elemental formulas are absorbed in the first few feet of the intestine. So to say that you’re going to feed this huge fungal overgrowth in your intestine when the formula doesn’t even make it past foot three of the intestine is pretty counterintuitive. When you understand that the majority of your intestinal tract (small intestine and large intestine included) will not be touched by an elemental formula, how can you conclude that you’re going to feed small intestinal fungal overgrowth or colonic Candida overgrowth? By definition, these formulas will most likely starve the intestines for fungal food just as they will of bacterial food.
So I think, again, what’s happened is people don’t understand that part of the equation. They see the oral thrush and they say, “It must be Candida.” Or even worse yet, someone is unfortunate enough to have a little bit of white tongue combined with a negative reaction to the formula and they say, “Oh, it must be a fungus.” Again, if there is at any point quality evidence showing that to be the case, I will be the first person to change my perspective on that. There is none to my knowledge, and I am very strongly suspicious that there is no risk, or an infinitesimally small risk, of fungal overgrowth on an elemental diet.
The whitening of the tongue is due to the rich carbohydrates that are easily absorbable in the elemental formulas. And in almost every case I’ve seen, it goes away shortly after someone ends their course on the elemental diet. If someone wanted an immediate palliative measure, they could use a mouthwash of some sort and they should be totally fine. But don’t throw out the vastly helpful elemental diet because you think that is going to potentially worsen fungal overgrowth.
There have been a number of cases where they were not doing an elemental diet for that very reason. They came into my office and I talked them into it. They were so happy that I did because it was vastly helpful for their symptoms. So, another example of observing little mechanistic pieces and then generating a hypothesis and a clinical recommendation from that. This is another example of how can that mislead us. So no, I would not be concerned at all about elemental diets propagating fungal overgrowth.
ER: Great. I’m so glad we had that question. There were a few times when I was moderating or helping to moderate some SIBO Facebook groups, and because it’s something visual that people can connect to and find easily on the internet, a bunch of people would chime in about, “Stop taking it. It’s probably fungal overgrowth.” I’m so glad that you broached the topic, and that we’re able to clarify that because I think people are very quick to make that assumption.
DrMR: Yeah, exactly.
ER: Especially in communities.
DrMR: Right. And remember, people can have negative reactions to the elemental diet. But I am not inclined at all to think it’s because you’re causing some type of rebound fungal overgrowth.
ER: Yeah. And I think what’s neat about working with you—and I’ve had my own personal experience getting to work with you in healing—is that for me it was all about what you didn’t say. Because I had 100 questions to ask you and I’m like, “But if he’s not bringing this up, then it’s probably not that big of deal.”
Anything that had any merit you would explain very clearly. So I think it’s also when people just have a book in their hand and aren’t working with you personally, a lot of questions come up. And the internet plays a big role in that. Just getting to work with you in a personal experience was cool because, I was like, “He’d probably say something if these were important questions that needed to be answered.”
DrMR: And in my view, that is half, if not more, of the battle in being a provider: knowing what to focus on and then knowing what superfluous trends you don’t need to get pulled into.
ER: Yeah, or just nuance that every single person is bound to bring because everyone reacts in their own individual way.
Dosing for NAC in Healthy Gut, Healthy You
Okay, so we’ve reached our last question for the episode. “Is the dosing for NAC really 2,700 milligrams three times daily? Is this a typo? Would you please explain more about this dosing?”
DrMR: If you’re seeing 2,700 milligrams three times per day, then yes, that is a typo. There were one or two typos that made it into the tables of the book. The text of the book was correct.
We had some challenges with the team that we used for graphic designing and unfortunately they if I’m being fully candid, didn’t do a great job with all the photos. I think what happened was, in a couple of instances there were small errors like that, that didn’t get carried from the text over to the table correctly. We have since updated all of those. Most of these we had caught within the first couple months of the book being out and we made updates and then all future Kindle and all future paperback were updated.
So this is likely from a very early iteration where a couple of those things snuck through, which I do apologize for. But there should’ve been the correct iteration of that in the text. Now, the dose that I call for, one 900 milligram capsule, three times per day, is higher than what was used in the one landmark study using H. Pylori. In that study, they treated H. Pylori using N-Acetyl Cysteine in conjunction with antibiotics and showed that the group receiving the N-Acetyl Cysteine plus antibiotics did much better than the group just receiving the antibiotics. They were using about 1,200 milligrams per day.
In the SIBO biofilm research, we did at our office, we used 2,700 milligrams per day. So you can go higher, in my view. N-Acetyl Cysteine does have some very nice secondary health benefits. That is admittedly a high dose, but we are using that as a short-term high those for a therapeutic endpoint.
So just to make sure we’re all on the same page here, the daily dose I recommend in the book is essentially 2,700. One could use that dose or even slightly less, instead of taking three pills per day. One could take two and shave that dose down just a skosh to about 1,800 milligrams, which is closer than what was used in the H. Pylori study. We used 2,700 in our SIBO biofilm study. What you are specifically pointing out here may have been one of a small number of table typos in the books which have now been corrected.
So thank you very much for that question and everything there should be up-to-date in the books, and I apologize for those couple that snuck through. We tried to weed out every single little typo like that, but with 120,000 words and something like 60 charts, unfortunately, a couple did sneak through (which drives my perfectionist side nuts). Nonetheless, I think we have all of those caught and corrected to date. So again, thank you for pointing that out.
ER: Yeah. Great question. Well I think that was a great episode. We’ll do another one on the same topic of Healthy Gut, Healthy You in a couple of months. I think there are always questions coming in, but I think that was a great start.
DrMR: Yeah. It was a lot of fun. Great questions, guys.
What do you think? I would like to hear your thoughts or experience with this.
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