How to Interpret SIBO Test Results & Improve Food Intolerances

Intro:

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

Dr Ruscio:

Hey everyone. Today I spoke with Dr. Joe Mather, from our clinic, and we covered a number of topics. We started off with a reminder on the appropriate way to interpret SIBO breath tests. This is really important, amongst other reasons, because what the lab machine will print out is not the correct and most up to date interpretation criteria. So we discuss if you’ve had a SIBO breath test, here’s how you interpret it to make sure that you know if you do or if you don’t have SIBO. We also went into some ruminations and reflections on how to treat hydrogen sulfide SIBO. In addition to discussing how often we see, what can be helpful for, and how people should expand their diet and improve their food tolerance.

Dr Ruscio:

And then we rounded things out with a few remarks on how important it is not to use a test that’s been validated, let’s say, in a population of patients with diarrhea as a screening test. And how we have to be careful—especially in our field of functional integrated medicine—when we use lab markers that, let’s say again, have been validated (like calprotectin has in the setting of inflammatory bowel disease), where oftentimes there’s chronic diarrhea as a screening tool and how this runs the risk of thinking there’s a problem when there may not be. Because we haven’t established that when calprotectin is used as a screening tool, what subset of the population (who is normal and healthy) will have elevations of calprotectin. So all that and more. Plus a few bad jokes, with Joe here coming up. And I hope you guys will enjoy the conversation as much as I did.

Dr Ruscio:

Hey everyone. Welcome back to Dr. Ruscio, DC Radio. This is Dr. Michael Ruscio, DC and we had an overwhelming amount of requests to get Dr. Joe Mather, medical director of the clinic, back on the podcast. In fact, much of the feedback was Michael, please stop doing podcasts and please have Joe do every podcast from here going forward. So in light of that feedback, I said, “boy, if we don’t get Joe back on the show soon, there’s going to be a coup.” So Joe, welcome back.

Dr Joe Mather:

Thanks, Michael. Even if that was completely made up, it makes me feel good.

Dr Ruscio:

Well, I do want to going to start off and for the audience, we’re going to go into some very important guidelines regarding interpretation of SIBO breath testing. So you can double check if the SIBO test you did with your provider is, or has been accurately interpreted or not. But before that, I just want to give Joe a pat on the back here. If you’ve seen a few of the patient conversations that Joe has recorded, just fantastic job, Joe. You can really see the amount of caring and your fantastic bedside manner come through on some of these case studies. There was a case study with Julie. There was the Crohn gentleman… What was it? What was his name? Kyle, was it?

Dr Joe Mather:

It was, yes.

Dr Ruscio:

Kyle. So just, well done. And, I want to say this for our audience, because one of the things that has been important to me is as we build a clinic, we don’t build this well, I wrote a book and there’s a podcast and that’s generated some visibility and now we’re just going to fill in the demand for doctors’ office visits with other clinicians who might be smart and well-intentioned, but are all doing their own thing. And this does happen at some clinics and that’s fine, but I don’t think that’s what anyone from our audience would expect. I think they would hope and expect that all of us in the clinic were working via the same model. And I think that becomes fairly evident when you look at the case studies with Joe and the individuals that he’s worked with is, that we’re really working together as a team more efficiently than, I think, even one can alone.

Dr Ruscio:

And part of that is because we’re all treating patients in a similar fashion. Not this preset program, [where] everyone gets the same thing—we have these guiding principles that allow us to personalize care to the individual. And the more that we’re able to all work in that model together, we can compare notes and we can enhance the effectiveness of the care. So just a couple side remarks there. And a thank you, Joe, for proving the concept that this model is not something that just one person can do, but it’s a model that’s really tried and true. And it’s now being replicated amongst yourself and Hannah and Rob and Gavin. And [it’s] a real treat just to see how we’re able to help so many more people because, Lord knows, we need that. And, again, just thank you, Joe, for all the great work that you’re doing,

Dr Joe Mather:

As you were going through that, I was just thinking, you and I have been trading notes for almost a decade now and working closely for most of that. And the system matters, right. It really matters to have a structure in which you’re treating patients. It’s not that we have to be lockstep, but we’re all sitting there in the band reading from the same script in that we have got a basic set of notes. But it allows us, not one person to go completely out of tune if we all are really focusing on the fundamentals first of really good GI care, making sure the lifestyle is nailed, and then once you see that some symptoms are remaining, you can dial in deeper to try to clean up any other clinical systems that are out of place. But yeah, it’s easy to look good when you have a great system in place. So thank you for that. And we’re all working hard to continue and make it better.

Dr Ruscio:

Absolutely. And we should also probably just thank Morgan and Eliza, our clinical nutritionist and our nurse, who do a fantastic job parsing through patient information. When new patients apply, we end up obtaining a fair amount of information about the individual and it’s not always fully accurate. Sometimes people use loose language or they describe their symptoms with syndromes of which that syndrome could have 10 symptoms. So if you name three syndromes that are bothering you, we still don’t know very much about the exact symptoms that you have. So little things like that to parse and to verify and make sure that we have the most accurate information.

Dr Ruscio:

Also makes it a lot easier for us because—and I’m sure many of the clinicians here can relate to this—sometimes you’ll spend the first half of a visit just verifying you have the correct information. So imagine how much more effective your clinician could be if that half of their time and focus was used more constructively to not verify details, but rather ask key questions to solve the problem. So, a big thank you to Morgan and Eliza. And also, of course, the whole staff. But they’re really key, Morgan and Eliza that is, in helping us look good. So to thank them for that also.

Dr Joe Mather:

Yeah, so we have a 40 minute visit and in previous practices I would spend all of an hour, sometimes more, just verifying that information. Now we’ve got it in place where I’ll spend 10 minutes with a patient (maybe 15) of the 40 minutes, just nailing down the information that’s already been given to me. And then the vast majority of the visit then is problem solving. What does this patient need? What hasn’t been done? What’s the best order? And it really lets us get, I think, results quicker for people than other operations.

Dr Ruscio:

Exactly.

Dr Joe Mather:

We’re building.

Dr Ruscio:

Yeah. And one of the areas that we get the results here—to bring it back to the topic at hand or at least the first move that we wanted to speak to—is SIBO (small intestinal bacterial overgrowth). We talked a lot about verifying prior hypothyroid diagnoses, but SIBOs another one. And, I know you had a number of thoughts, Joe, and the one thing I’ll throw out there for the audience—and, Joe, I’d love to get your expansion on this and anything related to it—is the piece of paper that the lab prints out isn’t being updated with the consensus guidelines as they roll it out every few years. So, the lab auto interpretation or the computer interpretation is something, but it’s really not super accurate. So one has to be very careful not to use what the lab says is high or low or positive or negative, and have a clinician interpret that.

Dr Joe Mather:

This came up because I had three patients in the last three weeks where they came in and they were freaked out about a diagnosis of SIBO. And they had symptoms, but not a ton of symptoms. And for years they had been under the assumption that they had this horrible case of SIBO. And I pulled up their breath test and by consensus guideline recommendations, they didn’t have SIBO. And it was a huge relief to each of them, to understand that they had been misdiagnosed.

Dr Joe Mather:

But I thought it would be useful for the next time that you and I spoke to just go over what one of the better consensus guidelines says. And so there are two consensus documents: there’s the Rome Consensus and there’s the North American Consensus document (and that one came out in 2017). And that’s the one, I think, that is a little bit more clinically valuable in our practice. And there were three main takeaways on my reread of the document. You mind if I just jump right in for that?

Dr Ruscio:

Yeah, please. I think this will be a valuable reminder for both patients and clinicians. So yeah, let’s do it.

Dr Joe Mather:

Yeah. So the first question that that comes up is: which is the better sugar to use to provoke the test, right? So the idea of a SIBO breath test is you’re giving a sugar solution and the bacteria in the small intestines will ferment that sugar and create a gas. And you measure that gas through the exhalation of the breath. And that’s how you’re doing the breath test. Glucose is the first sugar, lactulose is the second. And there was actually a funny standoff. I went to a SIBO symposium and you almost literally had the naturopaths on one side of the room and they were like team lactulose. And then you had the MDs and chiropractors on the other side of the room. And there was two points in the middle of the conference in which they were literally like yelling back and forth at each other across the room insults about which was better.

Dr Joe Mather:

And I think that as the evidence has come in, I think team glucose has won, and glucose has more evidence showing that it’s a bit more accurate than lactulose. So we do predominantly glucose breath tests in our clinic. It’s not that you could never use lactulose, but I think if you’re following the data, this is simply a bit more accurate, a little more sensitive, a little more specific than lactulose. You with me?

Dr Ruscio:

I am. There is one thing here, I think, that that should be mentioned in defense of the lactulose, which is the studies for the most part that these metaanalysis, that are comparing the accuracy of lactulose versus glucose are using, haven’t used the updated guidelines to close the interpretation window to the first 90 minutes of the test. And I think what that will do is it will prevent the amount of false positives that one sees with the lactulose. Because that’s one of the main problems that, at least as I understand, it occurs with lactulose because it goes further down the small intestine, all the way into the colon. If you don’t choose your cutoff window appropriately, you are seeing elevations when the lactulose makes it into the colon, and you should see elevations in the colon, hence a false positive. Now, because glucose predominantly does not make its way to the colon, you don’t have that problem.

Dr Ruscio:

So glucose had its own built in safeguard because it never made it to the colon. Lactulose made it to the colon. And when we were interpreting tests all the way down to 120 minutes, I think that’s where probably the majority of the discrepancy between the two tests came in—where the lactulose makes it all the way through to the colon. And if you’re not stopping your interpretation of the test in 90 minutes, you’re probably calling some SIBO inappropriately or a false positive. So I think one could make the counter argument that if you’re stopping your interpretation of lactulose at 90 minutes, it’s going to be more accurate. That hasn’t been proven. That hasn’t been studied. But that’s at least the way I look at this.

Dr Joe Mather:

That’s very reasonable. That was my second take-home. In each of the cases I mentioned above, they were patients who were diagnosed with SIBO at the 120 minute mark. And that’s just way off. Right? So as a general rule of thumb, what I would say is: 1) glucose over lactulose 2) stop reading it at the 80-90 minute mark. Most tests are 80 minutes, but some of them go 90 minutes. The incremental is just slightly different, but stop reading it. 80 or 90 minutes. And that’s going to take away a lot of false positives. So if the sugar is in the large intestine, creating gas there, you may see a false positive and mistakenly think you have SIBO when you do not.

Dr Joe Mather:

And then the third was just a reminder of what is a positive hydrogen and methane, to the best of our knowledge. And these are interpreted slightly different. So the two main gases on most breath tests are hydrogen [and] methane. There’s a third—which I’ll let you talk about in just a moment—but hydrogen is…you’re looking for a rise of 20 parts per million at the 80-90 minute mark. So from 0-80/90, you’re looking for a rise of 20 or more. If you get that before the 80-90 minute mark, then you are very clear that this is a case of hydrogen-dominant SIBO.

Dr Joe Mather:

For methane, you’re not looking for a rise but just an elevation. Particularly greater than 10. So anytime before 80-90 minutes, if you’re greater than 10, then that’s a very high chance that you have a methane-dominant SIBO. The point here is that there is some speculation out there that if you get a methane level of greater than 3 with constipation, that that’s a positive test.

Dr Joe Mather:

To my knowledge, that’s opinion-based. I don’t believe it’s been validated. And it’s important to note that three parts per million is the smallest amount that can be detected on the test. And there’s likely more error at that lower range of detection. Whereas it’s very clear that you can accurately measure parts per million above 3. As soon as you start getting closer to 3, I really do worry how accurate it may be. So if you’re bumping around 1, 2, 3, 4, 3…I just wonder how accurate that may be. So in my world, I will want to see a CH4 of, at bare minimum, over 5. But certainly I’m really not that concerned unless it’s over 10. So maybe I’ll just pause right there for any feedback or thoughts from you.

Dr Ruscio:

It’s a great point. And the piece on expert opinion versus what’s been robustly, scientifically demonstrated is a very important one. And, I think especially with Pimentel, because he’s done so much to advance the science in the field, I almost—I don’t want to say I feel bad—but I think it’s so easy for people to misinterpret what he says. And I could imagine being in his position where he makes one comment about a trend he’s seeing, not meant to be an official statement or a strict guideline, and people take that and run with it. They repeat it a whole bunch and before you know, this one comment from a symposia six months ago is now almost codified into SIBO law. So I want to, I think, be understanding that there’s this hard-to-strike balance of wanting to report in on trends that you’re seeing, that haven’t yet become official, on the one hand, and on the other realize that we want to take those things with the appropriate context. And I don’t think the SIBO community’s done a great job of that. There does seem to be this one or two things that take wind—like probiotics being bad for SIBO, I saw a post on that on Facebook the other day—and it’s still ingrained in some of the community.

Dr Joe Mather:

I think I hear that twice a month from patients.

Dr Ruscio:

Right. I mean, it’s good for us because people come in and they have SIBO or IBS and they’ve been avoiding probiotics, and it makes it much easier for us to get them results. But it’s not good for patients.

Dr Joe Mather:

The other point to make is that, I think we’re pretty well rounded clinicians, we treat a wide range of issues. And I think there does lead to some bias if you are a clinician only really known for specializing in one condition. Because people all across the country are going to come to see you for that condition. And therefore you will see the worst of the worst of the worst. And that just changes how you interpret these tests and how you look at patients. And it would be impossible not to. We are biased by the patients we see. And I think clinicians and patients alike should just think about that a little bit. What kind of patients is this doctor seeing? Is this clinic the right fit for me? And whenever I was in this symposium and hearing everybody yelling at each other, I was just wondered that question. One group [is] seeing different patients and therefore they’re seeing different responses. And gotta take everything with a grain of salt.

Dr Ruscio:

And there there’s no necessarily right or wrong answer to this, but this is a question I’ve thought a lot about in terms of: what is the optimum depth of specialty in GI? And, again, there there’s no right or wrong, but at least for the way that I, and I think we both, Joe, look at the world, there’s a point at which I think, again, according to our framing, where you get more detail than is constructive in helping patients. And this is why we do have a specialization in gut care, but we haven’t drilled down to become the parasite clinic, the SIBO clinic, the motility clinic. But we have the appropriate depth of knowledge in GI. But we’re also looking laterally at thyroid, at female hormones, at sleep. And even within those, we haven’t gone super deep. We’ve gone the appropriate level of depth that I think is going to be the most helpful for the highest number of people.

Dr Ruscio:

And again, I want to be careful to say, it’s not the right depth for everyone. You need those uber deep specialists. But oftentimes I think the uber deep specialists are helpful in uncovering a specific finding that’s then handed over to the clinical community and then integrated into a care model more broadly. And this is where I really think a lot of the strife comes from, is that how we translate research findings in the clinical practice isn’t always super obvious. And this is where I think a lot of the debates come from. But if we can reframe this in terms of, “okay, we have research findings and now the clinician community has to figure out the best way to integrate those so as to serve patients.” That’s, I think, the best marriage of research and clinical practice and why—as a center that does both—we have a lot of understanding of SIBO, but we haven’t made that the only thing that we specialize in. Because, again, at least for how we’re trying to help patients, it wasn’t worth going so deep into SIBO that we didn’t understand a lot about therapeutics or fungus or hydrochloric acid or these other things. But I’m curious, Joe, what thoughts you have there?

Dr Joe Mather:

I think this is one where I just agree with you so much that I don’t have much more to add.

Dr Ruscio:

Yeah, well, hence probably why we’re working so intimately in the clinical setting as we have.

Dr Joe Mather:

I was going to pivot, instead. You mentioned research, and this is one of the things that I’ve been so proud lately to be associated with a clinic where we’re really working hard to build the evidence base for some of these natural treatments. Particularly things that we see clinically work but just need to show that they actually do. And this ties back to the third gas that we didn’t mention, that wasn’t reviewed on the North American Consensus, because the trio-smart breath test wasn’t out yet. Now that it’s been out for a while, I wanted to get your big picture thoughts on hydrogen sulfide. And the first question is, I’ll give you a leading question, is hydrogen sulfide a clinically-distinct entity from methane SIBO or hydrogen-dominant SIBO in your experience?

Dr Ruscio:

In terms of the symptomatic presentation?

Dr Joe Mather:

We’ll break it into two parts: symptomatic, first, and then treatment next.

Dr Ruscio:

I haven’t been able to discern a signal of it having a different clinical presentation. Although I don’t think that I’m in the best position to adjudicate that meaning. There’s so much symptomatic signal that we get [that] it’s really hard to say, “this person who has just hydrogen sulfide SIBO has a distinctly different symptomatic picture than a person who had just hydrogen SIBO or methane SIBO.” We are tracking this. There is that short list of questions that are purported to associate the hydrogen sulfide. And we have been tracking this in the enhanced data collection that we’re doing at the office where we’re doing baseline symptom testing and a trio-smart, then we’re doing treatment with probiotic triple therapy, and then we’re repeating all those measures. That’s where I think we’re really going to get a scientific answer on this. But at least clinically, no. Although again, I’m not sure that I’m in a great position to isolate that variable or those few variables and have a good answer.

Dr Joe Mather:

Yeah. The first thing came to mind is actually because I think we’re at heart practical clinicians—how can we get this patient better as quick as possible—we aren’t doing the meticulous breath testing that some SIBO-specific doctors may be doing. And so those folks may actually be in a better position than us to answer that, if they’re getting breath tests every other month on their patient. Now I know you and I both think that that might be not the right financial choice for most patients, but it actually might put them in a better spot to comment on hydrogen sulfide.

Dr Ruscio:

True. And the other thing too is—unless you are really reducing the amount of variables that you see to a narrow band of digestive symptoms plus any other non digestive symptoms that are supposed to associate the hydrogen-sulfide SIBO and you’re doing repeat testing—I think it’s just hard for someone to have enough of that information in their memory and be able to parse it all and look for trend analysis. [It] isn’t always easy, especially with people who have an array of symptoms. They have problems with sleep or stress or brain fog, in addition to GI symptoms, so it can be challenging. But we’re tracking that data. And I’ll be incredibly curious to see, when we collaborate with our biostatistician consultants, if we’re able to produce a signal there. So jury’s out but we’ll see.

Dr Ruscio:

And the other part of this you wanted to pivot to, Joe, was the testing piece, I’m assuming, in terms of, does that hydrogen-sulfide SIBO finding tend to occur in isolation or along with one of the other two gases?

Dr Joe Mather:

Well, I was more curious just because I haven’t asked you specifically, have you found that specific alternate treatment pathways are needed for hydrogen-sulfide verse a case of methane SIBO, for example?

Dr Ruscio:

Yeah, this is a good question. And, ironically, I had one case who had a negative reaction to Bismuth. Now, it may have been because they were using Peptobismol, and then when we used a more minimal-ingredient formula, they seem to be okay. And there’s definitely published evidence showing an enhancement effect of Bismuth. The question is, is it enough of an enhancement effect to go beyond just showing statistical significance, but also showing clinical meaning in terms of having an appreciable impact in the outcome? I’m not sure. I haven’t gotten that sense yet.

Dr Ruscio:

Ironically, I had one individual who really responded well to Bismuth and when we did testing, they never had hydrogen-sulfide SIBO. They had come in reporting success with Bismuth, just through their own experimentation, and then we never saw any signal of hydrogen-sulfide SIBO, even when their symptoms came back.

Dr Ruscio:

Now we have documented, solely with Probiotic triple therapy, which I don’t say solely to mean that it’s not a powerful therapy. I think Probiotic therapy, as we study it more, is going to be shown to be quite effective. Since, as we’ve discussed in the podcast before, meta-analyses have found probiotics and Refaximin to have a similar effectiveness. Now you could baulk at maybe the studies were not all apple-to-apple comparisons. Maybe the Rifaximin trials were larger in number and usually the larger trials are going to show a smaller effect. Okay, fine. But at least looking at the best data that we have, they’re showing a comparable effectiveness, but they’re only using one probiotic formula as a monotherapy. We’re now using three. It’s almost akin to saying using three different antibiotics.

Dr Ruscio:

So, in any case, the triple therapy probiotics have shown the ability, unofficially. This is data that we’re gathering and we’re hoping to publish it soon, once we close this data collection window. But that’s been really reassuring to see. So I’m hopeful that we’ll be able to document that, at least from a probiotic perspective, hydrogen-sulfide isn’t this thing that requires a vastly different way of treating the individual and we still go through the process of taking the tools in our toolkit and personalizing those to the individual based upon their history and their symptoms. And really treat the people rather than focusing on treating the H2S number.

Dr Joe Mather:

I would say, that’s my biggest takeaway. After about a year now of ordering the trio-smart breath tests. Number one, I am just not seeing an appreciable number of positive hydrogen sulfide cases that need [a] specific different way of treating. I’m just not seeing a lot in general. And then number two, I think that the model we use fixes this in the vast majority of cases. And so I think that if someone is focusing their clinical approach only on H2S, they’re probably missing, say 95%, of the other cases. And, as our friend Gavin Guard, our excellent PA, said, “majoring in the minors.” We always want to focus on the most important treatments to help the most people.

Dr Ruscio:

And one of the things here that I just want to arm both patients and clinicians with is that we have to be careful not to fall victim to the new and the novel. Because if we do, if patient attention and clinician focus always drift the new thing, what ends up happening is what we have today, which is a model where people just do not do a good job with the fundamentals. And they drift toward all this new and speculative testing. And these treatments that have not been shown to be highly effective. Or in some cases have no clinical data, but rather just mechanism conjecture backing them up. And what we have to be guarded against is, “I’m not feeling well,” or “I’m a clinician and I want to help people feel better and I have some challenging cases,” It does not mean that the new, the novel, the esoteric are the best.

Dr Ruscio:

And we have to resist that gravitational pull. Because again, if not, all we’re going to do is just keep rewarding whoever has the craziest theory. That’s going to be the people who get the most press and you see some of that. There is clearly a remnant of that in the field. But I’m hoping that what we’re pointing to for people is the real magic is not the newest or the most fancy-sounding therapeutics. It’s being able to effectively personalize the available therapies to the individual. That’s really where the magic happens.

Dr Joe Mather:

Completely agree.

Dr Joe Mather:

Hey guys, Dr. Joe here, medical director of the Ruscio Institute for Functional Health. And I’d like to thank Athletic Greens for making this episode possible. It’s sometimes difficult to optimize nutrition during either long days in the clinic or when traveling. And that’s why I’ve added AG1 to my morning routine, either by itself or in a smoothie. It tastes great and helps ensure I’m getting high-quality vitamins and nutrients for the day. I particularly like their combination of greens powder, antioxidants, and adaptogenic herbs. One scoop of AG1 contains 75 vitamins, minerals, and whole-food-sourced ingredients, including a multivitamin, multi-mineral, probiotic, greens blend, and more. I also appreciate that Athletic Greens continues to improve their formula based on the latest research, totaling 53 improvements over the last decade. I highly recommend AG1 as part of your daily routine. Right now, Athletic Greens is offering a free one-year supply of vitamin D and 5 free AG1 travel packs with your first purchase when you visit athleticgreens.com/ruscio. That’s athleticgreens.com/ruscio. Thanks. And now back to the show.

Dr Ruscio:

One of the other things that I think can feel magical for patients is when they can expand their diet—when they have less food intolerances and more food tolerance. And this isn’t something that we talk a lot about, but I know for both of us and for all of us at the clinic, it’s one of the most common complaints that we see. “I feel somewhat better, but I’m on this really strict diet and I really want to be able to expand my diet and have less food reactivity.” So I thought maybe we could put this topic up on the board and just share some thoughts on this.

Dr Joe Mather:

Yeah. This is fantastic because this is one of those things that come up every single clinic day. And the first piece that comes to mind that patients need to hear more, is that what you’re reactive to now doesn’t mean you will be reactive to those same foods at the same level forever. It’s not a black and white, “you’re sensitive to this forever. Almost always it’s the opposite. It’s that when there is poor underlying gut health, you react to more things. And as you clean up the gut, the reactivity drops. And this is actually a very, very encouraging phenomenon. And I’m so glad that we’ve experienced enough, clinically, to be able to say that confidently with patients. Because it can be so horribly demoralizing to feel like, “I reacted to avocados once therefore I can never eat avocados again.”

Dr Joe Mather:

And I mean, roughly speaking, I would say 80% of my patients are able to vastly expand the types of foods that they’re eating simply by working through step-by-step good gut care. And the analogy I often give is that when you—and I often use FODMAPs as an example because it’s just easy and most people are already understanding what FODMAPs are—I say, “okay, look, when you’re just starting, your FODMAP canister is like a thimble-full. You only fit like a little, couple chopped onions in there. And if you go over that, thimble-full, you’re going to start getting bloated and nauseous, maybe heartburn. But as we work through the basics, let’s say we put you on a low FODMAP diet, we add triple probiotic therapy, let’s say we add gut-rebuild nutrients, and we simply do that for a period of time over that say 4-8 week period.” You see that thimble-full slowly growing in size. The volume goes up to maybe a teaspoon to a tablespoon to an eighth of a cup.

Dr Joe Mather:

And the more time we go on with the patient, oftentimes we can see it go much bigger. They can say all of a sudden, “I was able to eat a bunch of broccoli and I had some cheese and I didn’t blow up and I didn’t die.” We said, “okay, great. This is exactly what you’re supposed to do.” And, inevitably they then eat way too much and have symptoms. But it’s okay. You went from a thimble-full to two cups and you just went over that. So let’s just dial it back and keep working. And so that’s the first thing I wanted people to know, is that what you’re sensitive to now very likely is not what you’re going to be sensitive to later. And healing the gut generally leads to expanding the types of foods you can eat.

Dr Ruscio:

Yeah. It’s so important to clarify that. And also that, in many cases, the reintroduction doesn’t have to be super meticulous nor does one need this highly-prescriptive enzyme…

Dr Joe Mather:

I’m so glad you said that.

Dr Ruscio:

People oftentimes will have some, “well, do I have to do one food at a time and wait 3-4 days after the one food and then have the next food?” Well jeez, it’s going to take you six months to reintroduce half a dozen things at that rate. And what I recommend people do is start with the foods that they miss the most. Because there’s no need to have this list broken out by the different sugar types, let’s say—there’s polyols and there’s sorbitols. But rather, “do you miss broccoli? Okay. Let’s start there and see how you do with that and apply some simple rules.”

Dr Ruscio:

Like don’t make the broccoli reintroduction out to dinner after two or three glasses of wine and when you’re going to be having five other things. Try to isolate the variables to a reasonable perspective. And you might hit a little bit of resistance from your body on a couple things. But for the most part, this will probably go pretty darn well. And you’ll notice you have a lot more food tolerance. Will you be invincible and be able to go out and have six beers and Mexican food that’s really spicy and feel nothing? Probably not. But between where you were and there? You’ll probably be more than midway toward that ability to go out, have fun, and not really worry about anything.

Dr Joe Mather:

Absolutely. That’s the story for the vast majority of people. And there are the patients who say, “man, I know what you’re saying, doc, and I’m able to eat so much more now, but every single time I eat a potato everything flares.” And I just shrug my shoulders and say, “I guess don’t eat potatoes. But enjoy the rest of everything else.” And I do exactly what you said. I think getting overly prescribed on what categories you can eat, over what period of time, and wait how many days before looking for symptoms, that way lies madness. And I’ve never seen a patient be able to do that, [to] go from a “first I’m going to do this nightshade, and then I’m going to do this broccoli, and I’m going to do this…” It just does not work. I think for the vast majority of people out there.

Dr Ruscio:

Or those that are that zoomed in, they really need to have a paradigm shift. And this is where I think the clinician has to help them let go a little bit. Because that’s where you can be just so neurotic and dialed in about your diet that it’s unhealthy and it can be actually counterproductive to healing. And I get it. I mean, I food journaled for a while and it didn’t help me. The problem was I had an E. histo infection lysing into the lining of my intestines causing, I’m assuming, ridiculous amounts of leaky gut inflammation. So food journaling my way out of that wasn’t going to help. But certainly, in my case, the combination of herbal antimicrobials and antibiotics got me 70% of the way there. I was eating a low-carb paleo diet and probably eating a lot of histamine. And it took me years to figure that out. And I barely used probiotics. Gosh, now thinking back on it, I could have gotten the rest of that 30%. I said that 70% was antibiotics cleared the infection, that was game changing, but there were still, God, “I think I’m sensitive to beef. I think I’m sensitive to spinach. I think I’m sensitive to XYZ.”

Dr Joe Mather:

Imagine if you had laid the probiotics down first.

Dr Ruscio:

Yes. And a clinician could have looked at my symptoms and said, “man, there’s a lot of neurological symptoms here. You’re also eating low-carb paleo. Let me ask you about how much spinach and tuna and avocado and kimchi do you have?” “Oh, I have a lot of that.” “Well, let’s pull back on that.” And that plus probiotics? The brain fog that I struggled with for a year afterwards would’ve probably been gone in six weeks.

Dr Joe Mather:

One of the cooler cooler things is, again, Eliza and Morgan have been pulling that data for us. And that’s a great example of exactly the sort of information that we’re having our clinical nutritionist pull in and present to us. So we don’t have to go scrambling and going through food journals or all the diet—what they’ve done, what they haven’t done—it’s already presented to us. And so it really does make our job much easier in that regard.

Dr Ruscio:

Yeah. Because those patterns, they’re not always so obvious. But as you’re going through someone’s history and information, you might say, “Hmm, maybe this person is eating too high histamine.” And if we’re able toggle over to the diet history section where we can see the diets they’ve tried, their current diet, what they remarked as the best diet, and then some additional notes from Morgan or Eliza, we can get an affirmation of that suspicion or rule that out with a fair degree of confidence so quickly. And then we make this list for every patient in terms of, from the top down, what’s most likely the problem: item two and then three, then four. And we could then move something like histamine intolerance, which might be a mid or late-phase consideration for many people, up to item one, two or three. And those little things are really, what I think, allows us to get to improvement much more quickly. But it doesn’t happen without really a team effort.

Dr Joe Mather:

Absolutely. Absolutely. And no more food journals.

Dr Ruscio:

Yeah. I was happy to stop doing that. Because I mean, I can say, personally, it made me neurotic. Because I was starting to see trends that weren’t there. And to tell you the truth, no amount of trend analysis can help you if you don’t know how to interpret the trends. Like I knew nothing about histamine intolerance at that time. So I could have studied those food charts forever. And I probably wouldn’t have figured it out because I didn’t have the tag of histamine to associate to the food. So you can’t see the pattern until you know that. So yeah, I think food journals…maybe to a small degree so that you can figure out, “Hey, I’m eating a lot of this. Maybe I should broaden my diet. Maybe I should have a rotation.” Okay. Sure. But outside of a short-term intervention to help you calibrate and see patterns, I think they tend to do, like you’re saying Joe, more harm than they do good.

Dr Joe Mather:

I had a patient last week: “Dr. Joe, you need me to do a food journal, right?” Like, no. No. Don’t do that, please. She’s like, “oh, thank God. I really did not want to but I thought you were going to make me.” Anything we can do to make things easier for patients.

Dr Ruscio:

And I should also mention, it’s probably somewhat obvious, but just to direct this for our audience, if we consider let’s say dysbiosis—and I think it’s fairly safe to assume that if someone has digestive symptoms, there’s some type of microbial imbalance; it could be frank overgrowth, it could be imbalances, AKA dysbiosis (we use this catchall term “dysbiosis”, which isn’t always perfect, but it can at least get you a label that approximates what’s going on)—when dysbiosis is present this oftentimes causes the immune system to activate and clean up some of that mess with inflammation. That inflammation causes some bystander damage.

Dr Ruscio:

And this is where leaky gut comes in. And part of what happens in leaky gut is damage to the lining of the intestine, where the enzymes that break down things like FODMAPs and histamine and dairy are produced. And also the inflammation makes one more sensitive to gas pressure. There’s this “substance P” which is a pain modulator, and inflammation makes one more sensitive to this substance P. So you’re more sensitive to gas pressure and inflammation, and you have a diminishment of the ability to release the enzymes that your intestines naturally produce when you have dysbiosis.

Dr Ruscio:

So you could intervene anywhere along this cascade. But if the furthest upstream, let’s say, is dysbiosis, that’s why we put so much focus on the dysbiosis. And again, not that we’re just treating that number, but it’s to give patients a characteristic in terms of, okay, we’re not going to zoom in and test histamine and test the amount of inflammation per se, but we’ll do some testing, perhaps for SIBO, perhaps dysbiosis, but we’re really going to personalize treatment to use that we can intervene upstream and then fix the things downstream, like a damaged lining for the intestines. Then you release more DAO on your own and you’re more histamine tolerant. Then you release more lactase on your own and you’re more dairy tolerant. And so this is how all of this ties together to allow individuals to have better food tolerance. And a life. Because that’s what I think we’re trying to get people back to, to be able to travel and go out and do things and not always be worried about food.

Dr Joe Mather:

Absolutely. I just had this speculative thought that… You would think if… Leaky gut is something that we see change clinically pretty quick. Do you agree with that?

Dr Ruscio:

Yes. I think we can presume we’ll see that change fairly quick.

Dr Joe Mather:

I wonder if, to some degree, leaky gut’s the body’s way of sending up a red flag. “What you’re doing to me is not helping and that’s why we have joint pain and brain fog, anxiety, and depression right after you eat.” I wonder if there’s an evolutionary protective piece here.

Dr Ruscio:

Yeah. They say that omnivores have larger brains because it takes so much processing power to know what foods to eat, what foods are poisonous, how to procure those foods. So I could see that tying in with that in the sense that part of why (at least from what I understand, I could be wrong, I’m not an anthropoligist) but part of the reason why omnivores typically have larger brains is because there’s a lot of that information to remember. “Every time I eat this berry, I go diarrhea.” Now we need to know not to eat that berry and all the other stuff that can do that. So I think there’s definitely some plausibility to that.

Dr Joe Mather:

Yeah. And the good news then, therefore is clinically we can tighten up that leaky gut pretty quickly. And when symptoms go away, very likely your leaky gut has gone away. So you don’t need mannitol or expensive stool tests.

Dr Ruscio:

Exactly. Yeah. The less testing we can have people do the better. Because also with testing, people notoriously glom on to a test result. I think this is one of the things that we’re both very passionate about, Joe, is like with the misinterpretation of a SIBO test, protecting patients from doing a test and then associating more meaning to that test than they should because it can run away from you very quickly. “Oh, I am out to dinner with a friend, I got whatever food, and now I’m feeling tired and foggy.” And they see in their mind that red H for high next to zonulin and they’re thinking, “oh, this must be my leaky gut. And I remember that lecture that I saw that said leaky gut correlates with auto immunity and my joints hurt…Oh! Maybe I have RA.” And it can very quickly run away.

Dr Ruscio:

And I know this because I’ve been there. And make one very afraid, and that inflammation is not good for healing, and you may end up doing more damage psychologically than is even actually happening in your system due to inappropriately weighting value to some of these lab tests. It’s not to say all lab tests are bad. There are some, like if your doctor says, “Hey, your sugar is at a 175.” Okay, this is important. You need to do something. And maybe you should be concerned when your toes are tingling. But I think in a lot of the GI area the testing’s not very definitive, not highly validated, and it ends up doing more harm probably than it does good.

Dr Joe Mather:

I’m thinking of a patient that I saw not too long ago. She was a young gal, a 25-year-old, and she had a history of GI symptoms, chronic vaginal infections, and she had had a lot of testing (a lot of cultures done and went in and out of a lot of OBGYNs offices). She had mold exposure. She got COVID twice and tons of brain fog. So this was a previously healthy gal. She’s only 25 years old. And what she wanted from me was she wanted to see the whole picture. But the background, she had been trying to see the whole picture and she really had been abused financially. She had spent over $10,000 in testing and what she said was, “Doc, I spent over $10,000 and I’m worse than when I started.”

Dr Joe Mather:

And her trying to see the whole picture meant that no one was helping guide her to get better. What needs to happen to get better? Because every single time we get a new test, we went down to a new rabbit hole. And so when she came in and started working with us, it was so nice to just be able to explain to her that we don’t need testing, we just need to find out the systems in your body that just haven’t been adequately addressed, start there, and she’s improving already. It’s not hard. And so in her case, in particular, had we done any testing, we would’ve distracted her from the work she needs to do to help herself heal.

Dr Ruscio:

And this brings up another concept. And sorry for our audience if we’re getting a little bit theoretical here. But these are important pieces to understand, which is many tests—I can’t say all but many tests—they’ve been validated in a specific context, in a specific cluster of symptoms. And when we, in the functional health community, start using tests as these broad screening tools, we’re not really sure how often we’re going to be seeing false positives. Meaning that in a certain subset of individuals who don’t have that specific symptom cluster in which the lab marker was validated, when we start using these more generally, more broadly, more in a screening fashion, we’re not sure how often we’re going to find a false positive.

Dr Ruscio:

And that’s incredibly important to mention [and] something that we discussed in the clinic regarding inflammatory markers in the GI like calprotectin. And I suspect that there’s a subset of people either with IBS or who are otherwise normal and fine who have high calprotectin. And we see that in a subset of individuals, just as one potential. And calprotectin is very validated in the model in the context of inflammatory bowel disease. But what happens when we start using calprotectin as this screening that’s on a stool test that most patients are getting—that’s where it breaks down. So it’s another reason why we have to be careful about how much we interpret from labs.

Dr Joe Mather:

Completely agree. And yeah, we could do an hour on calprotectin, but I definitely agree with your point. It’s helpful for people to know maybe that because calprotectin is so useful in some settings, there is now research trying to say, “okay, well we know calprotectin correlates very well with disease flares and inflammatory bowel disease. That doesn’t mean that it correlates with IBS or IBS flares. But we do know that there’s more and more studies being done to try to ask that question. When is it good in IBS? What level would it be if it was pertinent in IBS? Can we use calprotectin to screen for cancer? We know it’s an inflammatory marker and that cancer will cause a ton of GI inflammation, will calprotectin help predict cancers?” So even on just that one marker there’s so many intricacies to try to sort through.

Dr Ruscio:

And an inverse example, C-reactive protein. There are individuals who clearly have signs of inflammation, like joint pain or brain fog or bloating and abdominal pain, who don’t have elevated CRP. And I’m sure most clinicians here are nodding their heads in agreement in terms of patients asking, “I have X, Y, Z symptoms. Why is my CRP normal?” Well it’s another good example of where that’s not necessarily meant to be a screening tool. And it does definitely have merit and validation, but these things don’t always line up.

Dr Ruscio:

And this is why it’s just, again, so important to make the lab testing about 1/4 of the data we use to make a clinical decision, with the caveat—I’m going to start being better about making this caveat—there are some tests that you don’t need much interpretation. Like I was saying, if your blood sugar’s 200, that is what it is. But especially in the area of GI, and even more so with these newer functional tests because a lot of them don’t have the requisite validation, they should be used as 1/4 of the data rather than the primary thing. Like your other patient, Joe, who was trying to get all the data and see the big picture. And if you’re doing that with the new age function medicine test, more often not, you’re being led astray.

Dr Joe Mather:

Yeah, absolutely. Absolutely.

Dr Ruscio:

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

Dr Joe Mather:

Can I say one more thing about calprotectin that’s bothering me?

Dr Ruscio:

Please. Yeah.

Dr Joe Mather:

I always feel like I have to stand up for fecal calprotectin. I don’t know. I feel like that’s one of the markers I think is pretty useful, but that being said, I did review a study of actually just 14 participants—and we published this in the Future of Functional Health Review so I think this is just a great example of a study that’s really helpful in clinical practice and we’ve got a whole bunch of them in the FFMR—but they took normal people and they did a whole bunch of stool samples leading up to a colonoscopy (eight stool samples actually) and what they found was in normal people that had normal colonoscopies, there were two main patterns of calprotectin. A third of those normal patients (without inflammation in their gut) had very low and stable calprotectin levels. So they were like roughly underneath 50. But 2/3 had an average fecal calprotectin over 50, but the variability was very, very high. So the cool thing about this study was that they did calprotectin day after day after day after day. And what they found was that, depending on the day, you might have a level of 40 or it might be a level of 90.

Dr Ruscio:

Yeah. Very cool.

Dr Joe Mather:

And so it’s just interesting that a fecal calprotectin in a normal patient is different than a fecal calprotectin in a patient with IBS, which is different than fecal calprotectin in a patient with inflammatory bowel disease on biologics. And you just need a good clinician who is poking through this and [I’m] just so grateful that we are building an operation where we’ve got our research team that can throw studies at us like that. Because, man, I can’t imagine, with the pressures of conventional medicine, seeing 40 to 50 patients a day, you barely have time to take a sip of coffee and take a deep breath. You do not have time to poke through that study.

Dr Ruscio:

Yeah. And that’s why I love what we’re doing at the FFMR and just the fact that we’re building up progressively and investing in the research arm of things. Because you’re right, it’s difficult to keep pace up with everything. And it’s also challenging when you’re getting most of your education from an industry-funded seminar. And that’s another problem because if it’s something that’s funded by, let’s say you might get a little bit of a cherry-picked narrative on a test, and it doesn’t mean the lab comes and it’s like, “Ooh, how can we make more money?” And get these doctors in cahoots so that they’re doing unnecessary testing on patients with this monopoly man smoking a cigar with his top hat in the back room trying to figure out how to rip people off.

Dr Ruscio:

I don’t think it’s that malevolent. But what can end up happening is you just get all the reasons why you should use the test. And as we’ve talked about before, you can find a couple studies showing merit to almost anything. But if that is 30% of the body of evidence and the other 70% shows some serious limitations, that’s where I think the challenge comes in, is that you may just get a portrayal of the best evidence for the test that the company makes that is funding the weekend seminar. And that’s a big problem.

Dr Joe Mather:

It is a big problem.

Dr Ruscio:

So that’s why we’re trying to do independent research and be as unbiased as we can. And we, of course, have bias. We have favorability towards things that we see work in the clinic: low FODMAP diet, probiotics, elemental dieting. And do we make some of those things? Yes, but I think the one incredibly distinct difference is the things that we have made are a byproduct of observing what works clinically and what is there an impressive trend in the literature for? As compared to, “Hey, there’s a lot of Google search going on for X. Let’s make X.”

Dr Ruscio:

And that’s like a lot of what I think supplement companies do is they get in front of a consumer or demand trend. And that’s why I think it’s important not to say anyone who either sells or makes supplements should be lumped into the same vein. And I can say, at least for myself, again, the things that I made were things that I wanted to have better control of because they worked well. They weren’t a, “well, there’s a huge boom for, let’s say, butyrate (just use one example), let’s go make a butyrate supplement even though we’re not confident in the therapeutic signal or the research evidence supporting this intervention.”

Dr Joe Mather:

And just speaking as a friend, when I had my private practice and I was thinking of working more closely with you, this was one of the reasons that I really joined up with you, Michael. And I don’t even know if I told you this specifically, but I will have a sharing session. I saw a lot of doctors making and selling things with very little evidence. Take the gluten products that came out a few years ago as one good example, butyrate being another, everybody jumping for specific fibers, and I did not see you doing that. And that, I think, gave me a lot of credibility that you were doing things the right way, with patients outcomes in mind. And the more we work together, the more I believe and see that.

Dr Ruscio:

Well, thank you. I appreciate that a whole heck of a lot. And thank you for sharing that and for our audience. We do make supplements. I think maybe it’s important to periodically just address that because you’ll hear some of the criticisms that were levied toward pharma now being levied toward natural medicine. And I think some of those definitely have merit, like we just did [with] lab companies. It doesn’t mean every lab company has bad intent. It doesn’t mean every supplement company has bad intent. Do I have some serious questions with a fair subset of both lab companies and supplement companies? Yes. So yeah, we’re just trying to thread that needle of the simple process, the stuff that we make has the requisite clinical evidence and published evidence. And then we look to have more control and freedom over something like an elemental diet or a probiotic.

Dr Ruscio:

I mean look at Probiotic Triple Therapy. That was purely a “patients are complaining.” I mean, I’ll give a shout to my buddy, Reid and his wife, Danielle, I never forgot that experience…And this was really the thing that motivated me to make the triple therapy. She had ridiculous FODMAP intolerance, and I got her set up with two things, our low FODMAP diet handout and our three bottles of probiotics. And two months later she was like, “Mike, oh my God, I feel so much better.” She was so thrilled. And then another month or so later I asked her how she was doing. She’s like, “still better than I was but I’m having some bloating and some reflux or food reactivity” and whatever her symptoms were. And I said, “are you still using the probiotics?” “Uh, it was just so hard. I had to keep one in the fridge and then two on the counter and open ’em all up and take three pills out of the one and then two outta the other.” And I was like, “okay, we have to make this simpler.” And that’s exactly why we put all of them into the single-serving tear stick because of observations like that. So the motivations for us are not consumer demand trend, minimal competition in the marketplace, but rather what works and how can we make this easier for people to do and to use.

Dr Joe Mather:

Absolutely. One of our clinical team members (who will remain nameless) had been asking me, “Hey, do you have a recommendation for this XYZ condition?” And I said, “honestly, the triple therapy probiotic I’ve seen work in this setting a number of times.” And I just got some feedback again. Doing really, really well. So, not surprising because we see it all the time in clinic, but it’s just a fantastic product. It just works.

Dr Ruscio:

Oh. And not to toot our own horns, but I’ll just share this really quick in case it helps anyone out there.

Dr Joe Mather:

Hey, it’s our podcast. We are allowed to do that.

Dr Ruscio:

So we recently brought on board a full-time in-house bookkeeper who has been absolutely fantastic. You know who you are. Thank you so much, if you’re listening to this. She just shot me a message this morning. She had been speaking with you and I, Joe, my gosh, maybe two months ago when she had COVID and we were trying to keep her as healthy as possible going through that. So we mentioned one of the supports that can be helpful—and now there’s actually some published evidence showing this—are probiotics. So she started using the Probiotic Triple Therapy. And she shot me a note today saying that she has such bad carpal tunnel that she wears bilateral wrist supports 24/7. And that has gotten so much better that she no longer has to wear her wrist wraps. And the only thing she changed was going on the Probiotic Triple Therapy, extended term. She was on some other therapeutics short-term for the COVID, but that was months ago. So, anecdote. One data point. But pretty cool to see that her carpal tunnel that’s somewhat debilitating is now so good that she doesn’t have to wear those straps anymore.

Dr Joe Mather:

That’s one of my favorite things about treating the gut is because you see that frequently. Not in everybody, but enough of the time to really keep your eyes open. When I was doing lots of nutrient replacement therapy, I never saw stuff like that. I was working on methylation. I never saw stuff like that. When I was chasing adrenal fatigue early in my career, I never saw that. When I was trying to treat viruses I never saw that. But the more and more that I got hooked up and lined up with with really being an expert in treating the gut, the more beneficial side effects. “Oh yeah, Doc, all that joint pain, that’s gone.” “Oh yeah, Doc, all that acne? Gone.” And so it just tells me that it’s one of the best levers to pull when working on patients.

Dr Ruscio:

And that’s why I and we have obsessed over that. And I was my own first case study in this and the more I felt around, just like you’re saying, [with] viruses, methylation, adrenal, you’d see results with those various lines of therapy, but it just didn’t hold a candle to the results that you got after focusing on gut care.

Dr Joe Mather:

Yep.

Dr Ruscio:

Well, our echo chamber here is reverberating nicely. Is there anything else that you want to leave people with, Joe, before we wrap up?

Dr Joe Mather:

If you need help, please come see us at the clinic.

Dr Ruscio:

Yep. Yeah. Guys, come over. We are proud of our expanding clinical team. And if you haven’t checked in on that in a while, a couple years ago when it was just me it could have been a long wait, but now with the awesome and amazing team that we have, we’re giving good care and there’s not a long wait to be. So, [I’m] really appreciative of you, Joe, and everyone on our team. And, yeah, hopefully that helps. And [we] will look forward to speaking with everyone, again, real soon.

Dr Joe Mather:

Fantastic. Thanks, Michael.

Dr Ruscio:

Thanks, Joe.

Intro:

Thank you for listening to Dr. Ruscio, DC Radio today. Check us out on iTunes and leave a review. Visit DrRuscio.com to ask a question for an upcoming podcast, post comments for today’s show, and sign up to receive weekly updates. That’s DRRUSCIO.com.

 

• Athletic Greens
• Dr. Ruscio’s, DC Resources