The Latest in Gut Health Research: SIBO, FODMAPs, and More - Dr. Michael Ruscio, DNM, DC

Does your gut need a reset?

Yes, I'm Ready

Do you want a second opinion?

Yes, I Need Help

Do you want to start feeling better?

Yes, Where Do I Start?

The Latest in Gut Health Research: SIBO, FODMAPs, and More

Surprising Findings About Dietary Interventions, Plus Supplementation Of CBD Oil, Vitamin B12 and D, Glutamine, and Probiotics For Crohn’s Disease, Gastroparesis, IBS, Hydrogen SIBO, and Celiac Disease

Another podcast about gut health research is in the books. This episode, I present findings about how health conditions like hydrogen SIBO, Crohns, Celiac Disease, skin rosacea, and allergic rhinitis respond to SIBO CBD oil, a gluten-free diet, glutamine, probiotics, the low FODMAP diet, vitamins B12 and D, and other interventions. Listen in to hear what the latest research says.

In This Episode

Intro … 00:08
Intelligence does not correlate with bias … 01:12
Vitamin D supplementation for IBS … 11:06
CBD-rich cannabis and its impact on Crohn’s disease … 11:43
Laxatives versus laxatives plus probiotics for constipation … 12:57
Glutamine and probiotics for allergic rhinitis in children … 13:49
Intestinal parasites in children … 15:17
The impact of FODMAPs versus gluten and how they affect digestive or IBS symptoms … 17:51
The effectiveness and tolerance of dietary therapies in non-constipated IBS … 20:13
Treatment for gastroparesis using  a prokinetic plus methyl B12 … 22:53
Hydrogen SIBO and its association with hepatic encephalopathy … 23:50
The effect of gluten challenge on the fecal microbiome … 25:43
The effect of Prucalopride on idiopathic chronic constipation … 28:01
Zonulin in patients with rosacea … 29:32
How FODMAP and IBS interplay … 30:13
Mediterranean diet or SCD for Crohn’s … 34:35
Low FODMAP for celiac patients with persistent symptoms … 37:28
Gut-focused hypnotherapy for IBS … 39:10
Outro … 41:48

Subscribe for future episodes

  • Apple Podcast
  • Google Podcasts
  • Spotify

Download this Episode (right click link and ‘Save As’)


Hey everyone. Welcome back to Dr. Ruscio radio. This is Dr. Ruscio and let’s jump into more updates from the research on gut health. Remember, I’m trying to parse these via probiotics as the one gut health in general, as the other thyroid and hormone health as a third, and then a broad assortment of other diet and lifestyle research. And today we will go into those on gut health.

Before we do it, I wanted to make one quick, I guess, comment. And we’re looking to have a guest on the podcast to go into more detail on this topic in the near future, but I’m reading, “Thinking, Fast and Slow” by Daniel Kahneman. He makes one point that is quite fascinating, that there is not a relationship between intelligence or IQ and bias. And this was very interesting for me to hear because I think all of us look to those who are intelligent or at least seemingly so in an area to obtain their advice and this, I think permeates all areas of life.

It wouldn’t matter if you’re talking to a plumber, you would want to look for signs of intelligence amongst that plumber or the ones that you’re interviewing to do a job. Certainly for healthcare and medicine this, seemingly so, would apply. But I’m sure all of us at some point have, especially if there’s an area where you have a fair amount of expertise, looked around and observed those who are seemingly intelligent, have perhaps achieved a high degree of academic achievement, and speak fluently, have a good vocabulary, etc. but [have] a peer bias. And this was very telling for me, seeing the research that Kahneman outlines that fairly well documents—and if you do a quick internet research, you can find other items that pop up right away to support this—that there is not a correlation between intelligence, IQ, and prevention of bias.

How I think this can be the most insidious is if someone arguably is more intelligent, they’ll have better verbal fluency and therefore be able to better construct an argument. Now that argument may be made out of biased points, but a compelling argument, nonetheless, it will likely be. I’m not sure what the solution there is other than perhaps maybe looking for some of the indices of bias, if you will, that we discussed in the podcast in the past, which are being overly confident, overly assured, not acknowledging contradictory data. I think those are all good indications that someone could be biased. But for whatever it’s worth, just [I just wanted] to lead with that and perhaps remind people to be as circumspect and guarded as you can in those in, I guess any realm, but definitely regarding healthcare advice that you follow.

And one of the other things that Kahneman lays out in his book, “Thinking, Fast and Slow,” which I’d recommend reading, is this system one and system two—as he arbitrarily assigns them in the brain. The fastest system one, the slowest system two. When you have to be analytical, you pivot away from the fast intuitive system one, to the more taxing and demanding and slower to process system two. Why I think this is relevant even further yet still to the piece on expertise versus bias or intelligence versus bias is the mind and an individual seems to want to use system one more intuitive based thinking as much as possible because it requires less effort and energy. And we’re always trying to reduce energy, at least to some extent. It’s a evolutionary pressure that we’re all still victim to. This is why certain foods are so addicting.

So how does this map onto the healthcare conversation? Well, it reminds me of whenever we perform a review of the evidence, I know it’s going to hurt a little bit because it’s a lot of work and I have to sit at my desk and really take every point that I’m examining as objectively as I can. And try to fight against my tendency to come to a quick a quick conclusion and really do the best that I can to summarize point 1, point 2, point 3, point 4. What does the tally lead us to? What is the trend in the data? And this most recently I think has come up with how we’ve reviewed the evidence on thyroid hormones—which ones to use when. Because there’s not this absolutist perspective.

➕ Full Podcast Transcript

Intro:

Welcome to Dr. Ruscio radio, providing practical and science-based solutions to feeling your best. To stay up to date on the latest topics, as well as all of our prior episodes, make sure to subscribe in your podcast player. For weekly updates, visit DrRuscio.com. 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. Welcome back to Dr. Ruscio radio. This is Dr. Ruscio and let’s jump into more updates from the research on gut health. Remember, I’m trying to parse these via probiotics as the one gut health in general, as the other thyroid and hormone health as a third, and then a broad assortment of other diet and lifestyle research. And today we will go into those on gut health.

Dr Ruscio:

Before we do it, I wanted to make one quick, I guess, comment. And we’re looking to have a guest on the podcast to go into more detail on this topic in the near future, but I’m reading, “Thinking, Fast and Slow” by Daniel Kahneman. He makes one point that is quite fascinating, that there is not a relationship between intelligence or IQ and bias. And this was very interesting for me to hear because I think all of us look to those who are intelligent or at least seemingly so in an area to obtain their advice and this, I think permeates all areas of life.

Dr Ruscio:

It wouldn’t matter if you’re talking to a plumber, you would want to look for signs of intelligence amongst that plumber or the ones that you’re interviewing to do a job. Certainly for healthcare and medicine this, seemingly so, would apply. But I’m sure all of us at some point have, especially if there’s an area where you have a fair amount of expertise, looked around and observed those who are seemingly intelligent, have perhaps achieved a high degree of academic achievement, and speak fluently, have a good vocabulary, etc. but [have] a peer bias. And this was very telling for me, seeing the research that Kahneman outlines that fairly well documents—and if you do a quick internet research, you can find other items that pop up right away to support this—that there is not a correlation between intelligence, IQ, and prevention of bias.

Dr Ruscio:

How I think this can be the most insidious is if someone arguably is more intelligent, they’ll have better verbal fluency and therefore be able to better construct an argument. Now that argument may be made out of biased points, but a compelling argument, nonetheless, it will likely be. I’m not sure what the solution there is other than perhaps maybe looking for some of the indices of bias, if you will, that we discussed in the podcast in the past, which are being overly confident, overly assured, not acknowledging contradictory data. I think those are all good indications that someone could be biased. But for whatever it’s worth, just [I just wanted] to lead with that and perhaps remind people to be as circumspect and guarded as you can in those in, I guess any realm, but definitely regarding healthcare advice that you follow.

Dr Ruscio :

And one of the other things that Kahneman lays out in his book, “Thinking, Fast and Slow,” which I’d recommend reading, is this system one and system two—as he arbitrarily assigns them in the brain. The fastest system one, the slowest system two. When you have to be analytical, you pivot away from the fast intuitive system one, to the more taxing and demanding and slower to process system two. Why I think this is relevant even further yet still to the piece on expertise versus bias or intelligence versus bias is the mind and an individual seems to want to use system one more intuitive based thinking as much as possible because it requires less effort and energy. And we’re always trying to reduce energy, at least to some extent. It’s a evolutionary pressure that we’re all still victim to. This is why certain foods are so addicting.

Dr Ruscio:

So how does this map onto the healthcare conversation? Well, it reminds me of whenever we perform a review of the evidence, I know it’s going to hurt a little bit because it’s a lot of work and I have to sit at my desk and really take every point that I’m examining as objectively as I can. And try to fight against my tendency to come to a quick a quick conclusion and really do the best that I can to summarize point 1, point 2, point 3, point 4. What does the tally lead us to? What is the trend in the data? And this most recently I think has come up with how we’ve reviewed the evidence on thyroid hormones—which ones to use when. Because there’s not this absolutist perspective.

Dr Ruscio:

And maybe this is a good, quick chance for me to really go on a tangent here, but just offer a few thoughts on T4 alone as compared to combination therapy. I’ve tried to do a good job in delineating that we and I, myself and we at a clinic, we are not anti-combination therapy or anti adding a T3 like cytomel on top of something like synthroid or Levothyroxine. But we do want to make sure that people start with their gut health, because that seems to be the better order of operations. And it’s much easier when I’m reviewing, let’s say, the constituent 10 studies that comprise of meta-analysis and look for, okay, well, it looks like five of the studies, or let’s say six of those studies—I don’t recall the exact numbers here, forgive me if they’re a little bit off—but found no preference. But if you look more closely, some of these in the sub-analysis did find, even though let’s say the six parameters measured did not show any preferential outcome for T4 as compared to T4 plus T3, people still ended up reporting a preference for T4 plus T3 in maybe 30 to 48ish percent of the time.

Dr Ruscio:

So we should acknowledge that data. And that means we shouldn’t be too flippant to dismiss the merit of T4 plus T3. But does this mean as we all too often see, and I’m happy to say that soon we should have a paper published on this in a peer-reviwed medical journal, when someone comes in on or after having gone on 17 different concoctions, starting with maybe Nature Throid or Armour, then adding Cytomel and then they’re doing a time release Cytomel, or they’re doing Cytomel twice per day, yet they still have abdominal pain, bloating and constipation.

Dr Ruscio:

Yeah. I mean, we certainly want to start with their gut health first for many reasons, but one [is] so obvious—that you have to absorb that medication and help with its conversion of T4 to T3 in a healthy gut and in a non-inflamed periphery. So the point I’m driving at is there’s the temptation to cherry pick and say, well so many people are saying T3, you need to have it, blah, blah, blah. And then come in with a counter argument for which there’s very good evidence showing that this is not necessary for many, probably most. And then just revert to that absolutist perspective. [It’s] much harder to really try to evaluate the evidence as critically as possible, because it requires you to dig more deeply and not say, well, these (again from the previous analogy), these six parameters did not show any better outcomes with a T4 plus T3, but why are some people still reporting a preference?

Dr Ruscio:

There’s something here. It takes much more mental effort to come up with that. And this is one of the things that is so irritating when in some cases, other doctors will comment back, “what about this study?” I mean, literally this one example is just so choice. “What about this study refuting your claim and really supporting that combination therapy is better all the time or nearly all the time?” It’s like, this study? You mean the one that was in the review that you’re commenting about yet, you didn’t even take the time to examine the fact that the cherry picked reference that you’re offering up was included in our analysis and we’re literally gift wrapping for you the conclusion, all you’ve gotta do is just read it objectively? That gets frustrating, right? Because it just is a clear admonition of how people don’t want to think.

Dr Ruscio:

So, I’m not trying to throw anyone under the bus, but I’m trying to, I guess, arm you with the perspective that intelligence and bias do not directly correlate. And I guess to some extent you have to be even more on the lookout because someone who is intelligent, again, may be able to construct a very compelling argument, but one for which may not be true. And this is by definition, a spurious argument. And we just want to be careful about that. So anyway, just I guess a few musings on information and how all these things associate and make it challenging for the healthcare consumer to find their path forward.

Dr Ruscio:

But let’s go over to the topic at hand and discuss a meta-analysis looking at vitamin D supplementation for IBS. Four clinical trials, about 300 patients were randomized to placebo or vitamin D and the vitamin D led to improvements in the IBS scores and in quality of life. Remember, good example of not all data here agree, but there’s certainly a trend in the data. So vitamin D not really a hard sell. One interesting study there.

Dr Ruscio:

The next study looked at the effect of CBD-rich cannabis and its impact on Crohn’s disease. So 56 patients with Crohn’s diseases (autoimmunity to the lining of the gut) were randomized to either placebo or a CBD oil. And after eight weeks, the CBD group had lower disease activity, more improvements in quality of life, they had no difference in endoscopic findings or the way the tissue looked, [and] no changes in CRP (or calprotectin inflammatory markers). So this is a good example of where if we’re just treating labs, we could be led astray and we could miss the important aspect of improved disease activity and improved quality of life. Now, conversely, does this mean that if you’re having a very dire endoscopic finding that you should just use CBD only? No, but this is one data point reinforcing the anti-inflammatory benefits of CBD.

Dr Ruscio:

The next study looked at the effect of laxatives only versus laxatives plus probiotics on constipation. 60 patients were randomized and after 12 weeks the combination of laxative plus probiotics did not show any difference in stool frequency. So all groups improved, but there was no edge for the probiotics. So this is important to keep in mind and want to just continually showcase for you that, like anything else, you are almost never going to see a 100% finding for any therapy for any condition. Now that said, zooming way out, we know there’sa good body of evidence showing that probiotics can help constipation. Is it the only therapy? No. Is it always effective or are they always effective? No.

Dr Ruscio:

The next study looked at children (pediatrics) with allergic rhinitis and also having gastrointestinal disease. This is known as functional gastrointestinal disease, so it’s a very catchall term. This affects about 40% of the US population in adults. I don’t know what the data are for children. But 80 kids with allergic rhinitis and functional GI disease were randomized to either a conventional histamine, antagonist, nasal steroids, and a prokinetic or the conventional drugs (same cocktail) plus glutamine and probiotics. After three months, the drug group plus a glutamine and the probiotics had higher responses—a 95% response rate—compared to a 77% response rate. So a good example of how we can use alternative and conventional medicine conjunctively and how really we can do so much for allergic and histamine mediated conditions when using gut therapies. And remember sequencing here is an option, where you can start with the natural therapies, reevaluate, and depending on how bad your allergies are, an H1 blocker at that point in time, I think makes complete sense.

Dr Ruscio:

All right, the next study looked at intestinal parasites and certain digestive symptoms in children. 300 kids with diarrhea were examine compared to 100 healthy controls and stool samples were obtained on all of the children. Intestinal parasites were found at a higher rate in the diarrhea group versus the healthy controls, 35% as compared to 17%. Blastocystis hominis was found in 13%. Cryptosporidium was found in 3%. And Giardia was found in 2%. Now, the crypto and the Giardia fairly uncontestable in terms of [being] problematic. The Blastocystis hominis, as we’ve discussed, there is a signal there. I wouldn’t say it’s 100% of individuals. The reason why I echo this is because you will see Blastocystis hominis in people who have no problems. And for some people, this may be a totally normal resin of their microbiota. And we want to be careful not to go guns a blazing in with heavy-handed antimicrobial therapy, which was the method of choice 10 or so years ago.

Dr Ruscio:

And when I was first starting off as a patient, learning from Kalish and Dan Bivins and some of the people like Timmins over at BioHealth, who I think did an excellent job of bringing to the forefront the importance of overlooked imbalances and pathogens in the gut. But at that point in time, I don’t think we understood how powerful probiotics can be. So if you were in doubt, [a] child with no digestive symptoms—maybe he’s got some here [or] she’s got some minimal symptoms extra intestinally—[and then] you find blasto in a stool sample. What do you do? This is where probiotics are such a great option because they can eradicate many of these findings in the gut, but do so in a very health promoting way. And seems to be a very reasonable compromise for helping to establish eubiosis (or balance in the micro flora) without doing anything that’s too disruptive, like antimicrobial therapy. Not to say that herbal antimicrobial therapy requires a huge level of justification, but we want to try to intervene as minimally as possible and always be shooting for and striving for the minimal effective.

Dr Ruscio:

The next study looked at, one of many of its kind, looked at the impact of FODMAPs versus gluten and how they affect digestive or IBS symptoms. [This was a] crossover study looking at 103 IBS patients randomized to a one week intervention of either rice porridge, placebo, FODMAPS plus rice porridge, or gluten plus rice porridge. So the rice porridge was the placebo. Each intervention was followed for a week. Then there was the one week washout and then the groups were swapped. FODMAP consumption led to the highest IBS symptoms. And this occurred in 240 individuals or occurrences as compared to 208 for gluten and 198 for placebo. So all these people tried the different interventions or the three different interventions, the rice porridge, placebo, or porridge plus FODMAPs or porridge plus gluten. And what you saw in terms of total number of reactions, 240 for FODMAPs, 208 for gluten, 198 for placebo.

Dr Ruscio:

So this is hopefully helpful in the sense that both FODMAP restriction and gluten free are viable dietary trials to run, but as you’re probably accustomed to, I want to try to flag for people the fact that too much weighting has been associated to gluten in my opinion. And the main thing that frustrates me here is people, at very least, should be able to go out and eat gluten periodically and not be avoiding it based upon faith or fear alone. And again, the one thing I’m hoping that these data points help our audience understand is that point. I’m assuming that most people here are so educated that they’ve already tried or are currently doing gluten free. So I guess I’m trying to help educate us back to the best balanced point of the pendulum.

Dr Ruscio:

The next study looked at the effectiveness and tolerance of dietary therapies in nonconstipated IBS. This was a randomized control trial and they were mainly looking at traditional dietary advice versus low FODMAP versus gluten-free. So very similar. A hundred IBS patients who were not constipated either had low FODMAP gluten-free or a traditional diet. And at the week assessment period, they found improvements in 42% with the traditional diet, 55% with the low FODMAP diet, and 58% in the gluten-free diet. So 42% improvement in traditional diet, 55% in the low FODMAP diet, and 58% better in the gluten-free diet. So it’s one of the reasons why I try to give you all the data and the trend does seem to be that there’s probably a better outcome for low FODMAP versus gluten free. But again, it’s not to say that gluten-free is something that we don’t want to do. Just trying to give you that middle ground here. And I guess the one thing that’s challenging is the extreme sell. But they sell and I think they grab people’s attention for a little while. And then at some point they go, well, that book on gluten scared the bejesus out of me and taught me a few things, but I’m trying to settle into a lifestyle it’s a little bit more livable here. And that’s where I’m hoping this data helps give you a balanced perspective.

Sponsor:

Hey guys, Dr. Joe here, medical director of the Ruscio Institute for Functional Medicine. 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:

Okay. The next study looked at treatment for gastroparesis—so this is very slow motility in the upper GI—using a prokinetic or a prokinetic plus methyl B12. Compared to the prokinetic alone the group with the addition of the B12 had improved gastric emptying and less recurrence of gastroparesis. So this makes sense. Now, the one thing I should mention, very important here, is this was in a diabetic cohort and you will see much more B12 deficiency in those who are diabetic. So this is in a pseudo model, you could say, of insufficiency. Or at least in a population that suffers from a higher level of insufficiency, right?

Dr Ruscio:

The next study looked at hydrogen SIBO and its association with hepatic encephalopathy. And as a refresher, hepatic encephalopathy is one of the best, I guess, medical conditions that establishes the gut-brain connection, if you will. Dysfunction in the liver leads to the liver having a reduced capability to filter toxins from the blood, toxins build up in the blood, as you would expect some of those cross into the blood brain or into the brain via the blood brain barrier, and now you have cognitive impairment. This study looked at 107 patients hospitalized with liver dysfunction and they found SIBO was detected in 29% of those individuals.

Dr Ruscio:

However, interestingly, there was no difference in liver function between SIBO positive and SIBO negative subjects, but hydrogen SIBO was associated with the hepatic encephalopathy. And let me say that again, just to clarify, when looking at SIBO globally, there was no association, but when looking at hydrogen SIBO, it was associated. So just to clarify, when looking at any type of SIBO (no association) it wasn’t enough signal to be significant, but when looking just at hydrogen sulfide SIBO, there was a higher rate of positivity in this hepatic encephalopathy. And we know that Rifaximin has been shown to reduce hepatic encephalopathy in that cohort. So anyway, zooming way out, simplifying: your gut, your liver and your brain are connected.

Dr Ruscio:

The next study looked at the effect of gluten challenge on the fecal microbiome in patients with celiac and with non-celiac gluten sensitivity. 17 celiac and non-celiac gluten sensitive patients who were previously on a gluten-free diet were looked at. And at two weeks of gluten challenge there was no change in the gut microbiome and composition in both groups, despite GI symptoms getting worse, were the same. So this is really interesting. And this also, I think, is an important reminder that we want to be looking at someone’s symptoms and their lab values, right? Because if we were in the treating the labs model, we would say, “well, Mary Sue, your microbiome looks fine, looks just as good as it did before.” “Well, doc, I’m crapping my brains out. Does that matter to you?” And I know that sounds silly when I exemplify it in such an extreme way, but you see this all the time.

Dr Ruscio:

“Well, Mary Sue, your adrenals are in the tank.” “But I feel fine.” “Doesn’t matter. Shouldn’t be having coffee. We’re going to give you XYZ supplements, reduce your exercise.” And this is so harmful because people will change their lifestyles in a negative direction when treating labs. And this is not the case in all areas, but when we don’t have exquisite validation data for a test, you want to make sure to weight the value or how much you interpret from that test lightly. Like we’ve talked about, one fourth of the data; we look at someone’s history, their symptoms, their response to treatment, and their lab values conjunctively. So in this case, if we’re looking at their history: celiac or non-celiac. Okay, that’s important. Their symptoms? Well, they had none. The response to treatment? We put them on a gluten provocation, their symptoms got worse. Their labs look the same. Well, if you interpret all those data together, then you come away with, “okay, yeah, you should not be on gluten even though your microbiota looks the same as it did three weeks ago or so.

Dr Ruscio:

Okay. The next study looked at the effect of Prucalopride (a prokinetic resolor, AKA) on idiopathic chronic constipation and who also had some degree of bloating. They examined six studies and the Prucalopride led to better improvements in abdominal bloating when compared to placebo—a 62% response rate compared to a 50% response rate. So an edge for Prucalopride. I wouldn’t say it’s huge, but makes sense that if someone has constipation, they may also have bloating and getting them regular will improve the bloating. And no quarrel with Prucalopride, but I would say that’s best considered as an end-phase intervention, because if we can use diet, perhaps fiber supplementation (in those who respond well to it), probiotics, antimicrobials, elemental resets, then we should be treating the motility upstream. And this is one of the things that again, sorry, this is a little bit redundant, but this is one of the things that I think some of the SIBO research has missed is really getting such a amazingly granular understanding of the impact of motility. But then assuming that the way we fix the motility is directly treating the motility, rather than thinking about how can we treat the motility upstream.

Dr Ruscio:

The next study looked Zonulin in patients with rosacea. 30 patients with rosacea and they found that Zonulin was significantly elevated in those with rosacea. So not surprising. And we’ve discussed that Zonulin is validated. There is a correlation, a trend, between many different states of health or disease and Zonulin, but it’s not perfect. And not all the treatment data that show someone improves symptomatically will correlate to improvements in Zonulin level. So it’s a good marker. I think it’s a little bit challenging to make treatment decisions centered around it though.

Dr Ruscio:

The next study looked at the gut-brain axis and how FODMAP and IBS interplay. This was a crossover study of 13 IBS patients versus 13 healthy controls. And they were randomized to one of three infusions—intergastric infusions—FODMAP, glucose, or saline. And abdominal MRIs were performed at one and two hours post infusion. The FODMAP group had more cramps, pain, flatulence, and nausea compared to the glucose group. There was also increased small bowel motility and ascending colonic gas in both IBS patients and healthy controls. So in short, this study demonstrates that FODMAP infusion led to increased GI symptoms, increased bowel motility (in a bad way, in this case, ostensibly, these people would probably be having diarrhea later), and increase gas production. Right? So it’s important to, I guess, mention that even though some slow motility can occur in SIBO, we don’t want to be looking at motility like some do thyroid hormone, [which is] the more, the better, the faster, the better. All right.

Dr Ruscio:

The next study looked at and is actually a systematic review with meta-analysis looking at the tissue health or the endoscopic findings and safety looking at… The intervention was placebo, so they’re looking at the effect of placebo when treating ulcerative colitis. 119 placebo controlled studies were examined, that’s a lot of studies, and they found that the remission rates in the placebo arms were 11% for clinical remission (perhaps the most important), 19% for endoscopic remission, and 15% for histological remission. So a 10 to 20% placebo response rate when treating ulcerative colitis. This is why placebo is really important and why I try to be so particular about making sure that we’re trying to reduce the placebo effect in the clinic, because unfortunately how the placebo and placebo effects are often used is to placebo patients into doing more treatment than they need. And they feel better, see, therefore “you needed to stop exercising and stop drinking coffee, take seven supplements and go on a low FODMAP diet because of your adrenal fatigue and your positive SIBO breath test.” And the unfortunate nature of that placebo and nocebo is that you’re convincing someone to work harder and live a less enjoyable life than they need to, to get to the improvement they’re wanting to get to.

Dr Ruscio:

So anyway, and the other side of that too is the lab testing, right? If the lab testing is used in such a way where individuals think we needed the test in order to do the treatment, then every time you don’t feel well (again, at least from a loose presumptive perspective), you’ve got to go back and do more tests because you need the test to know what to do. And over the course of a patient’s care, let’s say over a five year stent, you might end up doing three tests for some clarification. Or you might end up doing nine tests because you’re really doing this pre/post analysis on every test and using a number of tests that really don’t need to be used. The pre/post, I don’t take so much so much of an issue with, but it’s mostly the use of serial retesting to guide treatment when it’s really not needed in so many. There’s always exceptions to this but this is most broadly applicable in the functional medicine space.

Dr Ruscio:

Okay. The next study looked at Crohn’s disease. 194 Crohn’s patients received either a Mediterranean diet or the SCD (specific carbohydrate diet). And after six weeks, the SCD group had no difference in clinical remission, calprotectin, or CRP. Now I have no quarrel at all with the SCD diet, but if these findings are representative for a broader whole, it’s much, much, much easier to go on a Mediterranean diet than an SCD diet. So just important because , it’s easy for a doctor or a clinician to say, do this diet, right, but it’s really important to keep in mind, how much does the person have to do to effectuate that diet? And this is why at the clinic, we give a written recommendation for X, Y, Z diet. And then there’s a note right below that, to do your best. You don’t have to be 100% compliant.

Dr Ruscio:

Usually 75, 80% is sufficient. And then I’ll often tell people verbally that if you’re doing it 100%, it’s likely going to require so much additional effort and stress that it may actually end up being net and tical as compared to aiming for 75 to 80% compliance and translation. Okay, you’re doing a diet for a month. And in that month, there’s three social events. You can either go to those and not worry or be worrying the whole time when you should actually be enjoying yourself. That’s a, I guess, a simple translation to what that looks like in the real world.

Sponsor:

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 Medicine—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 FFMR—the Future of Functional Medicine Review—database which contains case studies from our clinic, research reviews, and practice guidelines. Visit DrRuscio.com/resources to learn more.

Dr Ruscio:

The next study looked at a low FODMAP diet and its ability to induce clinical remission in 70 celiac patients who had persistent symptoms even though they went on a gluten-free diet. So after four weeks of a low FODMAP diet, these patients who were celiac and went gluten free and still had symptoms had improved IBS scores and improved celiac disease scores.

Dr Ruscio:

So again, another reason why it’s important for us to think about these diets more as medium to short-term tests and then keep moving if you don’t see the response that you’re looking to. And also remember that there’s a small handful of diets on offer. And if once one gets through those, they’re not seeing the improvement that they’re looking to […] at the end of the month trial, you would want to say this is helpful, yes or no. Continue until you plateau. You might plateau anywhere between two and six months and then reevaluate, have you hit 80 ish percent? If so, I would consider that a win. If not, it’s important not to diet more and more strictly but to keep in mind, as we’ve discussed in the past and using celiac as a model, some of the non-responsive celiac patients have SIBO or an infection. So it’s important again, reminder, not to force a dietary solution to what might not be a dietary problem.

Dr Ruscio:

Now, this next study is also quite interesting and it ties in the importance, I guess you could say, of psychology and or mindset. Six versus 12 sessions of gut-focused hypnotherapy for IBS—randomized control trial of 448 patients who are randomized to either six or 12 sessions of hypnotherapy. And there was no difference in those who achieved improvement. So essentially for those whom they responded the six or the 12 didn’t make any difference. So two things: 1) hypnosis can be helpful for IBS and 2) you may not need to do a longer course. And at the end of the six [sessions], if you’re not seeing any benefit, then a different therapy would be worthy of consideration. And again, these things are really valuable because if you can judge a therapy in the appropriate time interval, let’s say six weeks, or another clinician was of the belief [that you should] double down, do it more, do it harder, give it time, it’s the onion peeling, and it took three months… If you had to evaluate five therapies at one month per or three month per, I mean, do the math, right?

Dr Ruscio:

And this is one of the things that’s sometimes saddening is that patients didn’t have the appropriate expectation of their clinician to maintain a certain cadence. And they did in three years what could have been done in maybe eight months. I want to be sensitive to clinicians needing to be able to work their process, but I also want flag for you that if something is working, you should notice a response usually within two to six weeks, roughly speaking. Some therapies may be a touch longer, like mold binding therapy, but that’s a decent window to consider an ample reevaluation period.

Dr Ruscio:

Alright all, I guess we can pin it there. Just one or two reminders—If you have not yet left a review for the podcast, I would really appreciate it if you did. And if you need a step-by-step guide for improving your gut health, “Healthy Gut, Healthy You” is always an option for you. Or if you want a deeper dive with a clinician, please feel free to reach out to my office anytime. And hopefully this helps you on your journey of parsing a whole bunch of information regarding health and your healthcare and the options that you have. And I will look forward to speaking with everyone next time. All right, guys, take care. Bye-bye

Outro:

Thank you for listening to Dr. Ruscio 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.

 

➕ Dr. Ruscio’s Notes

The efficacy of vitamin D supplementation for irritable bowel syndrome: a systematic review with meta-analysis

  • 4 RCTs, 335 participants with IBS randomized to placebo or vitamin D
  • Vitamin D led to improvements in:
    • IBS symptom score (-84 vitamin D vs -28 placebo)
    • Quality of life (+15 vs +6.5)
  • Commentary: Vitamin D may be an effective therapy for improving IBS symptoms and quality of life.

 

Oral CBD-rich Cannabis Induces Clinical but Not Endoscopic Response in Patients with Crohn’s Disease, a Randomised Controlled Trial

  • 56 patients w/ Crohn’s Disease (CD), randomized to placebo or oral CBD oil
  • After 8 weeks of supplementation, the CBD group had:
    • Lower disease activity
    • More improvement in quality of life
    • NO difference in endoscopic findings
    • NO change in CRP, calprotectin
  • Commentary: CBD supplementation led to improved symptoms and quality of life, with no change in endoscopic findings or inflammatory markers in those w/ CD.

 

The development of the cure of the functional intestinal disorder based on the differences of gut microbiota in aged patients: A randomized clinical trial

  • 60 patients w/ chronic constipation, randomized to:
    • Laxatives only
    • Laxatives + probiotics
  • After 12 weeks, the combined laxative + probiotics group had:
    • No greater improvement in stool frequency or consistency

 

Pediatric allergic rhinitis with functional gastrointestinal disease: Associations with the intestinal microbiota and gastrointestinal peptides and therapeutic effects of interventions

  • 80 kids w/ allergic rhinitis & functional GI disease (FGID)
  • Kids w/ allergic rhinitis & FGID randomized to:
    • Conventional drug (H1 blocker, intranasal steroids, prokinetic)
    • Conventional drug + glutamine + probiotics
  • After 3 months, the drug + glutamine + probiotics group had higher response rate (95% vs 77.5%)
  • Commentary: This study showed that treating the gut w/ foundational GI therapies on top of conventional drugs led to better improvements as compared to drugs alone.

 

Evaluation of Intestinal Parasites and Some Clinical Symptoms in Children with Diarrhea

  • 300 kids w/ diarrhea, 100 healthy control kids
  • All had stool samples
  • Intestinal parasites were found at a higher rate in the diarrhea group (35% vs 17%)
    • Blastocystis hominis (13%)
    • Cryptosporidium spp
    • (3%)
    • Giardia intestinalis (2%)
  • The presence of parasites were also associated w/ abdominal pain and nausea
  • Commentary: This study found an association of intestinal parasites and diarrhea. 

 

Fermentable oligo-, di-, monosaccharides, and polyols (FODMAPs), but not gluten, elicit modest symptoms of irritable bowel syndrome: a double-blind, placebo-controlled, randomized three-way crossover trial

  • Cross-over study of 103 IBS patients, randomized to 1-week interventions of:
    • Rice porridge (placebo)
    • FODMAPs + rice porridge
    • Gluten + rice porridge
  • Each intervention was followed by a 1-week washout period
  • FODMAP consumption led to the highest IBS symptom score (240) compared to placebo (198) and gluten (208) 
  • Commentary: High FODMAP consumption was associated with worse IBS symptoms compared to gluten or placebo. 

 

Efficacy and Acceptability of Dietary Therapies in Non-Constipated Irritable Bowel Syndrome: A Randomized Trial of Traditional Dietary Advice, the Low FODMAP Diet and the Gluten-Free Diet

  • 100 IBS patients (non constipative), randomized to:
    • Low FODMAP
    • Gluten-free diet
    • Traditional diet
  • After 4 weeks, ≥50-point reduction in IBS-SSS was achieved in:
    • 42% traditional diet
    • 55% low FODMAP diet
    • 58% gluten free diet
  • Participants found that the traditional diet easier to incorporate
  • Alterations in stool dysbiosis index were similar across the diets
  • Commentary: This is why we at the clinic often start with a relaxed paleo diet before moving to a low FODMAP diet. 

 

Efficacy and Safety of Mecobalamin Combined with Prokinetic Agents in the Treatment of Diabetic Gastroparesis: A Meta-Analysis

  • 24 RCTs, 1,878 patients w/ diabetic gastroparesis, randomized to: 
    • Prokinetic 
    • Prokinetic + methyl-B12
  • Compared to prokinetics alone, the addition of methyl-B12 led to:
    • Improved gastric emptying rate
    • Less recurrence of gastroparesis
  • Commentary: The addition of methyl-B12 led to greater improvement in diabetic gastroparesis compared to prokinetics alone. 

 

Hydrogen-producing small intestinal bacterial overgrowth is associated with hepatic encephalopathy and liver function

  • Prospective study of 107 hospitalized patients w/ liver dysfunction encephalopathy
  • SIBO detected in 29% of participants
  • NO difference in liver function between SIBO + and SIBO – participants
  • But, H2 SIBO was associated w/ hepatic encephalopathy (50% H2 vs 24% CH4)
  • 8 hepatic encephalopathy patients treated w/ Rifaximin
    • H2 SIBO patients had higher response rate of breath test improvement (67% H2 vs 20% CH4)
  • Commentary: H2 SIBO may be more closely associated with hepatic encephalopathy and liver function than CH4 SIBO. 

 

Lack of Effect of Gluten Challenge on Fecal Microbiome in Patients With Celiac Disease and Non-Celiac Gluten Sensitivity

  • 17 celiac and non-celiac gluten sensitivity patients, previously on a gluten-free diet
  • After a 2-week gluten challenge, there was NO change in gut microbiome composition in both groups, despite a worsening in GI symptoms 
  • Commentary: Lab findings do NOT always correlate with symptoms. 

 

Efficacy of Prucalopride for Chronic Idiopathic Constipation: An Analysis of Participants With Moderate to Very Severe Abdominal Bloating

  • 6 studies
  • Prucalopride (2 mg per day x 3-6 months) led to better improvement in abdominal bloating compared to placebo (62% vs 50% response rate)
  • Commentary: Note the placebo response rate of 50%. 

 

Measurement of the serum zonulin levels in patients with acne rosacea

  • 30 patients w/ rosacea, 31 healthy controls
  • Serum zonulin was significantly higher in those w/ rosacea (18.5 vs 13.2 ng/mL)
  • Commentary: This highlights the gut-skin connection. 

 

Gut-brain axis dysfunction underlies FODMAP-induced symptom generation in irritable bowel syndrome

  • Cross-over study of 13 IBS patients and 13 healthy controls
  • Randomized to 1 of 3 intragastric infusions:
    • Fructans (FODMAP)
    • Glucose
    • Or Saline 
  • Abdominal MRI was performed before, 1 hr, and 2 hrs post-infusion
  • The fructan (FODMAP) group had:
    • More cramps, pain, flatulence and nausea compared to glucose
    • Increased small bowel motility and ascending colonic gas in both IBS patients and healthy controls
  • Commentary: This study showed that an intragastric infusion of FODMAPs (fructans) lead to GI symptoms, increased bowel motility, and increased gas production. Dr. Rusico wanted me to mention this partially contradicts the ‘slow motility underlies IBS/SIBO hypothesis’.  

 

Pre-Digested Protein Enteral Nutritional Supplementation Enhances Recovery of CD4 + T Cells and Repair of Intestinal Barrier in HIV-Infected Immunological Non-Responders

  • 36 patients w/ AIDS, non-responsive to current antiviral therapy
  • All received a pre-digested protein drink (ie elemental diet) once per day in addition to their current diet
  • After 3 months, treatment led to:
    • Improved immune function (Increased WBC, neutrophils, CD4+)
    • Reduced intestinal permeability markers (LPS, D-lactate, DAO) 
    • Increased body weight 
  • Commentary: Using a pre-digested protein drink (e.g. elemental diet drink) as a meal replacement led to improved immune function, reduced markers of intestinal permeability, and weight gain. This supports our clinical observation that using elemental diets exclusively is NOT always necessary, but rather a hybrid approach can provide clinically meaningful benefits.

 

Systematic Review and Meta-Analysis: Clinical, Endoscopic, Histological and Safety Placebo Rates in Induction and Maintenance Trials of Ulcerative Colitis

  • 119 placebo-controlled studies of ulcerative colitis
  • Remission rates in the placebo arms:
    • Clinical remission 11%
    • Endoscopic remission 19%
    • Histological remission 15%
  • Commentary: Previously, we have documented a high placebo response rate in IBS studies. Now, we present a notable (although smaller) placebo response rate in IBD studies. 

 

A Randomized Trial Comparing the Specific Carbohydrate Diet to a Mediterranean Diet in Adults With Crohn’s Disease

  • 194 Crohn’s Disease (CD) patients randomized to mediterranean diet (MD) or specific carbohydrate diet (SCD)
  • After week 6, the SCD group had, NO difference in:
    • Clinical remission rate (46.5% vs 43.5%)
    • Fecal calprotectin remission (34.8% vs 30.8%)
    • CRP remission rate (5.4% vs 3.6%)
  • Commentary: This study showed NO difference between the MD and SCD for improving Crohn’s Disease. This is why we at the clinic follow a step-wise approach for dietary interventions (e.g. first start with a paleo diet before moving to a SCD). 

 

A low FODMAP diet reduces symptoms in treated celiac patients with ongoing symptoms – a randomized controlled trial

  • 70 Celiac disease patients w/ persistent symptoms, randomized to low FODMAP diet, or gluten-free diet (control)
  • After 4 weeks, the low FODMAP diet had:
    • Lower IBS symptoms 
    • Less Celiac Disease symptom score 
  • Commentary: Those w/ Celiac Disease and persistent symptoms may benefit from a low FODMAP diet. 

 

Six vs 12 Sessions of Gut-focused Hypnotherapy for Irritable Bowel Syndrome: A Randomized Trial

  • 448 IBS patients, randomized to 6 or 12 sessions of hypnotherapy
  • No difference in those achieved >50% reduction in IBS symptoms (79% in 6 session group, 74% in 12 session group)
  • Commentary: 6 sessions of hypnotherapy were non-inferior to 12 sessions in improving IBS symptoms.
➕ Resources & Links

Sponsored Resources

Hey guys, Dr. Joe here, medical director of the Ruscio Institute for Functional Medicine, 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, multimineral 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 one as part of your daily routine. Right now, Athletic Greens is offering a free one year supply of vitamin D and five free AG1 travel packs with your first purchase when you visit athleticgreens.com/ruscio.


Need help or would like to learn more?
View Dr. Ruscio’s additional resources

Get Help

Discussion

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

Leave a Reply

Your email address will not be published. Required fields are marked *