You’ve likely heard about the connection between a healthy gut and good health. If you have symptoms like bloating, excessive gas, and abdominal pain, you may already know that you have some gut health issues. But there is also a large group of people who are walking around with gut problems without knowing it. Did you know that gut problems can display a whole different set of symptoms that don’t necessarily manifest as overt gut symptoms (i.e. gas, bloating, indigestion, etc.)? These include joint pain, low energy fibromyalgia, chronic fatigue syndrome (/MECFS), insomnia, anxiety, depression, poor thyroid function, skin issues, and cardiovascular disease.
So, how do you find out if you have an unhealthy gut, and if you do, how can you restore your gut health?
In this podcast, I speak with Dr. Michael Ruscio, a doctor of Chiropractic, clinical researcher, expert on the gut and author of the bestseller “Healthy Gut, Healthy You.” Dr. Ruscio discusses the science behind gut issues, how to heal your gut, and the keys to restore gut health.
If you suffer from any medical condition that is not responding to normal protocols, this podcast may shed light on how to figure out if your gut is the underlying root cause.
In this podcast, we’ll cover
- The role of gut tests in diagnosis and their reliability
- The best diet to restore your gut health (it’s not what you think)
- Why ”listening to your body” is crucial when you heal your gut
- The most common (and uncommon) symptoms of an unhealthy gut
- Is SIBO (Small Intestine Bacterial Overgrowth) a real condition? What science says about SIBO
- What to do if you react to many foods
- Ruscio’s keys to restore gut health
- Gluten intolerance. Is it real or just another fad?
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How to Heal Your Gut and The Keys To Restore Gut Health with Dr. Michael Ruscio – Transcript
Ari Whitten: Hey everyone, welcome back to The Energy Blueprint Podcast. I’m your host Ari Whitten, and today we’re going to be talking all about gut health and how that relates to your health and energy levels more broadly, and a whole bunch of unique connections between the gut and different systems of the body and lots of new content that you almost certainly have not heard before. Today my guest is Dr. Michael Ruscio, who is a Doctor of Chiropractic, a clinical researcher and bestselling author whose practical ideas on healing chronic illness have made him an influential voice in functional and alternative medicine. His research has been published in peer reviewed medical journals and he speaks at integrative medical conferences across the globe and he’s also the new author… he is the author of the new book, I should say, “Healthy Gut, Healthy You.” So welcome Dr. Michael Ruscio. Such a pleasure to have you on.
Dr. Michael Ruscio: Thanks for having me.
Ari Whitten: Yeah. So to get started, I would love for you to just talk a bit about your background of how you got into this space of, I guess health more broadly, but then, specifically, what made you focus on going deep on gut health.
Dr. Michael Ruscio: Sure, sure. Well, I have my own experience while I was in college, and this was when I was pre-MED and still trying to figure out exactly how I wanted to plug into the health medical system. Originally I was thinking about going into conventional medicine, well, I was pretty much set on going into conventional medicine. It appealed to the kind of my type A analytical mind, but as often times happens, I had a few life experiences thrown my way and they kind of diverted my path or helped me become more granular in exactly what I wanted to do. And I didn’t know what was happening at the time, but I started having insomnia, brain fog, fatigue, bouts of depression, and I really was at a loss for why, as a college athlete, someone who was feeling near invincible up until that point, I was, very suddenly started to feel unwell. And I was getting enough sleep, I was eating a all whole foods, mostly organic diet, exercising. I mean I was studying this stuff so I knew how to take care of myself.
Yet, despite all my best efforts, I was still feeling quite ill at this point in time and so I figured, well, I’ll go see a few doctors, this is what they do and this is what I’m going to be doing and so let me, I guess, get a firsthand experience with this. And I saw an internist, an endocrinologist and a general practitioner and they ran some tests and essentially the narrative I got in return was, “Well, you know, you’re the picture of health. Everything looks good. All of your tests are fine. It must be stress, it must be school, what have you.” And there was really nothing that I was offered in terms of a diagnosis or a solution.
So, like many people do at that point in time, I turned to alternative medicine and I found a doctor who thought I may have had an intestinal parasite. And I remember thinking to myself, “This guy is nuts. You know, I hadn’t left the country, I never had food poisoning, I had no digestive symptoms.
How could I have a parasite?” And you know, that taught me a very important lesson, which is you can have a digestive problem that only manifests as non digestive symptoms. And so, lo and behold, a few months later, I figured out that I in fact did have an intestinal parasite that was causing all this gut inflammation but wasn’t causing any gut symptoms. No bloating, no gas, no diarrhea, no abdominal pain, only brain fog, insomnia, fatigue. I was also feeling cold. But before I got the diagnosis, I went on the internet and I researched and I thought I had adrenal fatigue.
I thought I had hypothyroidism or poor thyroid conversion. I thought I had heavy metal toxins. And so I did all the self help protocols for these purported diagnoses and didn’t really feel any better. It wasn’t until I actually figured out that I had a parasite and treated that problem in my gut that I started to respond. And so I decided to go into integrative and alternative medicine.
And when I got there, I liked a lot of what I saw. But I also felt like there was a fair amount of dogma and there was… some beliefs were very rigid, but didn’t seem to have any science to support them. And when I wanted to have an honest inquisition where, just an honest inquiry about “well, does everyone need to go gluten free” you know, “is there really evidence to support that?” And I’d get these, “oh they should,” these really strong answers, yet there weren’t really good data in my mind to support those things.
But you know, I was a student and so you’re… sometimes you’re not confident enough to take on your professor when you’re a student. But that seed was in my head and as I got into clinical practice, I felt like there were, again, a lot of great things in alternative medicine, but a lot of things that I felt like were half truths and potentially a lot of fat that could be excised from the model. And so this led me to performing some of my own research, some of which we’ve done at the clinic, some of which is on its way to publication, and other studies are in the pipeline, trying to find this right balance of what to use from natural integrated medicine. And then, what might be dogma that needs to be left by the wayside as we update this model.
And the gut therapies are the ones that I’ve consistently noticed, albeit I may be a bit biased, but consistently noticed deliver the most improvements for the patient. And that’s why my focus is there and that’s why I kind of have this somewhat critical view of things in healthcare and medicine because I’ve just seen there are a lot of things that are well intentioned but not supported. And if we can identify those things, we can make our model of care more effective.
Ari Whitten: Yeah. Well said. We also have a lot in common on one particular point, which is I’m not particularly liked by either people within just purely conventional medicine circles or alternative medicine circles because I’m in this sort of weird no man’s land in between those two where I’m, you know, kind of pointing out flaws within conventional medicine approaches to lots of different chronic medical conditions as far as the lack of education and focus on nutrition and lifestyle factors which are just, of course, massive in almost all chronic conditions.
And then on the other hand, as you were alluding to within alternative medical circles, there’s a lot of dogma and a lot of belief systems that aren’t necessarily supported by very good evidence. And so I’m also simultaneously saying, you know, kind of debunking certain things within alternative medicine communities. And so it sounds like you are also kind of in this no man’s land with me.
Dr. Michael Ruscio: Yes. And I like to think the population in no man’s land is growing. I like to think that is, as information is becoming so easily accessible, people are no longer falling for kind of the argument from authority. And that authority could be the conventional authority, it could be the alternative authority, but I think people are starting to look for factual support rather than expert driven opinions.
And I like to think that there was this pendulum swing toward, you know, dogmatic progressive views both in conventional and alternative medicine, but people are getting burnt out on those dogmatic views.
And, unfortunately, it used to be whoever kind of yelled the loudest got the most attention. But I think that’s been burnt down. Kind of like a marketing campaign in a city. If you’re the first guy to put up a flashing neon sign, you’re going to get some attention. But then eventually there is going to be so many flashing neon signs that people just tune them out completely and they’re looking for maybe the quaint little shop that doesn’t seem to be so in your face sales. And I think, I hope that’s what’s happening in healthcare, health and fitness, in medicine where people are looking for more of a nuanced, you know, opinion and not people that are so hard driving.
And, you know, there’s a quote I like to share, which is “dogmatism can only survive in the presence of ignorance.” And so in my opinion, someone can only be really hard driving on their views if they’re unaware of the contradictory evidence. Because once you are aware of the contradictory evidence to a given point, you have a more balanced view. Well, It could be this, but there’s also data to support that, so you have a softer narrative. And so I think people are getting hip to the fact, privy to the fact that people who give you these really staunch hardline recommendations, unfortunately, are oftentimes ignorant to the contradictory data and therefore giving you advice that’s not really well crafted and well developed.
Ari Whitten: Well said. Yeah, I agree 100 percent. So the gut specifically, it’s not really a new idea that the gut is very important to health. It’s been around since the time of Hippocrates, obviously thousands of years ago. But right now it’s kind of exploding in popularity, this idea that the gut and the microbiome are extremely important in our health. There’s even very big companies that are emerging in this space with Biome and uBiome. I hope to talk about that during this interview with you. But why did you feel compelled to write a book on this subject, you know, as there are so many people talking about gut health? What made you want to say, “I also want to be one of these people talking about gut health, but I want to do it in my way.” What was the motivating factor behind that?
Dr. Michael Ruscio: So the book initially started as an eBook or I just wanted to give people some advice, right some wrongs and try to give people a reasonable narrative. And part of the reason I had that objective was because I was seeing patients come into the clinic and they were, some were just decimated by fear of food.
And they went and they read about how gluten is bad, then about how carbs are bad, then about how dairy is bad, then how FODMAPs are bad, then about how high sulfur is bad while histamine is good. And they come in and they’re just crippled by fear. They don’t even know what to eat and they’ve totally forgotten how to just listen to the simple signals that your body throws you as a way of your body telling you what’s working.
So part of it was that. Part of it was also just seeing how other providers were overly reliant on tests and not realizing that a surprising number of tests have actually not been clinically validated. And so, you know, what that means is that, the real literal translation of that is what you’re looking at has zero meaning. So even though it says “high” or “low” or “bad,” or it’s in red or what have you, that doesn’t actually mean anything.
So it is possible for a lab to tell you something is wrong with you, but that hasn’t actually been validated to mean anything is wrong with you. This is a really unfortunate state of affairs where I think that consumer’s trust and the clinician’s trust has been violated. But I was seeing a number of patients who went to a doctor, had stool testing of some sort done, and the stool tests were treated at the exclusion of the patient’s history, their symptomatic context and the response to treatments and the failure point was there. And these patients would come into my office and it wasn’t hard to get them well.
All you had to do was look at lab testing as one fraction of a multicomponent system. Their history, their signs or symptoms or presentation, their response to previous treatments, their response to current treatments, and use all this to understand the individual and therefore what the individual needs. And once you do that, you’re able to get good results. It turns out that there were more than 60 pages that was required to achieve that end, which I originally thought an eBook would be, maybe 60 pages. My book ended up being about 334 pages with just under a thousand medical references supporting the approach.
So I wanted to give people a full guide for understanding your gut, what are the relevant players, what is a reasonable understanding and what steps you can take to improve your health. And I guess the one other thing, one of the other major items was, I wanted to give people a well rounded, kind of all encompassing approach.
So you kind of had a quarterback perspective. Meaning this isn’t going to be the book all about gluten or all about FODMAPs are all about probiotics or all about low carb or all about high carb and just give you what could be a very helpful treatment plan but that’s tunnel visioned into this one therapeutic avenue. But rather lay out the broad array of therapeutic tools that are available and help you determine which ones are best for you. And then help codify those to a sequence of steps that can help you figure out the optimum number of stimuli to present your gut to allow healing. And of course, you know, when you say it like that, I suppose it’s easy to understand that that wouldn’t really be an eBook that would be, you know, a little bit more of a robust read. But those were some of the main motivators for me to publish the book.
Why testing isn’t a valid marker when you want to restore gut health
Ari Whitten: Excellent. One thing I want to dig into a little bit that you mentioned there is the fact that a lot of the tests that are being used commonly, including in functional medicine circles, are not clinically scientifically validated. And there’s a lot of this going on in functional medicine circles and it’s very deceptive in my opinion, because you have… People will go and do these tests and they think, “Oh, if it’s a test, it must mean that it’s been scientifically validated. It’s really scientifically advanced cutting edge, technologically advanced, all these things. And it’s so much more advanced than not doing testing.”
And yet, you know, when you get down to it, you find out that a lot of these labs that are doing these tests are themselves businesses that are creating tests for the purpose of making money. And you know, basically what ends up happening is people do these tests, they think that they are science, that they’re backed by science, and as you said, a lot of these tests just are meaningless.
Dr. Michael Ruscio: Yeah, I mean it’s very well said. And one of the things that I try to cover in the clinical newsletter that we write for clinicians, as a training tool for clinicians, one of the philosophies is that more testing and treatment does not equate to better results. And it’s been a fictitious promise that we have been sold in, especially in functional medicine. And I don’t think any of this is done with malintent. I think most people are operating with good intentions, although there’s been a couple of labs that litigation has been brought against and they have pled guilty to essentially fraudulence. So it’s not to say we can look at the world through rose colored glasses.
You know, there is some culpability from, I think, a small number of labs that have really been malicious. But for the most part I think the labs, the supplement companies and the providers are all trying to do the best they can for people.
It’s just there’s some errors in how we’re thinking and how we’re processing information that allow erroneous conclusions to be drawn. And then those are propagated. And then, you know, years and years later you have a field that is performing way too much testing, way too much treatment. And we’ve gotten away from some of the rules that actually come back to conventional medicines’ evidence-based hierarchy.
And I think what’s happened is, and I talk about this in my book, I call it the “freedom effect,” where for so long we were shackled by the confines of kind of a conventional healthcare system. And when we finally got a chance to depart from that and have more freedom, we didn’t know how to really use that freedom or be responsible with that freedom. And the analogy I use in the book is you have a teenager who maybe went to a Catholic school and was really kind of isolated their whole life.
Then they go to college where they can drink and smoke and do drugs and they don’t know how to balance it and they just go off the rails because they don’t know how to responsibly handle that freedom. And that may sound like a flippant analogy, but it’s one of the ways I try to account for the fact that some of these tests, like these microbiota mapping tests that you mentioned earlier, while they do have their purpose and that purpose is to amass data so that we can eventually get to a clinical prescriptive predictive ability of these tests.
We are not there right now. And so if you’re someone who’s suffering and you’re going to put a few hundred dollars into one of those tests thinking that those tests provide the answer, they do not. And it’s really unfortunate with the exception of two labs, one called DayTwo that predicts glycemic response to foods and the other called GA-map not to be confused with the GI-MAP, which is available in the United States.
The GA-map is being pioneered by a group out of Norway, and that test is only just showing correlations, meaning this profile correlates to IBS or to IBD. They still haven’t gotten to the point where they can say we know what to do in terms of how to treat these findings.
So the best data that we have, one test shows the ability to predict your glycemic response to foods, so there may be some utility there. I’m certainly open to that. And the other is able to accurately show correlations between IBS and IBD and certain mappings of the microbiota. But treatments still cannot be rendered. And it’s crucially important that we’re clear on that because I see so many patients now that will come in and say, “Oh, I’ve gotten an X, Y, or Z test,” and I shrug my shoulders and say, “Well, you know, that’s great, but we can’t really do anything with that.”
And then I should just quickly mention that it’s not to say that you can’t feel good. There is a tremendous wealth of therapeutic options available to you. It’s just what we don’t want to do is get distracted into treating what I call meaningless measures on non-validated tests because that will give you the highest probability that the treatment that you do will not help you improve. And we want to focus on trying to identify what treatment do you present most likely to respond to and steer you toward those treatments. And ironically for many cases of digestive imbalance, whether they be IBS or similar, a lot of testing isn’t really required to make those adjudications.
Why there isn’t one specific ”gut health diet”
Ari Whitten: Yeah. Well said. One point I want to emphasize here, because I encountered this a lot with these GI mapping companies that are now emerging and becoming very popular. A lot of people are doing these tests. A lot of members of my community are going out and doing these tests with the impression… they are under the belief, and it’s not unreasonable that they’re under this belief because these companies I think are promoting, they want people to believe this.
They do these tests and they think, “Well, I got my GI microbiome mapped and, you know, now they’re, you know, now that it’s mapped, what’s the best diet for me? You know, now that we know what my microbiome is,” as if it’s this sort of static thing, “now I know the best bio individualized diet based on my unique microbiome.” And again, it sounds like scientific and really advanced and I just want to point out to people that, as you’re saying, this is in its infancy, and we are very far from a stage that we can like map somebody’s microbiome and say, “Here, based on this data, here’s the one best diet for you. You should be vegan or you should be keto or whatever.”
Dr. Michael Ruscio: In fact, we have very good data. I think that perhaps the best, arguably the best study that looked at this was known as the DIETFITS trial by Gardner, et al., over at Stanford. And they essentially took some gene markers to try to predict what person would respond best to what type of diet. Would it be a higher carb or a lower carb diet. So genes, a little bit different than microbiota mapping, but essentially, you know, one of the best analyses we have to look at this found that genetic testing to predict who would respond better to a higher carb or lower carb diet found essentially no correlation.
And, you know, so the point I’m making is, and you’re making is, just because we have information doesn’t mean that information can help you inform decision making any better than you would otherwise. In fact, if that data can’t inform your decision making any better, but it’s causing you not to listen to your body’s own response, it will in effect make you less effective in figuring out what works well for your body.
And I also talk about this in the book. There’s a couple different dietary maneuvers one can make to figure out what diet fits best for the microbiota. And it takes you about two to three weeks each diet to figure it out. So by the time you did a test and got the results back you can be halfway there or even all the way there if you happen to do the first diet, or the first diet that you did was the best one for you, to figuring out what works well for your gut, sans the $300-700 bill that you would test for, what the testing would cost you. And also so much on top of that, there are things that we know exists or exist that can’t be readily tested.
Small intestinal fungal overgrowth is one example of this. Now we know about small intestinal bacterial overgrowth or SIBO that’s fairly easy to test.
We also know that small intestinal fungal overgrowth may affect this same subset of patients who have digestive symptoms. Yet we can’t test for it routinely. The only way to test for is really to do an endoscopy and take a biopsy of fluid in the small intestine, which is very invasive and therefore, it’s hardly ever done. So someone could do a SIBO test, come back positive for SIBO and then craft their entire worldview, their entire treatment plan around the fact they have SIBO. Yet they’re missing the fact that perhaps they have small intestinal fungal overgrowth and perhaps are also hypersensitive to gas pressure. And so they’re making all these decisions based upon one slice, or you can think of it like maybe one eighth of data relevant to their gut. And so this is why unfortunately, I see so many people who are following the dictums of the diagnosis that they have, but they’re not listening to their body.
And just really quick here, one patient had SIBO in my clinic, she also had some problems with blood sugar regulation and she asked me, “Oh, Dr. Ruscio, will I ever be able eat fruit again?” And I said, “Well, you know, why, can’t you eat fruit?” She said, “Well, I have SIBO.” And I said, “Oh, okay, so is there something regarding fruit and SIBO that I am not aware of?” She goes, “Well, I’ve read that if you have SIBO you really shouldn’t have fruit, you can never really have fruit, it will feed the SIBO.” And I said, “Okay.” So I chose not to get into that. And I said, “How do you feel when you eat fruit?” She was, “Oh, I feel fantastic.” So yeah, and these things happen more often than you might think. So again, I don’t want to be overly critical on testing, but it’s important to not use testing that hasn’t been validated at the expense of listening to your body. Because you’d be amazed at how far you can get by kind of running through a well crafted algorithm for your gut health, listening to your response and then using your response to inform what you should do.
How gut health relates to energy
Ari Whitten: Yeah, absolutely. So we’ve kind of gone specific down this particular path. I want to go broad real quick and just assume that some people listening don’t necessarily already have a lot of familiarity with gut health and how it relates to overall health or energy levels. There’s obviously a lot of research here and I’m kind of tasking you with summing up this broad landscape with just a few sentences. But, you know, there’s obviously research related to chronic fatigue syndrome, showing gut permeability and lipopolysaccharide antibodies and you know, things related to brain health and you know, all sorts of different systems of the body.
And the more, you know, as this goes on in the coming years, we’re going to find, I’m sure, even way more links than we are currently aware of. But can you kind of just talk about the broad landscape of why gut health is important, and then from there, maybe what are some of the biggest factors or the biggest kinds of gut problems that are emerging in the world today?
Dr. Michael Ruscio: Sure. No, it’s a great question. And you know, maybe a way to kind of provide a philosophical framework to help people navigate the end, take-home, actionable and not get lost in the details that justify the actionable. I would say if you’ve taken some preliminary steps to improve your diet and your lifestyle and you’re still not feeling well, the next thing I would consider is going through a process that helps to improve and optimize your gut health.
And the reason I say that is because you can have a non digestive symptom that is being solely driven by a digestive problem. So you could have joint pain and insomnia, and those are the only symptoms that you have, and the problem could be emanating from your gut. And the gut symptoms could be silent, right? So this is why I don’t want to frame it around, well you’ve got to have gas, bloating, constipation, diarrhea, abdominal pain, reflux, in order for this stuff to be relevant, right?
So that’s a really important piece that we need to slide into place, which is you could have non digestive symptoms that are manifesting from a silent digestive problem. Therefore, look at this in terms of a hierarchy or a sequence. Now what do we know? Well, we know, for example, that, as you alluded to earlier, chronic fatigue syndrome has been shown in one study to respond to a low FODMAP diet. Those with IBS, in another exciting recent study have shown, so IBS is essentially gas, bloating, abdominal pain, and an alteration in bowel frequency, either constipation, diarrhea, or an oscillation between the two. And IBS subjects were shown to have higher scores of fatigue, depression and anxiety. So there is kind of your gut metabolism/gut brain connection and there’s also been, I believe, two meta-analyses, which are summaries of several clinical trials, with probiotics, which is of course a gut treatment, shown the ability to be efficacious for anxiety and depression.
There’s also preliminary evidence showing that either treatment of H pylori, which is a bacterium in the stomach, or a low FODMAP diet, essentially a Paleo type low FODMAP diet, can improve thyroid autoimmunity and lower thyroid antibodies to a significant degree. Other research has found correlations between small intestinal bacterial overgrowth and thyroid autoimmunity and also between small intestinal bacterial overgrowth and hypothyroidism.
Other treatment data shows the ability to improve either rosacea, so skin atopic dermatitis, or restless leg syndrome or, yeah, okay, I got them all, all via the different methods of gut treatment. So we see gut-brain, we see gut-thyroid, we see gut-skin, we see gut-joint. You know, it’s really remarkable the connections. Also, other preliminary evidence is showing the connection between metabolism, specifically I’m meaning blood glucose and cholesterol levels and weight correlate to small intestinal bacteria overgrowth and preliminary data show improvements in cholesterol and blood sugar.
And I’ve seen anecdotally reductions in weight, sometimes marked reductions in weight, but not always, after treating small intestinal bacteria overgrowth. And some preliminary evidence correlating, correlating not showing treatment outcome yet, but heart disease, cardiovascular disease to small intestinal bacterial overgrowth. So there’s a tremendous amount here and it can be very hard to say, “Well, these specific symptoms mean that I should improve my gut health.” Which is why I come back to the sequence of first, cover the basics. Then if you’re not feeling well and you’re thinking “is it the thyroid, is it heavy metals, is it toxins, is it lyme, is it mold?” The next thing I recommend you do is look into optimizing your gut health.
The most common gut problems today
Ari Whitten: Okay. Excellent. So what are the specific conditions? I know you’ve obviously mentioned a couple of them in passing, or a few of them in passing here. But what are, can you just kind of list off some of the most common gut problems that exists today?
Dr. Michael Ruscio: Sure. Well we can think of these in constellations of symptoms that are labeled as conditions, or we can think of them as symptoms and I’ll kind of tackle this from both ends. And then I do want to get back to the other part of your question which is what are some of the more effective treatments that people can get started with in optimizing their gut health. But we have IBS, and IBS is oftentimes encapsulated by abdominal pain, bloating, and then altered bowel function. So this can be diarrhea, constipation, or an oscillation between the two. Now there’s also what’s known as dyspepsia or indigestion, and this may involve stomach or kind of sternal area epigastric discomfort, burning, or belching or reflux. There’s also inflammatory bowel disease.
The two most common subsets are your ulcerative colitis and your Crohn’s. Although there are other subsets and the symptoms here have a lot of overlap with IBS, but the underlying cause is different. And so in inflammatory bowel disease or IBD, or also Crohn’s, you oftentimes have a diarrhea presentation. Diarrhea is much, much more common than the small subset that can have constipation. So we have diarrhea, sometimes bloody diarrhea, sometimes as many as 12 bowel movements a day, and they may not all be diarrhea, they may just be frequent loose bowels. There may be urgent bowel and there also may be abdominal pain. But we also know that IBD can also manifest as skin conditions also in there, especially with Crohn’s disease. There’s some skin conditions that can manifest as part of this. And then you also have things like gastritis and ulcers which are irritation to the lining of the stomach.
And this is where I think oftentimes, especially with with gastritis and ulcers, natural medicine actually does a disservice to people because natural medicine is so gung-ho to give supplemental acid, betaine HCl. Yet, oftentimes I find that those conditions do not need any more acid, and in fact, there’s something going on in one’s body immunologically that is causing a high level of acid. And I know that’s considered blasphemous in natural medicine, but it’s really what the data show, if you look at it objectively. So those are just a few of the more common things that people may be grappling with from a digestive perspective. But don’t forget that you could have active inflammation and damage in your gut that’s only manifesting in your joints, in your brain, in your skin, whereever.
What science says about SIBO (Small Intestinal Bacterial Overgrowth)
Ari Whitten: Excellent. I want to digress on one point if you don’t mind. There’s a point of contention around SIBO. One of my good friends, Dr. Alan Christianson has written a long article, which I know you’ve read, that basically is his attempt at debunking the whole concept of SIBO as a legitimate condition. And there’s a lot of layers to this. And kind of how he’s analyzed the evidence around, you know, the studies testing, is there really too many bacteria in the small intestine, the hydrogen breath tests comparing, you know, normal, healthy people without gut symptoms versus those with IBS symptoms and most studies failing to differentiate based on the amount of hydrogen gas. And there’s a number of other layers to this. But, I know obviously as you mentioned, you still believe in SIBO. So what is your general take on that situation?
Dr. Michael Ruscio: That’s a great question. So, you know, I don’t think we need to get into a debate of does SIBO exists or does it not exist. I think, you know, what we should do is look at the totality of evidence and then look where the data points, and always be open to updating our opinion.
And when you do that, you know, it’s fairly clear that small intestinal bacteria overgrowth is a legitimate condition. You know, are there areas that need to be updated? I do think so. And I do think Christianson made a few valid criticisms in his article. And mainly these stem around this kind of SIBO monoculture that seems to be budding, where people are just obsessed with SIBO at the exclusion and expense of anything else in the gut. And also they’re in this same mental framework. There does seem to be a lot of unnecessary fear. And I don’t think any of that is intentionally propagated. I think it’s just you have people who write and speak on SIBO, and sometimes we forget that we have to contextualize data points so as to not allow the consumer to run to the worst possible interpretation of those data points.
But you know, I think there’s certainly enough evidence to show that SIBO is a condition. This is likely why the arguably two largest bodies in gastroenterology in the entire world, the Rome Foundation and the North American Expert Consensus have both essentially issued guidelines for how to test SIBO and when to test SIBO and how to treat it. Now that falls, those two major bodies’ opinions do fall counter too much of what the SIBO community recommends. The SIBO community is probably a bit overzealous relative to that. And there are some imperfections with the testing, you know? Yes. But it’s one thing to say here’s something that is helpful, but it’s not perfect and there are some areas that need to be rectified. It’s another thing to say because of those few areas that need to be rectified, we’re going to throw the entire baby out with the bath water.
So, you know, I mean there’s so much that we can go into here. SIBO breath testing has been shown to be validated, at least the concept of showing dysbiosis. Whether that bacterial dysbiosis is the exact pattern of small intestinal bacterial overgrowth, I don’t think we can fully say that from the data because there’s been some changes in the interpretation criteria for how you diagnose SIBO. So I believe this is why the one meta-analysis commenting on this, again, very high level scientific data, did show that this… there’s a small intestinal or there’s a dysbiosis that’s more common and that may be elucidated by breath testing in patients with IBS. Is it the exact pattern of SIBO? In that I don’t think we can still fully say and some of this wraps even further into the controversy of SIBO, which is the time interval is important and you can see false positives, meaning the test says you have SIBO, but you actually don’t if you’re not interpreting in a narrow enough time window.
And this is an accurate criticism and this is why these two bodies that I outlined a moment ago are now endorsing a shorter time interval so as to guard against these false positives. We also look at, the overall trend does show that small intestinal bacterial overgrowth does seem to be significantly more common in those with IBS, but you can be perfectly healthy and test positive for SIBO. And this is where sometimes people have a hard time with the nuance. If we were to look at 100 people who are normal and 100 people who have IBS, we’d probably see maybe, just giving, you know, rough approximations, about four percent of those healthy subjects have SIBO and about 40 percent of those healthy subjects, I’m sorry, 40 percent of the subjects with IBS have SIBO. So you know, if you’re looking for this test as 100 percent accurate all the time, then you’re not going to find that. But that’s not really, that’s very infrequently found in healthcare. So we do see a trend showing that if you have the symptoms of IBS, you are more likely by a significant margin to have small intestinal bacterial overgrowth.
There’s also data, which in my mind is more important and more compelling, showing that when you look at a SIBO breath test and then you treat someone for the SIBO and then you retest, the values tend to trend in a correlating direction that correspond with someone’s improvement. So the worse the test results, the worse someone’s symptoms, you treat them, the better their symptoms get, the better the results become. In spite of all of that, I still don’t recommend serial retesting of SIBO, every time someone is treated to retest to guide treatment. I think that is an area, I don’t know if Christianson essentially made that criticism per se…
Ari Whitten: He did. Yeah. He said there’s huge lack of consistency in the results of the hydrogen breath tests.
Dr. Michael Ruscio: Right. And, I don’t know if we could say there’s huge lack of consistency in the results. I do think there’s enough consistency to show significant positives in a IBS population compared to a control population. But I think one of the comments he made was SIBO testing was over performed and I would agree. And I cite in my review article that the Rome consensus recommends very conservative testing and the North American consensus recommends somewhat more liberal testing. And kind of in the middle of those two was a systematic review published essentially saying that if you have someone with otherwise non-responsive symptoms, consider testing them to identify if SIBO is an issue. And then from there, treat empirically meaning treat based upon someone’s symptomatic response. And that’s essentially what I advocate. So it means we can use the testing to partially inform what we’re doing. But are we going to hang our hat fully on the testing, be overly literal with how we interpret the testing, and inculcate you into thinking that if you have SIBO you have some incurable condition and shroud this in fear? You know, all of those things I would disagree with and I think those were some of the criticisms that Christianson made. … And I don’t like being overly critical, but I think this is important because he made very strong definitive conclusions. And as I said earlier, be wary of someone who makes strong definitive conclusions because they are oftentimes unaware of the nuance in a body of literature. And so if you wanted to write an article…
Ari Whitten: I’ll just mention one thing just to be fair. He’s not saying these symptoms don’t exist, this cluster of symptoms doesn’t exist. The main critique is there’s basically lots of evidence pointing to the, in his opinion, that contradict the notion that it is specifically small intestinal bacterial overgrowth that’s responsible for those symptoms as opposed to let’s say just dysbiosis. And that the testing for detecting small intestinal bacterial overgrowth is not effective in accurately differentiating people with these symptoms versus those without. So, but you know I will leave it at that. I think ideally I would get you guys both on and you guys could debate back and forth for an hour on this subject, but since we’re limited in time here I think we will…
Dr. Michael Ruscio: Let me just say one more thing. In his article and in his video, he made very absolute statements and those absolute statements were untenable. There is not conclusive data to support his statements. Now I would have zero issue if anyone wanted to write an article criticizing something and using cautious language. You know, there’s some unanswered questions here. There are some contradictory data points that we need to explore. Fine. I have no quarrel with that at all and it’s very healthy. But his language was very absolute and very definitive and I think it was very misleading. And, I, you know, I’m happy to have a further conversation with him at any point. …
Ari Whitten: Okay. So yeah, I think also it’s worth mentioning on this subject that he has written an article, it’s publicly available. You’ve also written a rebuttal article that is also publicly available. So I would encourage everybody listening to read both reviews of the evidence and you can see Dr. Ruscio’s direct responses to Dr. Christianson’s statements in the article. So I think it’s worth exploring that for people listening. And again, ideally, it would be great to have you guys both on for an hour and talk back and forth directly. Dr. Ruscio, how much more time do you have, because I know you might have a hard cut off coming up here. There’s a bunch more topics I want to cover, but I want to narrow it down if you’re real short on time.
Dr. Michael Ruscio: I can roll for another 10.
What science says about non-celiac gluten sensitivity and gut health
Ari Whitten: Okay, perfect. So we have all these different gut problems that are emerging, gut dysbiosis, permeability, IBS, IBD, SIBO, SIFO, small intestinal fungal overgrowth. I’m curious what your thoughts are on non-celiac gluten sensitivity
Dr. Michael Ruscio: So, you know, in keeping with the theme we just transitioned out of, I think I’ve been one of the more active critics against this overzealous conclusion that’s kind of, you know, potentiated on the Internet that everyone has to avoid gluten. I think that’s harmful and I don’t think the evidence supports that. And there was recently a study published, a multicenter trial in Italy that looked at 12,225 patients. And this was a group of physicians who were really trying to better understand non celiac gluten sensitivity. And just for the audience that means that you don’t have celiac but you feel essentially you have a problem with gluten. And they devised a 60 point assessment looking at lab markers, subjective findings, objective findings, and they were trying to figure out what signs and symptoms and history and lab markers all kind of correlated into this syndrome of non celiac gluten sensitivity.
And they found some, they shouldn’t really be surprising, but I guess they’re surprising relative to the current ethos that exists regarding gluten sensitivity. And essentially what they found was about three percent of the population was found to be non celiac gluten sensitive. So this is both a good and a bad thing, right? If you’re overzealous about gluten free, then this probably comes off as a bad thing. I would say this is actually a good thing. This gives us some very high level support that yes, there are people without celiac who do have a documentable problem with gluten. And it also hopefully should be reassuring that that’s not the majority of the population. So we don’t have to be making these blanket statements that because gluten is bad for some, it’s bad for all. It’s like saying if you have type two diabetes, you have to be very careful with your blood sugar.
But if you have a blood sugar of 103, which is very, I would say it’s essentially normal, but it’s three points over the cutoff. If you have a blood sugar of 103, you have to be eating the same way as end stage type two diabetic. That’s kind of the conflation that’s made and that can be harmful for people. Now there’s some immediate rebukes that come up when I share this, which is the US is going to have a different grain supply than Europe. And I think that’s a fair criticism. Now in the same paper, the authors cite data in the US showing various studies have found a incidence of .6-6% of non celiac gluten sensitivity in the US. And the glyphosate use may contribute to that, essentially a pesticide that is more commonly used here.
So we may have up to double the amount of this in the US than we do Europe, but that’s still six percent of the population. And even if that six percent is underreported, we couldn’t expect it to be much more than double that, just throwing out some reasonable inferences here. So even at the highest level of extrapolation, maybe we get to 12 percent. That is still very far away from what feels like a 80, 90 percent of recommendation of the population to avoid gluten kind of in the current integrative healthcare narrative. There’s one or two other points, but one I think is very salient, which is you know, often times you get the comment that well, you could be eating gluten and fueling this underlying inflammatory/autoimmune process that may not manifest symptomatically for weeks or months or years. And you know, okay, I’m open to this, but we have to be looking at the evidence to inform whether or not the hypothesis has any validity or not.
And in this study they found that over 90 percent of people who are non celiac gluten sensitive, so who had a reaction to gluten, notice that reaction within 24 hours. So what that tells you is that if you’re going to do a gluten elimination and reintroduction, you have an over 90 percent chance, at least according to this study, that if you have a problem with gluten, you will have a symptomatic reaction within 24 hours. Why this is helpful is because if someone is sitting there and saying, “Well, I’m not sure, I have a family history of x, y, or z, that’s autoimmune and I’m not sure if I should ever have any gluten.” It appears that when you perform your reintroduction, you have a very high probability that if you’re going to negatively react, you will react within 24 hours.
And so I think that’s freeing for people. It can help them make a better discernment as to whether or not they need to avoid gluten and it can help them live a less encumbered lifestyle. I still have no problem with eating gluten reduced. But there’s a difference, you know, it’s a long road to go from gluten reduced to fully gluten free and the psychosocial implications of going 100 percent gluten free are somewhat damaging. They are difficult. And so if we can spare someone from adhering to that who doesn’t need to, then I think that’s a real win.
Ari Whitten: Yeah, absolutely. So I know we only have a few minutes left. Can you kind of get real practical here and kind of give an overview of what the steps of your approach to healing the gut look like?
Dr. Michael Ruscio: Sure.
Ari Whitten: Yeah, go for it. I’ll let you take it from here.
Dr. Michael Ruscio: So in the book, we essentially go through, you know, many of these different things. You know, carbs and gluten and food allergens and also probiotics and microbial earth and specialty diets and dysbiosis and prokinetics and fiber and what have you. And then at the end, if you really understand this stuff, you can portray it into an algorithm, meaning step one, do this. And if you feel great, then you kind of go to this maintenance finishing track. And if you’re not feeling great, you can escalate and then go to step two. And at step two, you feel great, you’re kind of done and you can go to your maintenance track. Or if not, you can escalate to step three. And so that’s essentially what I write in the book. But step one is really diet and lifestyle. And the real on boarding point for people to try to figure out what diet is best for them involves one meal frequency.
Some people do better with frequent meals, other people do better with intermittent fasting. I don’t think we can say everyone should do one or the other, but rather we can listen to one’s system to determine what their ideal meal frequency should be. But probably more unique to just gut health would be do you want to start your diet in the direction of kind of a Paleo diet, which is essentially an anti-inflammatory diet that reduces common allergens? That’s one track you can go down. The other would be do you need to reduce fermentable substrates in your diet? And this is known as the low FODMAP diet. Because for some people they may have too much bacteria in the small intestine and in the gut generally. Or they may have an immune system or pain receptors that are hypersensitive to gases and/or bacteria that are fed by high FODMAP foods. Therefore, they may feel better by going on a low FODMAP diet.
There’s a couple other nuances, but in terms of what is the initial divergent point, it’s trying to assess if someone’s unique gut does better on a Paleo diet or a low FODMAP type diet. And the good news is you only need about two to three weeks to discern if one of these is helping you and if one is, you ride out that wave until you plateau and then reevaluate. And if it’s not, then you move on to the other diets. So it’s not hard to, at least kind of peg the initial diet stroke. After that, there’s a succession of steps. But one of the next things we recommend people consider is probiotics. And there’s confusion regarding probiotics, which is really unfortunate. But just to say this somewhat succinctly, you can take every probiotic product out there and categorize it into one of three types. And category one is a lactobacillus/bifidobacterium blend.
Category two is essentially healthy fungus, saccharomyces Boulardii. And category three are your soil based or spore forming probiotics which oftentimes have bacillus, different types of bacillus species in them. And why this is important is because some people do well on one probiotic, some people don’t do well on another type of probiotic and some people do well on all three. And if, let’s say you take a category one probiotic and you react negatively, but you didn’t realize it was a category one probiotic, right? It was called, you know, Gut Saver Ten, or whatever. And it has 10 strains, and then, oh, you get bloated. So then you hear about this other one, you know, you see it on TV or whatever and you try that and it’s called, you know, Gut Restore Five. But you don’t realize that you keep trying the same category of probiotic and that’s where you’re having this repeat negative reaction.
Once you come to that realization, you can say, “Okay, the lactobacillus and bifido bacterium strain blends, category one, don’t work well for my system. I’m not going to use them anymore, but I am going to try a category two and category three and see which one of those works for me.” Retain that one, use one of the others, and then kind of keep working through the steps that we lay out in the book.
How to use your body’s signals and diet to restore gut health
Ari Whitten: Excellent. I have one last question for you, which is on this subject of kind of getting positive feedback based on interventions or dietary changes that you do. There seems to me to be one potential big pitfall there which is sometimes people are highly reactive to all kinds of things and end up on increasingly more extreme and restrictive diets that ultimately end up being extremely unhealthy and deficient in lots of different nutrients. And they get there as a result of sort of just listening to their body. How can you listen to your body while avoiding that pitfall?
Dr. Michael Ruscio: It’s a great question and there have been two studies that have looked at this and I’ll give you kind of the brief summary. That one study in Italy found that perhaps as much as 30 percent of people with non celiac gluten sensitivity actually had another underlying problem in the gut that was manifesting their symptoms. Now that’s just an observation of an association. We then have to prove that you can actually treat that and see an effect. Another study, and there’s been a number like this published, looked at I believe it was 15 patients who were celiac, went gluten free and didn’t improve. And essentially they found that two of these patients were intolerant to lactose, one had a roundworm infection, one had Blastocystis hominis, and then the other 10 had small intestinal bacteria overgrowth, and one kind of dropped out which accounts for that last remainder.
But the point is after the subjects were treated for small intestinal bacterial overgrowth or the other two infections, they all responded and they all overcame their symptoms. So if diet doesn’t work, and I directly address this in the book, we don’t want to try to force the non dietary problem, or I’m sorry, we don’t want to try to force a dietary solution to a non dietary problem. So if the diet doesn’t get you to a point where you’re feeling better and then you can eventually broaden your diet to the broadest diet possible, there’s probably something else going on in the gut that needs to be remedied. Because the goal is to not have you on a restrictive diet forever.
Use the short term to heal and also gather awareness to what a couple of your true food intolerances might be, but we should ultimately get you to a point where you’re feeling better, you’re able to expand your diet, still feeling better, and worse case scenario, you only have a handful of foods that are problematic for you and you can generally eat a much broader diet with a much more resilient gut. It’s an excellent point.
Ari Whitten: Excellent. Thank you so much Dr. Ruscio and I appreciate you going a little overtime here with me. I have like 10 more points on my list of things I wanted to ask you about but I guess we’re not getting to those. So where can people find out more about your work and obviously they can get your book “Healthy Gut, Healthy You “on Amazon. And where can people find out more about your work and follow you?
Dr. Michael Ruscio: As you said, the book’s available on Amazon and it is “Healthy Gut, Health You.” And then pretty much everything else I do you can plug in through the website which is drruscio.com, d-r-r-u-s-c-i-o.com. We have a weekly podcast, a weekly video, weekly article. And also, if you’re a healthcare provider, we publish a monthly newsletter that’s subscription access only where we go through case studies, research summaries, and we take all this stuff that we’ve talked about and we kind of look under the hood from the clinician end. Meaning, you know, this is what the research is showing, this is how we apply it in the clinic, here as a test not to run, here is a test to run. And yeah, I think that, I mean that’s the lion’s share of it. It keeps me pretty busy.
Ari Whitten: Excellent. Well thank you again Dr. Ruscio. It was a pleasure doing this with you and I hope to do it again.
Dr. Michael Ruscio: Been great. Would love to. Thank you.
Ari Whitten: Yeah.
How to Heal Your Gut and The Keys To Restore Gut Health with Dr. Michael Ruscio – Show Notes
Why testing isn’t a valid marker when you want to restore gut health (13:15)
Why there isn’t one specific ”gut health diet” (18:45)
How gut health relates to energy (24:06)
The most common gut problems today (29:11)
What science says about SIBO (Small Intestinal Bacterial Overgrowth) (32:00)
What science says about non celiac gluten sensitivity and gut health (42:30)
How to use your body’s signals and diet to restore gut health (47:39)
Get Chris’ book, Healthy Gut, Healthy You on Amazon
Dr. Alan Christianson’s article on SIBO is found here
Dr. Ruscio’s article on SIBO is found here