Written by Christopher Kelly
July 16, 2015
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Christopher: Hello and welcome to the Nourish Balance Thrive podcast. My name is Christopher Kelly. Today, I'm joined by a functional medicine practitioner, Dr. Ruscio. Hi, Michael.
Michael: Hi, Chris. Thanks for having.
Christopher: Thank you. I'm so pleased to have you on. I'm really excited. I've been really enjoying your new podcast which is absolutely fantastic. I've listened to all of them, actually. How many is there now? There are about 11 of them.
Michael: Oh, gosh. Let me look at my screen here. I think we are 14-15. We've been cranking them up pretty good.
Christopher: If you enjoy the denser, more technical podcast, I think you'll really enjoy this. There's very little fluff, shall we say, little padding. It's very dense, straight to the point. I've been really enjoying that. Check those out. I'll link to that in the show notes. How did you get into functional medicine in the first place? Because I think that's a really interesting story.
Michael: Sure. I'll give you the really kind of short version of this because there's a lot on the topic of the microbiota that I want to talk about. So I'll give you the Reader's Digest version. Essentially I was in college. I played lacrosse in college. I was also premed at the time, wanted to go to conventional medicine. Midway through my college career I went from feeling pretty darn invincible, having a ton of energy and drive and focus, to having really bad insomnia, bouts of depression, feeling cold, tired, fatigue, irritable, losing some weights.
It turns out I had intestinal parasite. I had an amoeba infection. It was missed by my three conventional doctors. It wasn't until I actually saw a functional medicine provider that we figured that out. I was able to treat that amoeba. That was a big eye-opener for me. It thought me the importance of gut health, gastrointestinal health because I thought I was suffering from all these other things. I thought I had depression, hypothyroid, low testosterone, and all these other things. It was really just an underlying intestinal infection.
So I changed gears from going to more of a conventional practice into functional medicine. That's what I do now. I spend half of my time in clinical practice and my other half of my time in clinical research and in writing.
Christopher: Interesting. Well, that's actually one of the questions I wanted to ask you. I thought you'd be a fantastic guy to get onto the podcast because you obviously do so much research. One of the places I've been listening to you is on Robb Wolf's podcast. It seems like you've been in cardboard somewhere for six months doing tons of research. So you break out and say, "Okay. I'm ready, Rob. Let's talk about this stuff now before I forget about it."
I was there for your presentation at AHS last autumn which is on the microbiota which is fascinating. That's on YouTube. I will link to that too. You already mentioned the amoeba which kind of brings us into the gut. So tell me about the types of testing that you do and when you do them.
Michael: There are really a lot of different tests that one can do. It depends on what the patient presents with, what the patient has done prior, and what you're suspecting as a clinician. Much of my focus is on gastroenterology, on the gut. We routinely will use a breath test for small intestinal bacterial overgrowth. We use stool, breath, blood and urine testing through both conventional labs like LabCorp and Quest, and also through some more specialty labs like Doctor's Data and BioHealth to do more routine parasitology looking for amoebas, parasite, worms, toxoplasmosis, yersinia, H. pylori, candida. That can be very helpful. That's a very helpful frontline screening.
There's also secondary screenings that we can look at for things like inflammatory bowel disease which can, in some people in this community, really be the underlying cause of chronic low-level digestive stuff, if you will, is a really successfully managed case of inflammatory bowel disease that hasn't gotten bad enough to elicit the appropriate investigation. So there are some preliminary screenings we can run for that. Of course, we do more standard blood work like a thyroid panel and liver and kidney panel, iron panel, screening for anemia, things like that, but that's some of the more typical blood work or lab work that we run.
Christopher: So you don't just run the GI testing on everyone then. You see how each person presents.
Michael: I think it's a really important point regarding functional medicine. I love functional medicine, don't get me wrong, but I've seen it wonder into this testing intensive place. This makes it very wasteful and very cost prohibitive for a lot of people, and it doesn't have to be.
[0:05:04]
I love the old adage that he who is the best can do the most with the least. So a truly astute clinician will be able to get to the problem more quickly, and they won't need to order $6,000 worth of lab work. Sometimes you do have to order an in-depth lab work if it's a very challenging case, but a lot of times there's a lot of lab work that doesn't need to done right out of the gate. Yes, I'm a big believer in having some more of an algorithm that you work patients through so as to maximize efficiency and to minimize cost.
Christopher: We're going to talk about the microbiota today. We should probably define that term before we go any further. So this is the collection of microbes that live in your gut. You've given one example. Mine was the same, actually, where I had a disturbance in the microbiota that was causing a ton of problems downstream. Low testosterone, as you mentioned, was also something I was suffering from. So how do you know then if it's worth investigating your microbiota?
Michael: I think maybe we should define some terms here because I think we're oftentimes using terms a little loosely. It may be helpful to redefine or define what I think is a more appropriate way to use some of this nomenclature. The microbiota, I think of that as the world of hundreds and hundreds of species of bacteria that live in your gut. That will be the microbiota. I think that's a bit different and distinct from what we would do in more routine gut infection testing, testing for things like parasites, amoebas, small intestinal bacterial overgrowth, H. pylori. Sometimes they get overlapped.
Someone says "I have H. pylori, so I'm treating my microbiota." I guess you are but I think it's really a bit misleading. You're really removing an infection that shouldn't be there, and you're not really treating your microbiota, so to speak. You're just kind of getting a nasty bugger out of there and letting the ecosystem go back to its equilibrium. I think it's really important point because, as I'm going to probably harp on in this podcast, there's a lot of bad information or misinformation being circulated about the microbiota. I want to try to help set the record straight for people and maybe to zoom way out and give it what is this, why should you care.
The microbiota, as you mentioned, is the world of bacteria that live in your gut, but not only in your gut, but also on your skin, your lungs, your genital tract, your mouth. So we're essentially covered in bacteria. This is an area we're coming to learn more and more about. It's a very hot area of research right now. So there's potential here to uncover some novel tests and some novel treatments to help people become healthier. So that's part of the reason why you should care.
Also, oftentimes when something becomes very popular and there's a lot of interest, we have people who maybe get overly excited and overly speculate. This can get people false hope. It can cause people to waste money on testing that's not validated or undergo treatments that are not validated and simply won't work. That's the other reason why people should care because I think right now we're at a point where there's probably as much or greater information circulating of what not to do as there is what to do.
Unfortunately, a lot of the research I've been doing is highlighting what not to do for people because there's been so much speculation in this area. Really read the science as I do, and you fact check the science. And then you read a blog or see a video, you see some people totally miss representing what the science actually says. I think people aren't doing this with ill intent. People are excited about it and they want to share it. Sometimes you can be honest but you can be honestly wrong, so to speak. I think that's happening quite a bit.
Christopher: Okay. So we even got the definition of the term microbiota wrong. So you don't include any of the bugs that shouldn't be there. So, really, the microbiota to you is the collection of microbes that should be there and none of the ones that shouldn't.
Michael: When someone has H. pylori, for example, I don't think it's really accurate. This is more of my opinion, to be clear. This is more of my opinion but it's based upon what we've seen in the research. When we do a microbiota test, we're looking at immense number of bacteria. When we do a routine parasitology panel and find H. pylori and treat that, we're treating one organism.
So yes, that organism has an effect on microbiota but I don't really see that as a true microbiota treatment.
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I think what's happened is it's being called a microbiota treatment because it's in vogue right now, but I think it's more truly, in that case of removing H. pylori, that's just removing a pathogen. It's not really treating your microbiota. Maybe it brings up a good point which is optimization versus manipulation. There's a lot of support I can use it to back this up but we really don't know how to manipulate our microbiota. Manipulate means to specifically rearrange things. I want this higher. I want that lower. I'm going to just specifically adjust. You really can't manipulate. I would really take anyone to task who says that we can.
But we can optimize. Optimize means providing the ideal environment for optimal expression. So we can optimize but we can't manipulate. What that kind comes back to is we do a microbiota test where we get maybe like a uBiome or American Gut analysis. We really can't manipulate those numbers into a more favorable position. We can do things to optimize the environment in which the microbiota is present to allow optimal expression, but we really can't manipulate.
Christopher: Okay. That's interesting. Do you think those are the best tests at the moment then if you wanted to find out what your microbiota, what it consisted of?
Michael: That brings up another important distinction which is what are you hoping to achieve from the test. If you're someone with some sort of illness and you're hoping to gather actionable treatment data from a microbiota test like a uBiome or American Gut, I would say you're going to achieve or receive no clinically relevant actionable information from that because we just don't have a great enough understanding to be able to do that.
I also want to say if you want to participate in that for research purposes so we can learn okay, here's someone with chronic GERD, and they've done a uBiome test, and we're going to collect data on these patients to hopefully establish a trend to hopefully establish a treatment, then great. By all means, participate. But if you're someone listening to this and you're not feeling well and you're thinking that doing this test is going to give you actionable treatment data, I would say that it's not going to give you that, and there's a there's a very large amount of science that supports that.
I don't know how deep you want to go so let me know how much you'd like me to expand upon these things. One example comes from a Korean study where they repeated a baseline a month later and then a month later, a microbiota analysis. And they found that the phylum balance, so the firmicutes and bacteroidetes and some of this other phylum shifted wildly from month to month. It's been repeatedly observed that your microbiota is constantly influx.
So let's say you're to do a test, taking a common misconception in microbiota discussion. You come back with a high firmicutes and a low bacteroidetes. One might erroneously say that that's correlated with weight gain and obesity which it's been disproven or it's not really fully been brought out. You may then want to do some sort of dietary or prebiotic manipulation to try to change those ratios.
The thing that a lot of people don't understand and is left out of this narrative is if were to do nothing and test again in 30 days, you may see a complete inversion of those ratios to begin with. So if the values are always changing, how can you really treat it? It's like someone who comes in one day and they have high blood pressure and five days later they have low blood pressure. How could you possibly treat that person if their blood pressure is needing to go down when they first present, but five days later they need to bring it up? Does that make sense?
Christopher: It does, yeah. My wife, she's a food scientist. She has master's degree in dairy science, and spends a lot of time doing work in the lab. That's always been her comment. When she looks at the PCR stuff she's like, "How the hell did they know that? How do they know what they're even looking at?" It's funny you should mention that specifically because when I went through the testing myself personally -- I did the Genova 2105 test which is now defunct I believe.
Michael: Yes. I think I was one of the initial people that caught wind of that. I was on Robb Wolf's show. I was lucky. A friend of mine, Nik Hedberg, a brilliant doc, shot me a study that was done at Loyola before it was even published that really debunked the PCR for screening for infections.
Christopher: I remember reading that paper. I do remember reading that. The test was actually quite useful to me because it found a pinworm using, I believe, the PCR DNA analysis. I just don't know how else that would have showed up. I don't think it would have showed up on a BioHealth stool test, for example.
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Yeah. It was kind of interesting to see. They have this little thing that's labeled the adiposity index. I'm looking at it right. The firmicutes are right up there and the bacteroidetes are really low. I suppose that means I'm supposed to be fat. I know at the time when I did this test my fat percentage was probably like 2% or 3% or something ridiculous, really [0:15:31] [Indiscernible]. That's at least one example where it didn't really work.
Michael: Right. It's not to say that that testing couldn't ever work. What the researchers did was they took stool from healthy people, and they put parasites into the stool, and then they sent that to the lab. The number of infections they missed was remarkable. I think it was over 70% of infections they missed. So it's not to say they wouldn't ever catch one but they missed a tremendous amount. Also, you weren't really treating your "microbiota." According to my definition, you were removing something that shouldn't be there.
This hits on one of the fundamental challenges in this area, is that that belief that the firmicutes, bacteroidetes ratio was a predictor and potentially something we could treat for obesity and overweight came from early animal data. When further studies were done in humans, it was found not to be valid. In fact, I would say 60% of the evidence showed that that relationship had no correlation at all to obesity.
I've spoken about that before and I'm writing a series on that right now where I go through the maybe 12 to 15 human studies. I outlined this study did not support it, this study did not support it. Unfortunately, people are not always judicious in what they write or the recommendations they make, that sometimes includes labs. And then we end up in this weird quandary where we have a lab saying you're supposed to be overweight because 15 mice had this ratio and they were overweight. It's not really good science.
Christopher: Right. Yeah. It's not really good practice either when you're holding a result that says, "But this result says you should be skinny." Good luck. You're explaining that to the person you're trying to help when, clearly, it's not the case. Do you do uBiome or Am Gut or any -- I know that this Genova test has been replaced by the 2200 series which uses PCR DNA analysis. Do you use that as a tool in your practice?
Michael: I do run the Genova profile, and the main reason I run the Genova profile is because it's covered through a patient's insurance. I only run the 2205 which has the parasitology plus the microbiota analysis. But truth be told, their values for what dictates a low, high or normal reading on the microbiota results are somewhat arbitrarily determined based upon sampling of a hundred people who work at that company, and they use them --
Christopher: Is that where the levels came from? I didn't know that.
Michael: Yeah. Really, I have patients come in, maybe they've gotten that test from another doctor and they bring them into my office, and I say, "That really doesn't mean anything." For example, I'll run that test mainly for the parasitology. The microbiota analysis comes with it. It's interesting for me to look at. I've repeatedly seen someone come back normal with Methanobrevibacter smithii which is one of the methane-producing organisms that causes SIBO or small intestine bacterial overgrowth. They come back normal on that test but they come ragingly high on the breath test that we do.
I think Genova has got some good tests. I don't want to put them down but I also feel like people have the right to know. Maybe I'm shooting myself in the foot by sharing this but I have seen that lab missed parasites numerous times, so many that I'm even tracking it in a Excel sheet where I'll find infection on another lab like LabCorp, Quest, Doctor's Data, BioHealth, and it won't be positive on the Genova screening. I'm even thinking about writing that up into some sort of paper and maybe even having that published because it's fairly alarming to see how much is being missed.
Christopher: Yeah, I know. I had exactly the same experience. In our practice we were using that test for awhile. I probably run about 20 often. The parasitology piece found nothing. Maybe 60% or even 70% of the BioHealth test showed something like H. pylori or crypto or Giardia or something like that. I stopped running it.
The sales rep called us up the other day and described this thing called EasyPay which I would describe --
Michael: The insurance billing option.
Christopher: That is anything but easy.
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Michael: We took some time to really understand that. My staff is well trained on that. We have a short little snippet that we wrote up for patients to help them understand how that all works. So we have been using it. One of the main reasons why I've been using that test is because of that insurance billing option. I'm very thankful to Genova that they're able to offer that because it's nice to be able save a patient that several hundred dollars. It's just unfortunate that the quality result doesn't seem to be there. They have other tests that I like, but that one, I haven't really been impressed.
Christopher: Yeah, the same experience. Do you think there's a limitation there just because of where they're sampling? So you mentioned you're not seeing something on the stool test but maybe that's because the bacteria are not living somewhere where they can be detected and store. If you're worried about SIBO, then maybe you'd never see that bacteria in a stool test anyway. Do you think that's a possibility?
Michael: Yes. Certainly, it's good to have different windows. The SIBO breath test gives you a window more so into the small intestine. The small intestine is actually a very important player. So maybe another example that we can throw out there to highlight this is we share so much from the crowd that is super into modulating or manipulating or whatever you want to call it, of the microbiota. We hear so much from that crowd about the importance of prebiotics and resistant starch and the like. These things help feed bacterial growth.
However, there's really some compelling and concerning data showing that some, not all, but some patients with hypothyroid, even some patients with hyperthyroid, patients with celiac have increased bacterial diversity and small intestinal bacterial overgrowth. So much of the fanfare is we need to be more diverse. We need to be more diverse. We need more bacteria. But a lot of this comes from us going and studying third world and indigenous people. We can't take an indigenous person's microbiota and try to shove that into us and expect a positive health outcome.
There are many examples of that. Not only what I just mentioned but also with Methanobrevibacter smithii, very well documented in human studies to correlate with small intestinal bacterial overgrowth that causes constipation. So this is a serious bug for westerners. I think every clinician out there can say that with SIBO, small intestinal bacterial overgrowth, the methanogens, methane bugs, Methanobrevibacter smithii, one of the most challenging bugs to treat.
Now, in Sub-Saharan Africa they have the highest level of colonization of Methanobrevibacter smithii. It's probably because they don't eat as much food as we do, and eat highly, highly fibrous foods. They actually benefit from the fact that this organism slows down digestion, thus giving them more time to break down their food, thus giving them more ability to extract calories from the food. So it works for them. It doesn't work for us.
I think we've seen the landscape. It's littered with this misguided -- I appreciate what people are going with it and wanting to try to uncover ways to help us get healthier, but we can't look at another completely different people's gut microbiota and say, "Well, they're healthy so we need to put that bacteria into us."
Another study compared African children from Burkina Faso to Italians. The study got a lot of attention. The African children were at a healthier weight and they had higher bacteroidetes. So everyone was like "Oh, my goodness. We need to eat more nonstarch polysaccharides and some of these carbs and grain and grain-like products because they eat a lot of those grains. They fed this bacterial colonization and they were healthy." Well, what's left out of that is they ate about half the amount of calories as the Italians did. They had to hand-grind all of their grains, and they got boatload more activity.
The logic in this is apparent but we can't look at the Africans, completely different people, and say "They have this bacterial balance. We need to mimic that" because, as I'm coming to understand it, what I'm starting to think is that the microbiota evolves with a person to help a person survive in the environment that they live in.
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It's a reaction to environment to a large extent and not something that we can just manipulate the way we want to and expect to have a positive health benefit for us because sometimes if we try to do that like with trying to feed some of these different bacterial populations we discussed, you may actually make someone worst.
That's why we do see in westerners, when westerners have high levels of that Methanobrevibacter smithii, that's correlated with high cholesterol levels, insulin resistance and obesity yet it serves the Africans well. So we have to be really careful with the recommendations we make. I do get frustrated watching people make these specific recommendations because in light of this evidence it's really, I think, irresponsible to do that.
Christopher: Okay. So do you think it's even relevant then to kind of pick out particular species as being good and bad or is even that kind of observation wrong?
Michael: I think that's exactly wrong. I really take issue with that. I appreciate the people who are working on this and trying to help people in the public get healthier, but that is a really questionable recommendation. I just listed a few reasons why that's erroneous because the bugs that work for other people don't seem to work for us because many of the bugs are constantly influx.
Another example, the Hadsa hunter-gatherers have no Bifidobacterium, yet that is one of the most helpful probiotic supplements that westerners take. The clinical trial evidence in probiotic supplementation in westerners has shown that that strain might be the most effective out of all the available probiotics for things like IBS.
I mean yeah, I think it really is very, very misguided to have these highly specific recommendations because when you look at the science and you look at the science objectively, you see it just doesn't work that way. I really believe the only way you can think it works that way is if you're really excited about it and you want it to work that way, and so you just look for data reinforces your opinion, and you know everything else. I hope I'm not being too heavy here, but I [0:27:38] [Indiscernible].
Christopher: No. To give some people some backgrounds, things that are shiny definitely appeal to me. The uBiome test, they allow you to export the data so that you can play with it. Reading some research and talking to other practitioners, they make some suggestions that some things are either present or missing from the data. Being computer scientist, it's very tempting for me to write a computer program that -- I can tell you how much Bifidobacterium is there or is not there. So what you're saying to that is it's not clinically useful at all then.
Michael: No. I really don't think clinically useful. I am certainly open to it. I mean I would love for it to be clinical useful. I follow this information hoping to find something that's going to be clinically relevant. But, really, the clinically relevant stuff is things like identifying infections and inflammatory disorders and treating those and aiding in gastrointestinal motility and potentially being able to sniff out some sort of abdominal adhesion or abdominal anatomical abnormality. These are the things that clinically really help people.
I was at the SIBO Symposium a few weeks ago at the National College of Natural Medicine that Alison Siebecker and her group puts on. You have some of the world's most celebrated gastroenterologists working in the movement of IBS and SIBO. I don't think once, any recommendation for microbiota testing or treatment came up in the whole weekend. I don't think in high level clinical circles you're seeing much discussed in the way of treatment.
If you read some of the best scientific papers you'll see things published like we do not know if the microbiota is a cause or an effect of obesity. I mean there's really not a whole lot of clinical stuff we can do there. I wish there was but with the microbiota, there's not treating infections, treating inflammatory disorders, fixing motility, fixing adhesions and structural problems, definitely. But saying your low in Faecalibacterium prausnitzii and we need more of it, there's not really any good data to support that. It's a little bit well-wishing.
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Christopher: Okay. Yeah, I know. I understand. When you run enough of these uBiomes on people and someone's made this observation that we're missing some important species Bifidobacterium, that's always true, they might have a huge diversity, massive. I've been generating these phylogenetic trees, these PDF diagrams that represent the microbes that are in the sample. There's a huge diversity there. Always, on the people that have done some sort of antimicrobial treatment, they're missing Bifidobacterium and [0:30:44] [Indiscernible] and some of these species that's been suggested to me are important. You don't see that same correlation then when you when you run the tests that people are just missing certain things all the time.
Michael: You make a great point which is we are still trying to piece together association. That is a far cry from treatment. That's one of the major mistakes that's made in this area of -- I shouldn't say research because I don't think most of the researchers are doing this. Just because we've seen association doesn't mean that treating an association is going to fix a problem.
There was a well-performed study done recently looking at patients with IBS correlating their microbiota to their symptoms. They did not find any correlation with microbiota populations or microbiota diversity in IBS symptomatology. Some of this, to zoom us way out, hinted the fact that when we take a microbiota sample, typically, we are looking at luminal colon, we are looking at the inside of the tube of the colon. We're not looking at the colon mucosa, we're not looking at the small intestinal lumen, the small intestinal mucosa, we're not looking at the oral cavity, we're not looking at the skin of the urogenital tract. These things do have an impact. In fact, there have been studies correlating the degree of periodontal disease, oral disease, directly correlate with the severity of rheumatoid arthritis.
So we're only looking at one of many windows with these microbiota analyses. We're missing a lot and we're also really missing the treatment data. People may be low on Bifidobacterium because they're avoiding dairy. When you avoid dairy your Bifidobacterium will go low. Many people who probably will find their way to a clinician who is doing this kind of work are probably experimenting with coming off dairy. So the low Bifidobacterium may not be the cause of anything. It may just be secondary to someone trying a gluten-free diet.
I don't know if that answers your question. Association and then saying we can treat it are two different things. I'm open to treatment but we haven't even pegged the association data. So I think we're very far away from treatment data. I mean you could have someone go on a Paleo type diet, treat them for any gut infection, use some probiotics and get miraculous results for them symptomatically. It's just a thing that we're going to custom-manipulate the microbiota to produce said health result. I think we're far away from being able to do that.
Christopher: It's going too far. Okay. So maybe we should concentrate then on providing more of a prescriptive. So imagine I'm an athlete, and maybe have a suspicion I might be overtrained, and I'm definitely experiencing a ton of bloating. I've noticed that sugar makes it worse. I've switched over to the Paleo Diet a couple of years ago, and that definitely helped but it's not really fixed my bloating. So obviously I suspect that the bacteria that live in my gut might be somehow involved. So where would you start with someone like that?
Michael: Definitely. That's an awesome question and I think that is hitting at what people are really looking for which is kind of like the bottom. What can I do?
Christopher: Exactly.
Michael: So what I would start with first, like you already said, just to reemphasize, I would definitely start with diet. Paleo is a great place to start. One or two other diets you may want to try for about three days to see if you improve, you can try the Autoimmune Paleo which is a little bit more restrictive than regular Paleo. You may also want to try the Low FODMAP Diet which is similar to Paleo but it's sort of a low prebiotic diet. It will help starve bacterial overgrowth if you have bacterial overgrowth. See if that helps.
Another one you may want to try is the Specific Carbohydrate Diet. Allison Siebecker put together a combination of Low FODMAP and the Specific Carbohydrate Diet. If you just type in Allison Siebecker Low FODMAP SCD you'll see that PDF. It's pretty widely available on the internet. That's what I'd start first.
[0:35:10]
If trying different dietary plans doesn't get you relief or even along with trying a diet, you may want to try a digestive enzyme support, something that has hydrochloric acid, pancreatic enzymes and bile. That will help if you have a little bit of digestive insufficiency. Along with that you may want to try a probiotic. There's a number of probiotics out there. I used a probiotic called Ther-Biotic Complete by Klaire Labs. It's a lactobacillus Bifidobacterium blend, very similar to another formation called VSL3. I would start there. Maybe also add in a soil-based probiotic. There are a couple of those available also. See if that helps.
If that doesn't fully resolve it, then there's a good likelihood that there's something there that shouldn't be there like SIBO, candida, H. pylori, yersinia. So I would get myself to a skilled clinician to have appropriate testing for that. That is sometimes really easier said than done. We talked about the Genova test. If you want to see a func med doc that is only running the Genova test, there's a good chance you'll be told "There's no infection. Let's move on to something else." So you've really got to vet the provider that you work with because it's easy to miss things in the gut. That would be my next step. It's a comprehensive screening for any kind of gut infection.
Maybe, lastly, after that or maybe even along with that, you may want to screen for inflammatory bowel disease because that's another condition that can cause similar symptoms to some kind of infection or as some kind of infection. That, if done appropriately, is going to work for the vast majority of cases. In going through that process, you will optimize your microbiota. You will optimize your microbiota because you will be putting your microbiota in the healthiest environment and, therefore, allowing optimal expression.
But I really don't think we can say we're going to custom-manipulate it but some things you can do to help improve or potentially improve your microbiota health, some other things that can be helpful in that regard or maybe some way that can kind of contextualize this for people because people are probably struggling with carbohydrates. Yes or no? If so, how much? And prebiotics. Yes or no? If so, how much? Because you hear information from the low carb camp and from the high carb camp, and they kind of see like these divisions starting to form. You also hear things about prebiotics.
I think the bottom line here is there is a spectrum. Some people will do better on the lower carb diet. Some people will do better on a moderate to higher carb diet. The same thing applies to prebiotics and prebiotic foods, things like FODMAP-rich foods. So I think the best way to sort this out is to go through an elimination and reintroduction. So do a carbohydrate elimination. Go lower carb for a little while, 100 grams or lower for a month or two. See how you feel. If you feel well, then slowly start to ramp up your carbs and see if you find a point where you start to feel less well, and that will be your carbohydrate threshold, and you probably don't want to go over that.
The same thing applies for prebiotics. As part of this process, you may want to go on a lower FODMAP diet for a little while. See if that improves. By the way, the Low FODMAP Diet has been very well-studied in IBS. If you improve, great. Stay on Low FODMAP Diet for a couple months, and then go through a FODMAP, prebiotic reintroduction. People will usually notice there's a couple FODMAP foods they don't seem to do well with, and a lot of others are fine with. This will help people figure out where they fall on the spectrum.
Don't be concerned about the noise you're hearing about the people in Africa eat a lot of grains. So you start eating more grains or more carbs. Don't worry about that. Just go through the process of finding your individual spot on the spectrums, the carb spectrum and the prebiotic spectrum.
Christopher: Okay. This is really solving the problem though. So say you have an overgrowth of bacterial in your small intestine, and reducing your carbohydrate, your prebiotic consumption improves that problem. Would it actually solve the issue or is it just going to come back as soon as you stop to change your behavior again?
[0:40:00]
Michael: With small intestinal bacterial overgrowth one of the underlying causes, as I think you're alluding to, is impaired motility where things don't move through the intestines quickly enough, for lack of a better term. When things are moving through the intestines quickly enough, you can have risk of overgrowth. So treating that motility can be important part of the process. That being said, if you follow the process as I've outlined it, you should allow your motility, to some extent, to improve.
So if it's a problem that someone can fix on their own, then going through that procedure will allow them to fix it on their own. If they got damaged motility to the extent where they need some kind of prokinetic agent, whether it be natural or pharmaceutical, they're probably going to want to have a clinician oversee that. We're actually setting up a randomized clinical trial in my office to start studying this very question or part of this very question.
So to your question, is it treating the cause, well, maybe. I mean it's hard to say because that cause, in particular, is repairable with time. So part of what we see with FODMAP avoidance is people's FODMAP tolerance, over time, improves probably because once they clean up their diet, remove any infections, and then practice a restrictive diet things repair. And as things repair you have more dietary flexibility in the future going forward. So yeah, I do think it kind of treats the cause but there are other fractions to this also.
There are certain gene polymorphisms like DECTIN-1 and CARD9 where people have an impaired ability to regulate fungus growth in the gut. These people are prone to fungal overgrowths. It's even been speculated that this may set the stage for the immune attack that occurs in inflammatory bowel disease. So some of these things may have to do a genetic variance where some people may have this variant. That variant may be helpful in some sort of environment like it's been suggested, I know Robb Wolf talks about this, that people with celiac have a much lower incidents of gut infections.
So people with celiac have a very strong gut immune system. Maybe when parasites were always all over the place when we were more hunter-gatherer type society this conferred a survival advantage. But now that that's not the case, that may give you a survival disadvantage. So sometimes we just have to find what works best for that individual person's genetics because we can't treat the genetics but we can treat the environment or modulate the environment energy that the genetics are presenting in.
Christopher: That does make sense. It was my experience too, actually. I can remember just a single strand of sauerkraut would make me blow up like a balloon, and then I wouldn't sleep that night just because I was so bloated, that kind of horrible trapped wind that's obviously farther up in your digestive tract. It's not just like commonly tooting. It was absolutely awful. Now I can eat any amount of sauerkraut and don't have any problems at all. That's true of many other different types of vegetables, things like asparagus and artichokes and all those types of foods.
That's really scary though, the idea that the problem with the bacterial overgrowth might be genetic. So what would that person do to stay super low carb or super low prebiotic for the rest of their life?
Michael: That person just probably has to avoid a lot of sugary foods. Fructose and maybe starch would be more of a problem for this person. Each person, depending on severity, is going to have a different threshold. I'm sure you've heard of people who say, "I really can't do much fruit or I just get bloated and brain fogged."
By the way, I'm working right now on a series on the microbiota [0:44:21] [Indiscernible] a series to help people restore their gut health role or kind of codify this into an easy to follow list of recommendations. So if people aren't following me and they want to be made aware of that, I have it on my website. They can plug in to be notified when that's available. I'm trying to put together some really easy steps for people to follow.
In going through this process that I'm talking about, the person with that gene polymorphism will give themselves the best chance to have the highest dietary diversity possible for them. So it's really all you can do, is just do the best to optimize the hand that that you've been dealt.
[0:45:03]
It reminds me of another point, it's a little bit tangential but I think it's important to mention. One of the things we often hear with this boom in the microbiota research is, again, how important prebiotics and carbs are, right, Chris? I'm sure you're hearing this kind of thing.
Christopher: Yeah. Of course. People tell me I'm going to die because I'm eating a low carb diet. I'm eating ketosis for a couple years. People are saying, "If you don't eat five pounds of sweet potatoes per day your microbiota will starve off and die. And that will be the end of you." So I know exactly what you're talking about.
Michael: Right. Again, come back to this process of finding where you fall in the spectrum because that will ensure that you end up being where you need to be. But an interesting point in that regard is you shouldn't eat much fat because fat will cause LPS transmigration or endotoxemia. Have your listeners heard of that before, Chris? Is that something --
Christopher: Yeah. I do know what you're talking about, yeah, and I think most of my listeners will do too. So if it's polysaccharides being the toxin that's in the cell wall of the gram-negative bacteria.
Michael: Yeah. Exactly. So it has been shown that when people eat a lot of fat they will have some inflammatory changes and some LPS transmigration, and maybe even some changes that downregulate insulin sensitivity slightly. This really pegs at the root of one of the problems we're seeing right now with misrepresentation or misinterpreted of research.
That is true, that finding is true, but you have to look at this in the broader context of what it means as a living, breathing humans. When we take people and we put them on a low carb diet, that has been shown to work equal, if not, better than the low fat and high carb diets. So if that mechanism of LPS transmigration was so important, then why is it when we put people on a diet that's higher in fat and lower in carbs, they tend to lose more weight than the people on the opposite diet? Probably because the more important mechanism is regulation of your blood sugar.
So to put it simply, you're going to have to eat high carb to feed your gut bugs or you can eat low carb to manage your insulin. It seems like managing your insulin is more important than feeding your gut bugs in that context. But within that same breath I want to be sure to mention that a higher carb diet does work for some, and we partially know why that is.
Christopher Gardner, a researcher over at Stanford, wanted to figure out why some people only lose weight on a low-carb diet and other people lose weight on either a low carb or a high carb diet, What he found out was it had to do with what's called heterogeneity of insulin receptor sensitivity. So in other way, different people have a different threshold for absorbing carbs, and that people that can absorb carbs well are more prone towards insulin resistance and diabetes need to be in a low carb diet. The people that have very robust, very healthy insulin sensitivity can lose weight on any diet. Does that kind of make sense?
Christopher: it does make sense. I don't think I ever talked to any of the people then fall into the high carb camp. So I noticed this because I've got buddies that I ride with that have absolutely no problems with sugar or maltodextrin-based sports supplements, and they do just fine. They're eating healthy and they win bike races and all the rest of it. I never speak to those people on the phone during my work, during [0:48:39] [Indiscernible]. It's always the people like me that are crushed by carbohydrates. They just can't make it through the day because this experience is wild, energy swings and insomnia and all the rest of it when they try and consume too much carbohydrate.
Michael: Right. I think it's the people that do better with low carb that are really going to be disrupted or kind of thrown off by this microbiota boom because they're going to feel this pressure to start eating more carbohydrate. I don't care if someone is high carbohydrate or low carbohydrate. The approach of navigating, and I hope this is transparent and clear, is that there's a spectrum. At one end there's going to be a lower carb, maybe lower prebiotic, and at the other end there's going to be a higher carb, higher prebiotic.
Different people are going to fall at different positions on that spectrum. What we should do is honor everyone's individuality and help them get to where they fall on that spectrum instead of just saying, "Right now low carb is en vogue." Everyone and the mother needs be low carb. Right now the microbiota is en vogue and the Africans eat lots of grains and carbs. Every needs to do that.
We have to step back from all this and try to say, "Okay, Mary Sue. Let's figure out where you fall in the spectrum and what's going to work best for you" because, ultimately, this stuff should always help drive the ability for people to get healthier more quickly.
[0:50:10]
Christopher: Yeah. Absolutely. I'm all for self experimentation. And that's kind of why I'm drawn to these shiny things. It's changing all the time. The whole quantified self-movement is just so rapidly evolving. New things are possible now that weren't even thought of 10 years, least of all, commercially viable. I'm definitely into that.
Michael: Yeah. I get that and I think that's great that we're getting more scientific and dialed in on these things as someone who really looks to the science for answers. Also, you have to be careful with those things.
Chris Kresser came on my podcast a little while ago. We discussed what I termed the dark side of being healthy where people can fall into obsession about their health, and they can lose a life. They can lose their life. They can lose hobby, friend. That can be really problematic. I'm seeing more and more of that every day. I think it's probably in part due to the fact that there's so much information out there that if you wanted to, you could just read on the internet all day and obsess over your macronutrient ratios and your microbiota tests.
Sometimes the healthiest thing you can do is just get the heck out of the house, hang out with friends, have some fun because if you really want to be ancestral about this, our ancestors did not sit in front of the computer for four hours a day reading about their gut health. They didn't, right? So hopefully that resonated to some people because there is a double-edge to this the sword.
Christopher: Yeah. I listened to that Podcast. It did and it didn't resonate. I got your point and I get your point that you just made right now. I tried that. When I was 18 I used to go to night clubs and dance until 6:00 in the morning, and drink tons of beer and eat pizza. I used to make my own bread. It was so much fun. I ended up like a wreck of a human being. Now when I spend all that time reading on the internet and interviewing people like you and running these tests and taking tons of supplements that I've spent as more fortune on, I end up feeling fantastic. I'm very much more drawn towards the latter than I am the former.
Michael: I think the ideal approach is to use both. If you become one-sided, that's when you're going to have problems. Maybe you would disagree with this, but if you didn't have any friends or any hobbies or anything else you do besides this, I'm willing to bet you'd get burnt out after a while. So yeah, maybe you can't do what you did when you were 18 which is drink regular beers and eat tons of bread, but we want to make sure that you don't lose a life, and you definitely learned from the great information that this movement has to offer, but then don't lose that grip on the other side of having friends and hobbies and other stuff that you do outside of health.
Christopher: Yeah, I know. Absolutely. I am falling into that trap sometimes. I'm a bike racer. I'm a pro mountain biker. Sometimes it's tempting for me to say, "You know what? Screw it." Like it was even today, actually, and say, "Screw it. I'm not going to go ride my bike. I'm going to do this interview this afternoon. I could spend more time doing some more research and make that a better interview." I resisted that temptation in the end and went for a ride. Maybe a detriment to this interview but I get your point.
Humans tend to do that, right? They swing like pendulums. If a little bit is good, then more must be better. So you end up on the other side of the scale before you know it.
Michael: Right. I think sometimes maybe swinging too far to one side or the other is what helps you figure out where your balance is. I mean I'm guilty of the same thing. I love this. For a while I got really burned down because I was doing too much of this and not enough of anything else. I had to take a step back in my own life and say, "Okay. I need to do some other stuff besides reading, researching, reading, researching, seeing patients, reading." You got to have a good balance, that Yin Yang.
Christopher: I just want to ask you one more question I'm going to off at a tangent at the very end here. I read a paper, and it might even have been you that linked it, that kind of got me interested in this. It was a comparison between some prescription medicines. I think it was Rifaximin and botanical herbs for treating small intestinal bacterial overgrowth. The herbs turned out to be slightly more effective but the success rates were depressingly low. Even the botanical herbs were still only maybe less than half, like 46%, I believe, success rate. This was quantified using a breath test.
[0:55:01]
I've worked with quite a few people now and lots of them have taken this botanical herbs placebo. I've actually had, in the last few weeks, a couple of people come back to me and said, "You know what? I felt great a few weeks after taking those herbs or a few weeks after finishing the herbs. Now I feel like I've gone back and I've regressed. That was kind of my worst nightmare. Maybe a whole year, that didn't happen. And now I'm sort of starting to get a bit worried."
What do you see in your practice? Is it really only less than 50% success rate when you take these botanical herbs?
Michael: The study you're referring to, it was published by Gerard Mullins who is a gastroenterologist at John Hopkins. Maybe there's one thing I should mention about that because yes, they did show that the herbs worked slightly better than the antibiotic but I'm almost positive, he only used Rifaximin. Rifaximin works great for hydrogen SIBO but Rifaximin should be paired with neomycin for methane SIBO. So those numbers may be [0:56:16] [Indiscernible] misleading.
That being said, I found about equivalent effectiveness. Now, the success rate, I think, and in talking with other colleagues of mine who specialize in SIBO, really depends on the patient population that you're seeing. The sicker the population, the more chronic, usually the lower their cure rate because you're working with a more challenging populations. If you were a rehab expert and you specialized in seeing people that no one else could fix, your success rate for the rehab might be lower than someone that deals with 18-year-olds who sprained their ankle for the first time ever.
So I was talking with Allison Siebecker on this. I would say my average cure rate for one round of treatment is probably around 50% to 60%. Hers was much lower but she only treats SIBO and tends to see the most chronic of SIBO cases. So a lot of that figure has to do with the population that you're seeing.
When I see someone who is new to the healthcare movement and hasn't done anything else, in a lot of cases those people will clear SIBO very easily. If it's someone that's been suffering with it for a while, maybe more severe case, then the cure rate may be a little bit lower. There may be a missing piece to the SIBO treatment. We may be able to do better with restoration of motility. That's something that the lead researcher or one of the lead researchers, Dr. Mark Pimentel, is working on right now. A test was just released to be able to test for the autoimmunity that underlies impaired motility. I think he's hoping to have better treatments in addition to just antimicrobials to help fix motility.
Sometimes people with chronic SIBO have other things that are problematic. Abdominal adhesions or obstructions, inflammatory bowel disease can all change the anatomy and motility of the intestines and can cause chronic SIBO relapse. So sometimes you have to do some digging to get it all sorted out if someone does have relapse in SIBO. Sorry for the long answer to your question.
Christopher: No. That's fantastic. Thank you.
Michael: There's a lot of context involved in that.
Christopher: Right. Yes. Most of the people I've been working with are athletes, probably not that sick. Sometimes I wonder whether I should even bother talking about supplements at all. 99% of the gains that I'm seeing are actually coming from diet and lifestyle stuff rather than any kind of supplement that the person might be taking.
Michael: I would agree with you. I think the best approach for most supplements most the time, in the short term, to help remove something that shouldn't be there or repair something or rebalance something. Then the long term people should really need little to no ongoing supplementation.
Christopher: Excellent. Thank you so much for your time. I really appreciate this. This has been extremely insightful and a learning experience to me. I'll probably get back and listen to this one again. I've got the habit of doing that. It's like you can't really listen while you're doing an interview. So yeah, it's fun for me to get back and listen. Thank you so much. Where can people find you?
Michael: So I'm over at drruscio.com. Like you mentioned, we've had a podcast going for a little while now. I have a lot of, as I probably bore people nearly to death with some of the facts about the microbiota I've been doing, a lot of research I'm putting together right now. I'll be releasing that in some kind of format soon, whether it's an eBook or what have you.
[1:00:16]
So if people want to connect with me over my website and follow what I'm doing, then when that's out you'll be notified. Hopefully that will help a lot of people to start their way through this kind of a sticky topic.
Christopher: Okay. So maybe I'll hold off on my computer program that finds missing sub3s in 16S [Phonetic] data until you've released that.
Michael: I think it's very interesting. I'm just trying to bring a voice of reason to this information, and just maybe help anchoring ground some of us because I know people are excited and they want to have something to offer people, but I don't want us to overreach because I don't want to give people a false hope or advocate testing or treatment that hasn't been really shown to have much of an effect.
Christopher: Okay.
Michael: Yeah. I say keep up the research and the observation but maybe be a little bit more judicious in how we all know discuss this with the public so that they don't get misled into thinking we're at a real high treatment position than we're maybe still in the data-gathering phrases.
Christopher: I understand. Great. Thank you very much. I really appreciate your time.
Michael: Thanks, Chris.
Christopher: Cheers.
[1:01:30] End of Audio
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