Written by Christopher Kelly
Dec. 17, 2015
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Christopher: Hello and welcome to the Nourish Balance Thrive Podcast. My name is Christopher Kelly and today I'm joined again by Dr. Michael Ruscio. Hi, Michael.
Michael: Hey, Chris. Thanks for having me back on.
Christopher: Yeah, I know. I'm delighted. I'm very excited to have you back on. I've really been enjoying your podcast, which is you've put a lot of time and effort into that. There's a lot of episodes now.
Michael: Yeah. We're cranking them out. When you look back in retrospect, I don't know how we've been doing it but somehow we've been getting them done.
Christopher: Yeah. I really enjoyed the last episode. The SIBO protocol podcast was fantastic. I would like you to talk a little bit more about that, if you don't mind.
Michael: Yeah, I'd love to. There's actually one thing I wanted to ask you. Is there a lot in the way of functional medicine education out where you are in the UK area?
Christopher: No. I'm not sure you realize that I'm actually near Santa Cruz in California.
Michael: Oh, geez. Well, your accent really--
Christopher: Yeah, I know, it's confusing. Yes, I am British. I was working in London and then I moved over here ten years ago. Now, I live in Scotts Valley.
Michael: Oh god, you're only a couple of hours away from me.
Christopher: Yeah, exactly, exactly. So, yeah, the answer is I've done all of my continuing education online. I've never been to an institution. Why do you ask?
Michael: Well, I was just wondering because we're getting geared up to do a seminar in London in January, January 16th and 17th and I've heard from some of the doctors and health care practitioners that follow my podcast that there's much less out that way in terms of functional medicine providers or functional medicine seminars and so they were happy that we were going to be coming out to do the educational event. So I thought I'd get your perspective but there I go by just assuming that the accent means you actually live there.
Christopher: I think they call that casual racism.
Michael: Right. Oh boy.
Christopher: I'm just joking. But I do know what you're talking about because for whatever reason people hear my British accent and they assume I'm in the UK. They make the same mistake, I guess. And they think that I'm going to be able to help them with finding somebody in the UK. Usually I really can't. I really can't. I did Robb Wolf, of course you know his podcast recently and I had one British functional medicine practitioner approach me. Other than that, I just really don't know of anybody. I think, like the paleo diet and some of the other things that you and I talked about on our podcast, that stuff is yet to arrive in the UK to some extent.
Michael: Hopefully we'll be doing our part here with the event that's coming up. Yeah, I guess, let's talk about if you wanted to talk about the SIBO treatment protocol episode, we could definitely expand on that if that's where you'd like to go.
Christopher: Yeah. Before we leave the conference that you have in London, why don't you tell us more about that? So what is it exactly?
Michael: (re)FIND Health is organizing an event, a two-day event. The first day, Melissa Hartwig of the Whole30 will be doing a presentation on the Whole30 program and all the tips and tricks for her amazing Whole30 New York Times bestselling paleo program which is just great. I'm sure most people have heard of that. She'll be doing about the first 60% of day one. And then she'll hand things up to me to discuss if you've done a really healthy diet program like the Whole30 but you're still not feeling the results that you'd like to feel, what would your next step be?
That, of course, would be then venturing into the world of functional medicine to try and figure out what's happening internally that's not allowing you to fully respond to diet. And that first day is more geared toward a lay audience. And then the second day will be just me speaking about for the first half of the day the gut, the microbiota, and then in the second half of the day talking about thyroid and different thyroid conditions.
And this will be accessible to someone from a more general lay audience but it's more geared toward clinicians. That's why I'm excited to be bringing that out that way because I've heard a number of people asking about doctors or training out in the UK. And so I'm happy to be able to be hopefully helping out some of the docs and nutritionists and practitioners out that way who are looking to sharpen their clinical skills.
Christopher: That's awesome. It's funny, I've been on so many different podcasts now and there's so many people in the community that had been really helpful to me, not least Robb Wolf, of course. It's the Whole30 that I still recommend. We do this free consultation and there's three of us that do it, my wife, Julie, who is a food scientist and my colleague Amelia who is a registered nurse. And that is our go to. And the reason we like the Whole30 so much is because the shopping list and the meal planners and all the resources are so fantastic.
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And I really like the book as well It Starts With Food. It's still one of my favorite books.
Michael: We're just really fortunate that we've got some great minds like Robb and like Melissa and Dallas and some of the other iconic paleo books where people have just done a really good job of taking what might seem like a complicated topic and just really breaking it down to "Hey, here's some dietary principles. Here's some shopping guide. Here's how you can implement this stuff," to really make it accessible for people because I think for people like you and I, Chris, it makes it much easier in the clinic to get people to the dietary point that you want them to be so you can then jump in deeper to some of the clinical stuff.
Christopher: Right. I think I've done close to a thousand of these free consultations and I would say there's a good number of them where people have never heard of the paleo diet, never heard of the Whole30. I make my money selling my time to interpret some of the labs and do diet and lifestyle coaching and sometimes I don't ever make any money out of those people because they just do the Whole30 and I never hear from them again. Like, "Thanks very much, it was great. It worked perfectly, thank you."
Michael: Yeah. Admittedly, I love when a patient comes in and they've barely worked in their diet because I know it's going to be easy to -- In a lot of cases, it's going to be pretty easy to get them feeling better by changing their diet because it's such a powerful first step absolutely. But most of what I see is people that have been paleo maybe even autoimmune paleo, maybe GAPS, maybe SCD and they've really been at the diet piece for a while and then we have to get in there a little deeper and figure out what's going on underneath the surface.
Christopher: And what about in London, the location set yet?
Michael: The location, I don't believe it's set yet. It will be somewhere central in London and if people go to -- I'll, of course, send the links but if they go to re-findhealth.com/michael-ruscio. That's the page for us. They can probably even just search "re-find health Michael Ruscio" and they'll see the page come up. And as soon as we finalize the location, we'll put it up there. But it will be somewhere in Central London. We're looking at a couple of venues right now. We're just trying to find one that has a high enough seating capacity but also has windows and lots of lights and so you don't feel like you're -- I'm sure, Chris, you've been to some of these seminars.
Christopher: Yeah, it's like a basement of a hotel.
Michael: Yeah, exactly. And there's no light all day and it's just like, "Ugh," at the end of the day. So that's soon to come. Hopefully, we'll have the most light beautiful spot and that will be a great place to hang out for a day and learn some stuff.
Christopher: Yeah, that sounds great. I was lucky when I went to London, I was on the 26th floor of the Millbank Tower, which is right by the Houses of Parliament, where I have this fantastic view of London and that was incredible. But that's not the normal conference experiences.
Michael: Right.
Christopher: Yeah, that'd be great. That's really exciting. I wish I could be there. Yeah, back to the SIBO protocol then. So maybe, I think, most people listening to this podcast will know what SIBO is but maybe for people that don't, SIBO stands for small intestinal bacterial overgrowth. This is a condition where some of the bacteria maybe from the large intestine are somehow translocated to the small intestine where it causes maybe gas and bloating and malabsorption. Is that right? Do you agree with that definition? Is there anything you'd like to add?
Michael: Yeah, that is a very good definition.
Christopher: And so in your podcast, you presented a case study, a lady that you'd been working with recently. And I thought that was super interesting. You laid out the protocol that she did and she got great results. I think that's fair to say, isn't it?
Michael: She did. She had really good results and actually the back story there is what I'd like to do is periodically sit down with the patient and just discuss their case. I don't like using the word testimonial because -- and nothing against testimonials but sometimes that feels a little bit too self promotional. I was trying to, with the video that we recorded with this patient -- her first name is Christine -- we were illustrating a concept that her SIBO values had improved but she was still technically positive for SIBO yet all of her symptoms were gone.
And she had even remarked that she felt better in her mid to late 30s than she did in her 20s. She lost over 40 pounds. All of her digestive symptoms were gone. Her chemical sensitivity has improved. Her ability to eat foods improved. Her energy improved. Just she did really, really well. But she was still in the positive range for the SIBO lab value and that's what we discussed. That was the concept I wanted to introduce with the video conversation with this patient, is that there can be, at least in my opinion, there can be a positive lab value but the patient can still be fully healthy and fully asymptomatic, which just illustrates the concept that we're not exclusively treating labs, we're treating a patient and we're using the labs to guide treatment and guide decision making.
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And after that, people left and right were asking for the protocol that we used. And so I thought that was an interesting opportunity to discuss the fact that there's not a magic protocol. And we did discuss what we did with this patient and I can elaborate a bit in a moment here if you'd like but I think the most important principle, hopefully anyway one of the most important principles people took away from the follow up podcast where we expanded on the protocol was that principles are more important than methods.
If you understand the principles of SIBO and the principles of nudging the gut back to health, then there's all different protocols you can use as long as you're trying to achieve the principle. And I think that's really important to mention because I think oftentimes in functional and integrative medicine we are very protocol driven. It's this protocol or it's that protocol. And unfortunately, what is left out of the equation oftentimes is really thinking through what am I trying to achieve here or what is my therapeutic rationale? What is the bigger objective I'm trying to achieve with this treatment rather than just using the protocol I was given at XYZ seminar or training course. Do you follow me on that, Chris?
Christopher: Yeah, I know, I do absolutely. I sometimes wonder where do you start though? I mean, you didn't start teaching or practicing from principles. Surely you must have started with the protocol and then the principles were something you learned about later. Am I right in thinking that?
Michael: What was the most helpful for me actually was when I first started studying functional medicine I really started studying very aggressively. I went to a few seminars through Company A, let's say, and I started to get into that mentality of just following the protocols that the expert speaker was advocating. But then I did many seminars through a different teacher and what he was saying was different than the other things from Expert A.
So Expert A and Expert B didn't really agree on many things. That was very hard for me but it forced me to think about beyond the protocols that they are using, which are different, what is the deeper principle that we're trying to drive at here? And it really challenged me to think for myself. And so, yes, I do think having protocols is a good place to start initially but as long as one who's using a protocol initially is looking at the protocol or using the protocol not blindly but they're really trying to think through the protocol, they're questioning the protocol and they're questioning what they've learned and they're doing their own research and they're trying to think through these things rather than again just using them blindly. Does that make sense?
Christopher: Yeah, it does. It does. I know that in traditional western medicine or allopathic medicine that junior doctors are actually assessed on their ability to execute a protocol. So creative thinking is not encouraged in the emergency room. But maybe this is not the same situation and so it's better to understand the principles.
Michael: Certainly, I think emergency medicine and more functional medicine are quite a bit different because the acuteness and the speed through which need to react and I think it's been shown that when you have to make decisions under pressure it's best to have a protocol to run through because imagine someone on a crash car coming into the ER and you've got 15 minutes to try to save someone's life, that's where, I think, having a really well established protocol and check list that you run through is going to work really well.
I have a lot of empathy for ER docs because they have a lot of pressure on them. That's one of the things that's a bit nicer about functional medicine is we're not dealing with acute life threatening incidents that need to be quelled immediately. That's where I think traditional medicine really shines. But here's an example that supports what I'm discussing. We've all heard of the microbiota and this huge bowl of microbiota research that's wonderful and just flooding the scientific journals right now.
Now, here's an example how we can look at somebody's information and just -- and if we didn't think through the concepts we could be led to an erroneous conclusion. So right now we're studying a lot of African populations. And many of the African populations were sometimes we are advocating that we should try to replicate the microbiota of the African population because the people in Africa are thin, they're healthy, they have less autoimmune disease.
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So we take a stool sample and we say, "Here's what their bacteria in their gut looks like." We want to try to make our guts in the United States or in the west look like their guts in terms of bacteria. We wanted the same bacteria. But that's a little bit of a flawed logic because we can't take something from a different population and try to force it into a western population. And so here's the example of that.
Sub-Saharan Africa has the highest colonization density or an organism known as Methanobrevibacter smithii. And this organism seems to really help those in Africa. This organism slows down the speed at which food moves to the intestines, which the African diet is a very dense fibrous sort of diet that's hard to break down. So by slowing that food down, it gives the body more time to digest it and extract more calories on it which is also important because the Africans don't have the same plenty of calories that we have in the west.
So this organism, the Methanobrevibacter, it slows down the rate at which food moves through which allows the Africans to digest more of the calories which is good for them because they don't have enough calories to begin with and they have this very hard to digest diet. Now, if we go to the west where our diets are different, quite a bit different, or our lifestyles are different, we see when there are high levels of that -- It's not a bacteria. It's actually an archaea. I'll just say organism to keep it simple.
When there's high level of that organism in a Westerner that causes a type of SIBO that we were just talking about that leads to constipation, bloating, abdominal tension and may even correlate with weight gain, high cholesterol and high blood sugar levels. And so if we think about the principle of this, in the African population it helps to slow down food so more could be absorbed from the food.
But if we take that bacteria and we just put it into a western population that has a different diet, a different genome, a different environment, that causes too much of a slowing, which causes constipation and potentially an over absorption of calories which causes high blood sugar which causes cholesterol, high cholesterol levels and, of course, the constipation. So I'll pause there for a minute if there's anything you want to jump in on, Chris. I know I just kind of--
Christopher: No, no, that makes absolutely perfect sense. There's a lot of athletes listening to this podcast and I'm sure they'll understand this principle that we're talking about because you can make the same mistake with a training plan. So maybe I could poke around online or maybe I could go on to Strava and find Peter Sagan who is a very successful, very talented professional cyclist, his training plan online. And then I could just try and copy it. I could try and do 25, 30 hours a week of cycling, do all the same work as all the details as there on Strava. I can look at his power files, mimic it in every way.
Of course, I'm not going to get the same results because the rest of my life is completely different. Like Peter Sagan doesn't have another day job and he doesn't have three kids. He has someone that can massage his legs every time he rides. It's unrealistic to expect to duplicate something that was found elsewhere in the world and expect to get the same results that those people did.
Michael: Exactly. And one of the things that I think can help one guard against that is by how they use science. And this is something that I've talked about on the podcast quite a bit. But when we go and we do these observational studies or we do studies in animals or we do studies in a cell line, that's very interesting data and that is one of the first steps in the scientific process. But before we formulate treatment recommendations for humans, we really should be taking those recommendations and filtering them through clinical trials in humans to see what kind of effect that we have.
And this is one of the most common mistakes that's made in this space is that people really over speculate. We've seen observation from Africa and we want to make the recommendation that everyone should now consume 70 grams of fiber a day or try to boost this bacterial population. But when we look at clinical trials, we don't really see that bore out in many of the clinical trials where we put people on very high fiber diets. It can be helpful for some but for some it can cause quite a bit of constipation or diarrhea or abdominal pain or even flare underlying conditions like ulcer, colitis or Crohn's disease if the fiber consumption is too high.
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And a similar thing has been shown with different prebiotics. And so what I try to do is look at the observational data to help with my thinking but before I make recommendations for any of my patients or any of my readers or what have you, I really try to filter that through clinical trials because that's ultimately what people are after. If we read all these cool interesting stuff coming out of Africa, if you're Mary Sue and you're a few pounds overweight and you're kind of constipated, ultimately what Mary Sue wants is a solution to her problems.
And she wants to know if I take this supplement, will it make my problems go away? And that's really what we do in a clinical trial. It's not what we do in an observational study. In an observational study, we just say, "Boy, these people in Africa eat a lot of this and they don't have any constipation. Maybe if everyone eat a lot of this everyone's constipation would go away." That's the hypothesis.
But then to test that, you have to do a clinical trial where you take a group of people who are constipated, you have them eat X or take X supplement and you see if the constipation goes away. And so that's really what I think people are after and that's why the clinical trials are so important and that's why, I think, for anyone listening to this call, any healthcare consumer, any clinician, doctor out there, if you are learning from another person, look at the references and make sure the references are clinical trials. It's going to be a fairly surefire way to prevent yourself from being misled.
Christopher: But don't you think the clinical trials are so expensive and so difficult to do and take so long and maybe when they come out there are still problems with the way they're organized or designed or published or something else. So if you see something which seems like a fairly low risk intervention like adding some extra fiber into your diet, do you not think it's worth a punt to see if you see any improvement?
Michael: I totally agree. I very much agree that if the intervention is fairly non-invasive and fairly safe then a therapeutic trial is definitely worthwhile. But I think where the argument falls apart in a lot of cases is in a lot of cases we have ample clinical trial evidence. So, Chris, I totally agree with your point where if it's an area where we don't have much science, we've got to do the best with what we have. But when it comes to fiber, when it comes to prebiotics, probiotics, many of these microbiotal interventions, we have quite a bit of clinical trials. We even have meta analysis which summarize ten, 10, 30 clinical trials and give you a mathematical score in terms of how effective the intervention is.
So with many of these things, and this is a point of frustration for me, we have the clinical trials but many times what happens is many people are looking for a-- they're looking to reinforce what they already think and just find references to footnote their opinion. That's a lot of what we'll be going over in the clinical training seminar is there's one section that we break down for every disease, IBS, inflammatory bowel disease, diabetes, weight loss, celiac, we look at all the different interventions that kind of modulate the microbiota, fiber, probiotics, prebiotics, anti-microbials, antibiotics, fecal microbiota transplant therapy.
We look at all those interventions broken down by the different diseases or conditions and we help people know what a reasonable expectation is. And so, for one example, there's great evidence for diabetes or insulin resistance with prebiotics. And people can expect some really nice results in diabetes or insulin resistance when using prebiotics. But if someone has IBS or SIBO then that may actually make their condition worse.
And so this is what I'm trying to help people with is if they're wanting to do some self experimentation like you mentioned, Chris, this would be a guide to help steer them towards the things that will be the best for them and to avoid the things that might be the most detrimental for them.
Christopher: I see. It's so difficult because you don't know. You can never know when someone is telling you something but they're omitting some of the evidence. And that's not okay. If you know about a study that says that opposite to what you are writing about or what you are saying, it's not okay to omit it.
Michael: Not to get too -- I guess, we're getting pretty analytical on this but I enjoy this part of the conversation so hopefully I'm not boring people too much with this, but I think one of the reasons this happens -- and this is something I think we all need to be improving on. It's something I try to improve on myself every day and I'm surely not criticizing people that are doing this but I think it's something that we should all be open about and by acknowledging this we can all improve the state of this field.
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But in this field, information is a very powerful form of marketing. So many people are producing information as a way of marketing them, their services, their opinions, what have you. And when that occurs, it's tempting to get information out there that's not always thoroughly checked. To go through the process of examining all the scientific evidence on an issue, it's a very time intensive process. And I even have a team of research assistants that help me comb through the literature and then organize everything in such a way where I can clearly see trends and then write about that for my listeners and followers and what have you.
So it's a very time intensive process but if you were someone who was really excited about a low carb diet you may just go out there and write an article about a low carb diet and then quickly find through your four references that support what you think and then boom there you go. It's much harder to try to comb through all the studies on low carb and then try to weigh the evidence and really give a factual dialogue.
I think because information is marketing sometimes you get a lot of information out there that's not super high quality and is more positioned towards just more information for the sake of having a new blog, having a new podcast, having information because it's kind of this keep up with the Jones marketing sort of syndrome that we fall into in this space. And I think it's something that if we're aware of it we can all work to improve that.
Christopher: Yeah, I know. I totally agree. I love the audience, the people that I work with. They're all fantastic critical thinkers. They're all people from other industries that have done really well for themselves with their analytical mind. And it's quite difficult to get that kind of stuff past them. I don't think that type of marketing would work very well for me. If they would fall for these types of tricks, like okay, say I put together some random supplement and then I back fit the reference afterwards just to try and support some of my claims and someone were to buy that from me and then come to me for my help afterwards and work with me one on one, I don't think they would be a great client because it's the smartest people who also get the best results. And they're also the most fun to work with. I'm hoping this critical thinking thing and the intelligence protects us against this type of stunt.
Michael: Yeah, I hope so too. I definitely see the consumer based nowadays being more savvy. Definitely. This is something that I think everyone in the field, the better of a job we can do in the field with this the better the field will do in general. And I think that's what we're all really after, is the field growing, the field being able to help more people and so on and so forth. I think guys like you, Chris, are doing a fantastic job or bringing good information to people to crowd out some of the more snake oily things that are going on out there.
Without getting, I guess, too far field into the political or pseudo political issues here, I know we've talked offline about a lot of gut related stuffs. Are there any things that we should jump into or do you maybe want to come back to SIBO treatment a little bit more? Where else do you audience want to go with this?
Christopher: Yes. So, tell me about some of the infections that you see in the gut and what kind of improvements you see when you treat them? I mean, H. pylori is one that everyone talks about. We know about that. What else do you see?
Michael: Yeah. H. pylori and another infection that's similar to H. pylori in terms of its implications with thyroid health is Yersinia enterocolitis and I actually didn't become aware of Yersinia until a bit later in my career because it seems for some reason that the antibody profile for Yersinia seems to be much more effective than the stool antigen test. And this is one of the things that we'll be going over in the seminar but the testing that you use really does have a big impact and there's one lab that I like for pretty much everything else but Yersinia. I've had patients come back positive with Yersinia on another lab and I've never ever seen this other stool lab come back positive for Yersinia.
The testing is a really important piece because it's not uncommon for an infection or an imbalance to evade a certain test. And that's why having testing that looks for things for multiple windows and also has some redundancy built into it is very helpful. But coming back to your question, Yersinia enterocolitis is a gut pathogen that has also been correlated with thyroid autoimmunity. And treating that one can be very helpful.
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Toxoplasmosis is another. And I recently came across a paper looking at toxoplasmosis. This was animal data. So again, I try to be a little bit cautious but showing that toxoplasmosis infection initiated gluten sensitivity in these animal models and so I can't help but wonder if the same thing may be happening in human. Either way, if we find a toxoplasmosis infection, we want to treat that. It's just interesting to speculate if that maybe something that after it's addressed someone's tolerability to gluten could go up.
Christopher: That's really interesting. So how are you testing for toxo? I always think about this. I spend so much time thinking about all the things that I must be missing. You run these lab tests. What am I really looking at here, just a tiny, tiny fraction of what's going on and what am I missing? So tell me how are you testing for toxo?
Michael: For toxo, the best results I've seen for toxoplasmosis are through either LabCorp request running an antibody profile and they'll run the IGG, IGA, IGM for toxoplasmosis. There's also a follow up test called toxoplasmosis agglutination which is if one wanted to be very by the book, that would be kind of a secondary screening to really firm up the initial antibody results. However, it's not routinely available through LabCorp request yet so we haven't been experimenting with that a lot. But mostly it's been through the antibody assays.
There are, to your point, there are many infections and there are many sequela associated with these different infections. It can be very difficult to keep every different symptom of every different infection straight in your head because there's so many. That's why having a good medical database that you can cross reference these things with is very important. And then just coming back to a real practical position of looking at the patient story and having them morph through this process of first changing their diet and their lifestyle. If they've done that and they're still not feeling well and then you find a gut infection, it's very likely a gut infection is contributing to their symptoms.
Whereas, if the person had a bad lifestyle, they weren't sleeping enough, they were very stressed and they were eating a really poor diet, if those things were on the table and you found an infection, there's a good likelihood that the symptoms may go away just from changing the diet and the lifestyle. And that's what we see with Blastocystis hominis where this protozoa may or may not be a problem for someone. And I like the Mayo Clinic's recommendation to treat this infection if someone has symptoms but not to treat it if they don't have symptoms.
And so that's why I like this model of having patients start with their diet and lifestyle and then go through a gut evaluation if things haven't cleared up because there are -- Sometimes there are these organisms that we're not really sure if they are parasite or they're not a parasite. We know we're not really sure what box to put them in. And so to prevent over treatment I think it's important to address the dietary and lifestyle issues first because if someone has no symptoms after they clean those things up then if they have Blastocystis hominis, for example, it probably doesn't need to be treated.
Christopher: Okay. And so you wouldn't automatically treat blasto then if you saw it on a stool test?
Michael: Well, every time I see blasto, it's in a patient that has symptoms.
Christopher: Right. They wouldn't have seen you otherwise.
Michael: Right. But for me, I always do treat blasto. But again, I always have people go through the diet and lifestyle first. So the people that need to be tested are tested and the people that don't need to be tested aren't because like we were talking about before, if someone comes in and they're eating a bad diet, in many cases, you change their diet and you don't need to do anything more. So that's why I try to have a little bit of a clinical process I work people through to make sure that we're only doing the testing on people that need to be tested and testing them at the right time.
Christopher: I've been really fascinated recently. There's a Blastocystis hominis Facebook support group which is quite active. There's a lot of people there. And it seems like a lot of them are in Australia I want to say. And it seems like they're all having incredible trouble not just with the symptoms but with treating it. And I've run a whole bunch of stool tests and used Dan Kalish's protocols. Let's start this from scratch. I do think, I promise. No, I didn't start from scratch. I used his protocols. I think only once have I had a person come back with a retest and it'd still be there. Is that what you're seeing too? I'm just trying to figure out why these people on Facebook are having so much trouble.
Michael: Yeah. I've not seen a case of blasto yet that we haven't cleared in one round of treatment. Actually there was one exception. There was one patient that she did not clear in the first round but it's because she didn't follow the treatment protocol accurately.
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And then when we had her do the treatment protocol the way we recommended the second time she cleared it. I'm sure at some point my situation there will change and I won't have a perfect record so to speak but I've seen very good results with treating blasto and I wonder if the people that are struggling with it maybe are not tending to the other dietary and lifestyle pieces first. Because those things are really significant especially when it comes to treating infection and in helping to rebalance the ecosystem of the gut because it has been very powerfully shown that things like stress and sleep very acutely will affect your microbiota.
And it seems that to put it loosely the more inflammatory the microbiota is the more hospitable of an environment that is for pathogens. And so the way I look at treating infections is we want to really try to nudge the whole microbiota ecosystem back into a healthier direction before we even treat someone because that tends to really enhance treatment results. And we see that being published quite impressively actually with H. pylori and with using probiotics when treating H. Pylori.
There's this, I think, slightly erroneous line of thinking that someone should not take probiotics while they're taking antibiotics or antimicrobial herbs. And I think that's quite incorrect because we have a number of high level studies. So systemic reviews with meta-analysis, so this is taking multiple clinical trials and examining them together to try to see what the overall trend in the data is. This is pretty top shelf scientific support. And we have systemic reviews with meta-analysis looking at co-administering different probiotics like saccharomyces boulardii or other lactobacillus, multi strain lactobacillus probiotics in conjunction with H. pylori antibiotics.
And when we do that, the eradication rate goes up quite strongly and we do see that same sort of data trickling in with other infections even with SIBO, small intestinal bacterial overgrowth. Another area of controversy is should you be taking probiotics in SIBO? There is recently a published study showing that if you co-administer with antibiotics, either a probiotic or prebiotic, they are trying to determine what gave the highest likelihood of clearing SIBO.
It's actually the probiotics co-administered with the SIBO antibiotics that yield the highest clearance rate. And there had been other studies looking at probiotics as a sole treatment for SIBO showing that you may have even a 30% clearance rate of SIBO just by using a probiotic. So sometimes the devil is in the details with knowing how to sequence all these things. So applying that to, let's say, SIBO, I have all my patients on a probiotic before we start treating them for SIBO because looking at what the scientific evidence shows, it enhances treatment and what I think is probably happening is the probiotic is helping to nudge the ecosystem back into balance plus making it easier to clear the infection when you come in with antibiotic or with an antimicrobial.
Christopher: Interesting. So everything is very sequenced then with you? You don't try and do everything at once. You do phases.
Michael: Yes. I mean, for the most part, sometimes if a patient is very acute and highly symptomatic we may kind of condense the phases so to speak. But usually I have a phasing, as you termed it, because again when we're looking at a more holistic way of treating infections it's not just the antibiotics but it's what kind of environment is the host providing. Is the host providing an environment that is hospitable for an infection? And we want to really try to change the internal milieu, if you will, as favorable as we can for healthy bacteria to live and not for unhealthy bacteria to live. And that's where, I think, you can have -- and this has been published -- you can have quite a bit of better results with your treatment of infections if you start to get things balanced in the gut before trying to clear an infection.
Christopher: And do you find things that you can't fix? Do you have a standard panel of blood test you run and then sometimes you find something, a virus or something, you can't fix and then you know that the person is just going to have to do something special to live with that.
Michael: You ask a great question. There's always, I think, no matter how well trained or how much of a specialist a clinician is, there's always going to be a small percentage of patients that are fairly non-responsive. And this is, I think, many things in life organize themselves into a bell curve where we have some non-responders, a high amount of responders and then some people that respond super well.
[0:40:04]
So I think that bell curve exist for all clinicians. I think that's an important thing for clinicians to know because you can't really beat yourselves up about patients that don't get the results that you'd like them to get and I very much include myself in that. There are sometimes symptoms that don't fully clear and there are sometimes lab markers that don't fully clear.
Now, the lab markers, I'm less concerned about the lab markers and I'm more concerned about the patient symptoms, like what we talked about the SIBO case. The SIBO case was still positive but the symptoms were still gone. But there are also other lab markers that seem to be less prone to improvement. I've seen Barr virus is one where I really have not made up my mind in terms of the clinical utility of the Epstein-Barr testing. And I've read quite a bit of literature on it and there seems to be very not much of a consensus in the literature on Epstein-Barr virus and even in terms of what constitutes a reactivation in comparison to a latency.
And so what I mean there is Epstein-Barr virus, the virus that causes mononucleosis, 95% of adults will have evidence of that virus in their blood by adulthood. That's normal. But depending on the pattern of the evidence so to speak that may indicate the virus is reactivated or it may mean that the virus is asleep or latent. And there are some guidelines. Or really if you see the early antigen positive on Epstein-Barr virus then that usually indicates reactivation. But there's not a lot of agreement on that even in the literature.
And what confounds things even more is we see Epstein-Barr virus correlated with many diseases and oftentimes the correlating markers, excuse me, are not the markers that are indicative of Epstein-Barr virus reactivation. So I hope I'm not getting too deep with this but that's one that I really am thinking on in questioning in trying to come up with a straight answer on it but I haven't made my mind of completely on where I fall with the Epstein-Barr. But that being said, when I do find it positive, I usually reevaluate the Epstein-Barr markers after we've treated someone's gut.
And I have seen in a few cases that virus will go into latency or will go to sleep after treating a problem in the gut which shouldn't be overly surprising knowing that viruses can reactivate when the body is under stress. In fact, there was one study published in Asia showing that the higher the level of socioeconomic stress, the higher the level of Epstein-Barr virus reactivation. So it's not crazy to think that if we improve the health on someone's gut, these viruses will improve.
Christopher: What markers do you look at if you don't mind me asking? I've just tested myself for Epstein-Barr and I had an elevation of the IGG antibodies, the capsid and the nuclear but no--
Michael: That's normal.
Christopher: That's normal.
Michael: Viral capsid antigen and nuclear antigen, elevations are somewhat normal. It's the IGG early antigen that can -- and when you see the viral capsid antigen and a nuclear antigen positive and in conjunction with the early antigen, that usually signifies a reactivation. And there's one fraction of IGM that's typically run. I believe it's the early antigen IGM that's typically run. That one is kind of the plus or minus but it's really the early antigen IGG that seems to be an indicator of, if it's positive or not positive.
I also sometimes will run PCR or what's called the Epstein-Barr heterophile and those have been published in some papers but they're of questionable clinical utilities. So right now I'm running those and observing what happens with patients and seeing if I can tease out any kind of trend. But Epstein-Barr is definitely one of the more confusing ones out of all these guys.
Christopher: Yes, super confusing. And then what can you do? So, say, you do find someone with an active infection, can you treat that?
Michael: You can. there's a number of antivirals, things like monolaurin are antiviral. Reishi contains a compound I believe known as triterpenes. I maybe botching the pronunciation but those are highly antiviral. Quercetin is antiviral. The vitamin D has some antiviral characteristics to it. So, yeah, there's another herb called Larrea tridentata. There's a number of herbs that are anti viral in nature. And there's also prescription antiviral like Acyclovir. And I actually recently read a study that showed that the effectiveness of the prescription antivirals were not super strong.
[0:45:02]
I don't know of any head to head comparisons but I'd be curious to see how the natural antivirals stack up against the prescription antivirals. But with every passing day, I really have a reaffirmed respect for the power of natural medicines looking at things like the herbal antimicrobials that we use to treat SIBO and seeing how in some of the head to head studies they've shown equivalent effectiveness.
Or looking at some of the front line anti-inflammatory therapies for inflammatory bowel disease like Mesalazine and looking at how an herb artemisinin has been shown to have equivalent results. And we even have systemic reviews with meta-analysis showing that herbal medicines are as effective as the front line anti-inflammatories for inflammatory bowel disease in inducing remission. So kind of a long tangent on your answer but there are definitely some natural and some pharmaceutical options available.
Christopher: Yeah, I know, that's amazing. And it's incredible that anybody is paying for those comparisons. You can't patent Artemisia or Arteminisin so who's going to pay for that study? I'm not sure. You know how much a proper clinical trial cost. It's ridiculous. It is incredible that information exists.
Michael: Well, I think it depends on how you set up the clinical trial because we're about to start a clinical trial on our office in the next few months and we just had our IRB approved which is you have to submit for approval any time you do a study on humans to make sure what you're doing is ethical. So we just had approval for the study. And we've gathered some funding from a lab, we've gathered some funding from a company that manufactures the nutraceutical and they're going to assist us with providing some placebos. It's going to be a blinded SIBO control trial and there's been a couple researchers that have come out of the woodwork that are passionate about this area and need to publish as part of their Ph.D. status at their university.
So instead of having to pay them we've just had them satisfy some other publication requirements for the universities. I think there is a gorilla form of clinical trials that I think is how many of these studies get done. I think the design of the study has a lot to do with it and we're just using my patient population to help with this which also really drives down the cost. But clinical trials don't have to be as expensive as we always think. They can be but if you try to do it on a budget, I guess, there are definitely ways that you can do a good scientific study but not need to really burn a huge budget.
Christopher: Yeah, that's amazing. And so tell me about what you know about vitamin D. You mentioned this a while back, always seeing the 25-hydroxyvitamin D being low on the blood chemistry and there possibly being a connection with intracellular infections. Is that something you know more about now?
Michael: It is. So, I guess, the back story is there's been some papers published showing that or speculating that when a patient has chronically low vitamin D, it maybe because there's an infection and/or an inflammatory process present that is causing them to convert all of their vitamin D into this metabolite called 1,25 vitamin D or also known as Calcitriol. And that's being done in attempt to suppress the immune system so that the infection can continue to live.
I recently released a video about one of the drugs that's used as part of this treatment protocol. There's a treatment protocol out there known as the Marshall protocol that administers a drug called Olmesartan that blocks the conversion from vitamin D to this metabolite. So they give this drug and they also administer quite whopping doses of antibiotics for quite a long period of time. And I just read a few studies that have shown that this drug Olmesartan can cause what's known as enteropathy or quite a bit of damage to the gut.
And so this is a video I sent out warning people about this who may be looking at the martial protocol. I really advise caution with that. And also the Marshall protocol makes me a little bit uneasy because of the high doses of antibiotics for such a long period of time. But that being said, I'd been tracking this ratio in my patients' pre-imposed treatments and I don't think we have enough data collected yet to really report on it but I'm getting an initial inkling that after we treat even gut infections that we may see the metabolism go back to normal.
[0:49:58]
And there are other pieces with this that have to do with calcium and parathyroid hormone. And we've been checking those other markers and everything else checks out. So I think we can somewhat isolate for the effect of infection or inflammation on the vitamin D and vitamin D metabolites. But to answer your question more succinctly, we've been tracking these on some patients having gathered enough data to really report anything conclusive but the initial inkling I'm getting, I could be wrong, but the initial inkling I'm getting is that after we address any kind of infection not exclusively intracellular infection but any type of infection that may help to rectify the vitamin D imbalance.
And this ties in with something else that we see published in the literature which is we observe that populations with higher vitamin D are generally healthier and sick people tend to have lower vitamin D. But when we give sick people vitamin D supplementation, we don't see near the improvements that we thought we would see which has led some of the higher level scientific papers like systemic reviews with meta-analysis looking at vitamin D supplementation to conclude that low vitamin D is probably a marker of ill health but not necessarily a cause of ill health.
I still think people should get reasonable sun exposure or supplement with a small dose of vitamin D if they can't get adequate sun just to make sure they're having adequate intake. But I am really questioning the vitamin D panacea for fixing many different health conditions because of what's been published lately although I do think in autoimmune conditions opting for a little bit higher vitamin D level maybe even all the up towards 60 is reasonable. But that's some bits and pieces on vitamin D.
Christopher: That's really interesting. It certainly makes sense. I don't have that data. I don't have the 125 metabolite but I do see the 25-hydroxyvitamin D and I see it very low in people who live locally even here in California and around the mountain bike cycling for I don't know how many hours per week. It's obviously plenty of time to get adequate sunlight exposure and yet still their 25-hydroxyvitamin D is 25 points which makes absolutely no sense.
Michael: And you know something interesting is that when we examine, I believe it was the Hadza hunter gatherers, we saw that their vitamin levels was about 49 and I used to think it was because they were spending a lot of time in the sun. But I've recently heard a few interviews looking at the sleep patterns in the Hadza and apparently they get light exposure usually up until about 9 o'clock in the morning and then during the midday when the sun is the hottest they generally try to avoid the sun and stay in the shade. And then they get more sun again toward sundown when the sun is not as hot.
So that kind of reinforces that the healthy hunter gatherer 49th level of vitamin D may not be because of this whopping dose of sun that they're getting but it maybe because they're just healthier and as some of the researchers have concluded vitamin D can be a marker of ill health if low or good health if it's high. It's always good for us to be open-minded and never stick to any one belief too fervently.
I am writing a book right now on the gut and on the microbiota and I'm hoping that will be out within the next maybe three or four months, sometime somewhat early in 2016. And one of the chapters really elaborates on the vitamin D piece. And I lay out some guidelines for reasonable sun exposure. And I take recommendations from the Endocrine Society, which is a very prominent endocrinology society in the states and they have recommendations for how much sun exposure will change someone's vitamin D levels.
And so I extrapolate from their recommendations there to what a treatment dose of sun exposure is compared to what a maintenance dose of sun exposure will be. And I talked about this I believe it was on Robb Wolf's podcast and I think in my podcast. I just kind of narrowed the information maybe about six months ago and I apologize I don't have it all committed to memory. We provided people a fairly simple table. If you're light skinned and you're vitamin D deficient here's how much sun you should get and if you're light skinned and you have adequate vitamin D here's how much sun you should get to maintain your levels and so on and so forth.
Christopher: How many hours do you work per week?
Michael: Right now, typically Monday through Thursday, I started 8:00 or 9:00 and usually end around 11:00 or 12:00 p.m. or a.m., I guess. Right now, they're pretty long days admittedly.
[0:55:00]
Christopher: I just don't know how you get it all done. You must be extraordinarily productive as well.
Michael: Yeah. Thank you. I think right now I'm doing pretty good. It's a necessary evil right now because there's so much happening, like with anything else right now where the clinic is doing a lot more research. We have two clinical trials about to start and a lot of other data mine that we're doing in addition to everything else. And so I've been fortunate that I've been able to attract and build up a good team around me. And I'm hoping that over the course of the next several months I'll be able to maintain the same level of output but without having to do a routine 12 to 15-hour day.
Christopher: Right. Yeah, I know that's awesome. I'm really grateful as well for all the content that you've produced because it's excellent and I really enjoy the podcast. I really enjoyed all the podcast episodes with Robb Wolf. People should check those out too. And then hopefully there's some people listening there in London or in the UK and fancy taking a trip t London to come and see you and Melissa. I think that would be a really fun day out too.
Michael: Yeah. I think that will be a fun day, definitely.
Christopher: Yeah. And I will, of course, link to that. It's re-finehealth.com with a hyphen in it. But I will link to those in the show notes. Of course, people can find you. It's drruscio.com. It's your website.
Michael: Yeah, drruscio.com.
Christopher: Sorry. I've got another -- Every week I tell people that they have another podcast that they need to listen to and yours is definitely one of them. I think it's fantastic.
Michael: Well, thank you. It's always nice to hear that the work is helping people and then it's appreciated. And thank you, Chris, for having me on and for sharing and for all the good work that you're doing.
Christopher: Yeah, I know. It's my pleasure. Thank you.
Michael: Will talk to you next time, Chris, thanks.
Christopher: Okay. Cheers then, bye.
[0:56:39] End of Audio
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