Dr. Michael Ruscio on SIBO and gut health as drivers of MCAS: Mast Cell Matters with Dr. Tania Dempsey

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Jill Brook: Hello, Mast Cell patients and wonderful people who care about Mast Cell patients. I'm Jill Brook and today we have an episode of Mast Cell Matters Deep Dives in Mast Cell Activation Syndrome or MCAS with our amazing guest host, Dr. Tania Dempsey, world renowned expert physician and researcher on MCAS and related conditions.

Dr. Dempsey, thank you for being here and which of your superstar colleagues did you bring with you today?

Dr. Tania Dempsey: Oh, I'm so excited to have Dr Michael Ruscio here today. Let me, let me do a brief bio and then we'll, we'll jump right in. Dr Ruscio is a doctor of chiropractic medicine, a natural health provider, researcher and clinician, and he serves as an adjunct professor at the University of Bridgeport and has published numerous papers in scientific journals.

He also has a B. S. in exercise science. A D. C. ,he's a board certified doctor of natural medicine. So he's [00:01:00] really, really well rounded. Very well pedigreed. And he's the founder of the Ruscio Institute of Functional Health, which is a consulting practice and research clinic that helps patients heal a wide range of G.

I. conditions. From his research, clinical research and experience, Dr Ruscio authored a book called Healthy Gut Healthy You. He's created numerous courses. He developed a elemental diet formula that's on the market. You know, his specialty really is in the gut. And we're really excited to talk all about the gut today.

Welcome Dr. Ruscio.

Dr. Michael Ruscio: Thank you. It's great to be here.

Dr. Tania Dempsey: So, so, let's, let's dive in. You know, let's talk a little bit about you know, how you became interested in gut health.

Dr. Michael Ruscio: Yeah, I had zero interest early in my life until, uh, until in college I started having insomnia, food reactive brain fog, [00:02:00] fatigue and depression out of nowhere. And, um, you know, it'd be one thing if I was living that college lifestyle of drinking every night and, and being up late and eating a really poor diet.

You would look to those obvious things, but being at that time pre med and really into holistic health. I was doing all the things, right? I was eating organic food. I was exercising. I was tending to sleep. I mean, sure. I was having some alcohol and doing some of the college kid stuff, but nothing in excess.

So it was really sort of a quandary in terms of why would my health have fallen apart so acutely like that. And I went to see a few doctors and, you know, they all did their workups trying to help me. But said, no, you know, you're, you're young, you're healthy. You've got a good body composition, your lipids, your liver enzymes, all, you know, all the things in the standard panels checked out.

And I got the well intentioned, but sort of platitudinous, it's probably stress. So I kept digging because [00:03:00] obviously that wasn't going to work for me with insomnia and food reactive brain fog and all the symptoms. And so I found my way into integrative medicine and I still remember fairly distinctly

the doctor saying he thought I had an intestinal parasite. I thought he was nuts. Because it wasn't on my radar, right? And I hadn't traveled or the history didn't support that. I didn't go to Mexico and get food poisoning. There was nothing like that, but I didn't really have much to lose. So, I did a stool test.

I came back with an amoeba, amoeba histolytica. And as far as findings on stool tests go, that is one of the worst pathogens you can have. You know, there's many things in the gut that are kind of commensals. They normally behave. Sometimes they can get out of whack like SIBO, which we'll talk about later.

Candida, the same thing. They're not overtly parasitic as amoeba histolytica is, as I know, you know, Tania, but this will kill people in [00:04:00] third world countries due to diarrheal dehydration associated causes. So that was big eye opener to, oh, your gut can really skew your health. And it was a little bit of a road to recover from that.

But that's what really shifted my perspective from wanting to go into orthopedic medicine into more holistic and, and gut focused healthcare.

Dr. Tania Dempsey: That's quite that's quite an experience. I'm sorry you had to deal with it. But actually, you know, the, the, it really benefits all the, all your patients now, because you've, you've lived it. Right. And now you're tuned into that.

Dr. Michael Ruscio: Tends to be how it goes for, for a lot of us, I think, in this camp, who, who just, who move outside of the standard model, because the standard model for, for many different disciplines will get you so far, but there's always going to be some gaps in the research literature that usually informs those models.

And that's where, when you have to be in the trenches of suffering as a patient, you're, you're, you learn like your life depends on it [00:05:00] essentially. You're much more open minded. And you just, yeah, you, you definitely come away with a better understanding of how to help people when you've gone through it yourself.

Dr. Tania Dempsey: So so that sort of propelled you into this area. Right? One of the things that I've heard I hear you talk a lot about in your social media, I know that you've done some research on this, is SIBO or small intestinal bacterial overgrowth. And I know that our audience asks a lot of questions about SIBO.

Many of them are suffering from SIBO. So, I'd love to talk a little bit about what SIBO is, and we'll talk a little bit about your approach and all that. But maybe we can start with some background.

Dr. Michael Ruscio: Sure. So SIBO stands for small intestinal bacterial overgrowth. Interestingly, the, the definition has expanded over the past few years. So it's not limited to just the small intestine. Some of the bugs that can overgrow might be actually in the colon and it gets a little bit complicated, but [00:06:00] essentially in your digestive tract, mostly in the small intestine, but maybe also in the large intestine, there's too much of the bacteria that's normally there. Because there should be bacteria

there's people probably know your microbiome, the healthy bacteria we've all heard about probiotics and the like are good. We want those things. But, like so many concepts in physiology, there's sort of this Goldilocks zone. You want to be right at that optimal sweet spot. Too much or too little can be problematic.

So when there's too much bacteria, they can ferment. This can cause gas pressure. The excess bacteria and some of their byproducts can cause inflammation, immune system reactivity, whether that be higher histamine or, or increased triggering of the mast cells. It can lead to malabsorption, problems with motility, so this could be constipation, diarrhea, or both.

And, and really sort of stems from this, this overgrowth and the overgrowth has a few different [00:07:00] causes. And we can sort of, you know, go more into that, but that's the simple definition is there's just too much of a good thing essentially in the intestinal tract.

Dr. Tania Dempsey: So then, so then, why does that happen? You know, why are some patients really afflicted with this? And what do you think the, the, the triggers or the, or the, the impetus for, for the development of SIBO is.

Dr. Michael Ruscio: A couple of different theories on this. There's a top down theory. This mainly incepts from a finding via Richard McCallum, who found that that there was quite a lot of oral bacteria that were found when they sampled the small intestine, the, the colony of overgrowth. There was actually a lot of oral bacteria that were overgrown in, at least in his study.

So he introduced sort of this, what's known as top down. And this might be the people who have insufficient production of hydrochloric acid, which is a subset of the population, right? So, for some people, it's this top down seeding, [00:08:00] oral cavity bacteria aren't being sterilized by the adequate stomach acid.

They're getting into the small intestine and then they're overgrowing.

There's also a theory of bottom up, and this is where as you go from the stomach to the small intestine and then into the large intestine, there's progressively more bacteria, kind of the farther away you get from the acidic sterilizing stomach, the more bacteria grow, which is a good thing.

That's, that's the way it should progress.

This that then triggers a autoimmune process in the intestinal tract that doesn't allow that motility to keep pushing things downward. And all of a sudden they have this propensity to have the food reflux back upward.

So that's the other, it's known as post infectious IBS.

And then there's two others. One is some people, if you think about the intestinal [00:09:00] tract as a road. If you're driving on a highway, you can drive pretty fast, right? You can just drive 60 miles per hour. But if you're driving on a mountain road with a lot of hairpin turns, you have to slow down.

Some intestinal tracts have more of what's known as tortuosity, these tight hairpin turns, just anatomically the way some people are born. Or some people can have scar tissue if there was a prior surgery, let's say maybe a hysterectomy. Maybe a resection in the small intestine for an inflammatory autoimmune condition, you know, whatever. If there, if there's a prior intestinal pelvic surgery, that may have created a little pocket of scar tissue that's pushing on the, the hose, the garden hose, that is the intestinal tract. And for these people, not to go too far afield into treatment, but a simple intervention of abdominal massage has actually been shown to improve constipation. And to me, that was a little bit surprising, but at this point we actually have a meta analysis summarizing [00:10:00] multiple randomized control trials that have found simply rubbing your belly and you kind of go from bottom right up over down to kind of follow the path of the colon. But that can lead to two, three, four more bowel movements in a week for people.

So that can be one way of getting around that that issue. And if there's scar tissue, then certain manual therapies will break down that scar tissue. So we have the top down. We have the bottom up. We have the windy road or the scar tissue. And then another one that I think is really important to mention, because a lot of this is a little bit pathologized and this is more so my opinion, but I think in some people you just have wear and tear on the gut.

And we forget this sometimes because we want to be fit into this highly pathological box. And sometimes we need to do that. But sometimes it's an accumulation of prior antibiotic use, stress, poor diet, poor sleep, this [00:11:00] affects motility. This affects the immune system. This affects the growth of healthy bacterial populations.

And I think that, that last category is really important again, because what I see oftentimes in people with SIBO is this real degree of sort of adversarialness with their system, thinking about they have to kill or what's wrong. And, and sure that that's a perspective, but sometimes the system's primed to heal,

if we just change some of the environmental factors like sleep and stress and diet and alcohol consumption and the like.

Dr. Tania Dempsey: In that case, how do you think, well, maybe in all the cases too, how do you think the immune system, let's talk a little bit about mast cells and how they fit in here and what the relationship is, because I imagine that at least definitely in the last case, but I would say in all those cases, there's right, there's a, there's a relationship.

Dr. Michael Ruscio: Yeah. And there, there are data [00:12:00] that have really looked into this. 2019 meta analysis of 20 randomized control trials did find that people with Irritable Bowel Syndrome had a higher density of mast cells in their small intestine. So we know there's, there's really something to that. Now, the people with sensitive digestion, it's probably twofold where they have an increased density of mast cells in the small intestine, but they also have increased triggers.

And so those triggers might be the bacterial overgrowth. And kind of like you're alluding to, it's the immune system that should be keeping the bacterial populations in check. One of the things that helps keep the bacterial populations in check, right. So, if there's constant triggering of the immune system, then yeah, you can have this sort of mass activation syndrome.

You can have histamine intolerance. And there have been studies that have, have really demonstrated if we can change that internal environment, [00:13:00] let's say by reducing dietary intake of prebiotics or FODMAPs, these are the food stuffs that feed bacteria. If we can reduce the consumption of those, it's actually been demonstrated the ability to significantly lower histamine levels. And what's probably happening here is someone has an excess of bacteria. So if we reduce the food for those bacteria, if we reduce the FODMAPs, the prebiotics in the diet, that can help starve that overgrowth. And that overgrowth is no longer going to trigger the immune system. Therefore, we can see a normalization of histamine levels when we do that.

There's one component. I mean, there, there's many, but that's just one. Yeah.

Dr. Tania Dempsey: Yeah, yeah, but I think that's that's important. So then you know, that's one area where you can intervene. Right, you know, you're, you know, you're sort [00:14:00] of trying to, you know, not to use the word attack, but really trying to address these different things from from the various angles. Right?

So, understanding the immune system is definitely, you know, is important. So, so what is your approach to so, how do you, how do you figure out whether a patient has SIBO or dysbiosis or abnormal gut flora and, you know, what do you, you know, once you know, first of all, let's figure out how you figure it out.

And then what do you, what do you do?

Dr. Michael Ruscio: The the SIBO breath test is widely available. It's definitely amply studied. It's been validated. It's an accurate test. So this is where someone that goes into a doctor's office or they take an at home test kit, they drink a solution, either glucose or lactulose, and then they collect breath samples every 20 minutes for about three hours.

And what we're looking for in this test [00:15:00] is, when we graph out the levels of gas, because part of the test is people will breathe into this tube apparatus and take a sample from each time point, we should see relatively small levels of gas until we reach the large intestine in about 90 minutes, and then gas level should go up.

If the gas level spike before we hit that 90 minute interval, that tells us there's more bacteria in the small intestine than there should be. There's sort of large intestine level bacteria in the small intestine. So that's the merit of the SIBO breath test. There's a few nuances that I think make it problematic clinically.

I think it's much better for research. But clinically yes, people with symptoms do test positive more often than people without symptoms, but there's a significant amount of false positives. And so it's, it's really important to kind of keep that in mind in terms of the lactulose tests [00:16:00] will produce more people positive,

but it also has a significantly higher false positive rate. The glucose test, less people will test positive, but it also has a much lower false positive rate. So it kind of depends on what's your goal. If your goal is a positive test, then the lactulose SIBO breath test is air quotes here the best. If you're looking for maybe the most accurate test, then the glucose might be the most

accurate.

At the end of the day, I don't see a SIBO test being the make or break in someone being able to improve their gut health, which is why even as someone who's published on SIBO, we really rarely do the SIBO breath testing in the clinic now, because so many of the therapeutics do not require a positive test to administer, even taking the antibiotic Rifaximin, Xifaxan, that's FDA approved for IBS.

Well, that's just it. It's FDA approved for the symptoms of IBS. [00:17:00] You don't need to do a SIBO breath test in order to use the antibiotic successfully. The other thing too is more people will have IBS symptoms. So Irritable Bowel symptoms, gas, bloating, diarrhea, constipation. More people will have those symptoms than will test positive for SIBO.

So you know, the testing can be helpful, but it's fairly commonplace that people will say, well, I did a test and I was sure I was going to have SIBO and I didn't. And this is because to your point, there can also be dysbiosis. And that's, that's not overtly overgrowth. It's just an imbalance in the levels of the different players.

And I also think really importantly, fungal overgrowth, which is harder to test for and used to be what was in vogue like 10 years ago, and then it swung to SIBO being a really popular thing. As we've been looking more into this, [00:18:00] fungal overgrowth probably accounts for 20 ish percent of the people who have symptoms

but don't have a SIBO breath test. And one researcher, Satish Rao, he's at University of Augusta. He found that about 20 percent of people had SIBO, and this is in a cohort of people with unknown cause GI symptoms. 20 percent had SIBO, 20 percent had fungal overgrowth, and 20 percent had both. So there can definitely be more than, than just bacterial overgrowth. Fungal overgrowth, much harder to test.

You can do a stool test. That's going to be incomplete. You can do an antibody test. That's going to be incomplete. You can do an organic acid test. That's also going to be incomplete. It's helpful, right? But I don't think it's really necessary. And then for dysbiosis, there's other stool tests that can be used for dysbiosis.

There's this, this technology known as the GA map. Not to be confused with the GI map, the GA map is actually I, are they from [00:19:00] Norway? They validated a measure for dysbiosis that's actually integrated into the doctor's data.

So that panel is integrated into the doctor's data. G. I. 360. it's called the Dysbiosis Index. That being said, as great as it is that they validated. that, that dysbiosis test can discriminate healthy controls from sick cohorts, they still don't have any predictive validity for, well, what do you do with that data?

Right? So then we kind of come back to, let's listen to the individual. And this can tell us a ton in terms of how we start to help them. Even little things like listening to what the dietary triggers are. So kind of coming back to SIBO for just a second. Some people, when they're trying to improve their health, go, you know what?

All right, it's going to be healthy fruits and vegetables and lots of fiber. And they go on this healthy diet kick. Inadvertently, they go really high FODMAP when they do [00:20:00] that. And they go, Doc, I'm doing everything to improve my gut health and I'm feeling worse. And that's because they didn't understand, but that's because they inadvertently went really high fiber and really high prebiotic.

So just listening to, Oh, so you're saying salads trigger you. Broccoli and asparagus trigger you. Avocado, all these foods that are typically high FODMAP or that are high FODMAP are typical triggers. Okay. So now we know how to modulate the diet or conversely, someone may say, I thrive on this sort of lower carb, high fiber diet.

But if I eat too much starch or rices, you know, rices, breads, potatoes, things like this, I get really triggered. And that's more demonstrative of a fungal overgrowth type. And, and the really important kind of bifurcation here, the way I look at this is, bacterial overgrowth versus fungal overgrowth. The fungal overgrowth types, they will do fine on lots of fiber and prebiotics and salads and veggies, [00:21:00] but they will not do well on carbs.

And total mirror opposite, the bacterial overgrowth types will get really triggered by the fiber in the, in the fruits and vegetables and salads, but they'll do fine on starches and rices and things like that. So, the testing does have a time and a place, but I think you can learn a lot more when you really listen to the individual to get clues for what's actually driving their symptoms.

Dr. Tania Dempsey: I love that you say that because, you know, I think that's like the most unappreciated thing about the kind of work that we do right is the history taking. Because there's so much. I mean, I love I love data too. Right? You know that I, you know,

you love data and you'd like to, you know, and you want to publish and I want to publish.

Right? So we, we, we love to do that. But, the end of the day, right? That history taking is so critical because there's so much that you can learn about, about the patient and then really gear your [00:22:00] treatments to that. Yes, sometimes you need validation with some testing. Sometimes it's helpful to have the testing because I think that the, for patients who have been suffering for a long time and don't under, you know, don't have answers, the testing, at least,

again, it validates there that there is something wrong, right? And so sometimes it's helpful. Sometimes you do need confirmation. But yeah, I love how you said that. I think there are two points you made that I think are excellent. One is, is, you know, taking that history really thoroughly, understanding what

patients triggers are because then you can really piece it apart. And the other thing is about the individualized need, you know, for dietary changes. There's no diet that's perfect for everyone. And I say that all the time.

Dr. Michael Ruscio: Agreed. Yeah. Yeah. Oh, and one other thing that you're reminding me of as you're saying that is, what I've observed in some cases is they'll have a prior SIBO breath test and now everything they do, I call it SIBO [00:23:00] tunnel vision, is for SIBO. And it might be obvious during a good history that they actually need to pivot to a antifungal

candida diet, right? And so the one lab marker, like if, if we had done a really comprehensive assay, maybe we would have seen, they have inflammation plus fungal overgrowth plus SIBO, but they just had this one test from a prior healthcare provider. And now all they're doing is like double, triple down on SIBO.

And one of the nice things about the gut care as compared to maybe things like treating Lyme and vector borne infections, kind of different animals. Response is pretty quick, and you're going to be able to know fairly quickly and usually get someone through the thick of things in only a couple months.

I mean, sure, there might be a little bit of a need for a few months afterward of, of kind of refining, but you can really turn things pretty quickly in the GI. So the point I'm trying to make is if someone's been on the SIBO train [00:24:00] for 18 months, they're probably on the wrong train, so to speak. And we need to modify our approach.

Dr. Tania Dempsey: Yeah, I think I think that's definitely an important point. And not to get too off field here, but, you know, we started the conversation talking about parasites. Right? So, how often do parasites play a role in some of these things that you're talking about?

Dr. Michael Ruscio: This has been, I guess life gives you the lessons that you need to learn because as you can imagine early in my career, I was gung ho for finding parasites, given my own experience, right? So I was doing two stool tests on every patient, you know, two different labs just to make sure we can find the parasites.

And I can say for amoeba histolytica specifically, I had maybe seen four cases in my entire career and I don't know if I was ever able to successfully cross validate one instances of those, meaning you did a repeat test or you tried to verify via a different methodology. And [00:25:00] then other parasites, incredibly rare, incredible,

now there, there is one newer lab. I won't mention unless you really want me to, but that specializes in parasites. And we ran this on multiple patients in our clinic in a row. And you just saw literally every patient had Giardia and it just doesn't make any sense to me that eight out of eight of the patients that you test are going to all come back positive for Giardia.

And I'm not talking about like an endemic pocket where there was maybe an outbreak or maybe like a family that went camping and we, you know, they all got sick from drinking the, you know, the river water. So I do think there's at least one test out there that's probably producing false positives for parasites.

So I have some concerns about that too, but pretty rare. Like I have to say, I was very surprised at how rare true parasites were defined.

Dr. Tania Dempsey: That's interesting. I, my experience is a little different and, [00:26:00] and we do we do use a different, hopefully it's a different lab than the one you're talking about. And we don't necessarily see, like, Giardia a lot or, or things like that, but what, what we're starting to see is that particularly in patients with altered immune systems, you know, typically there's some kind of

immunosuppression or immunodeficiency may be driven by mast cell activation syndrome, may be driven by autoimmunity, may be driven by true, you know, they have a common variable immune deficiency or something is Cryptosporidia. And I can, I can really sort of understand, Cryptosporidium is, is one of these parasites that I used to see often when I, you know, I did my training at Bellevue Hospital in in New York City, we had a large HIV population and and Cryptosporidium was something we used to see very often in the HIV [00:27:00] population because they're immunosuppressed.

And then I didn't see it. You know, then I just never could imagine that, you know, people who, you know, didn't have HIV could, could get this. And then I started doing this test and, and periodically, not consistently, but periodically it would show up. And I remember my first case, I was thinking, oh, this has to be

false positive because this patient doesn't have HIV. I just never thought that anyone else could have it. And then we repeated it and validated it. Right? So we knew that it was there. And then it's sort of then made me realize that many of our mass cell patients who probably are the ones that also have, maybe they have mold exposure.

So they have a suppressed immune system from mold. Maybe they have a chronic infections that suppressing their immune system, particularly Bartonella, which really does a number. I mean, all of them can can be problematic and and then they were, it was making them more [00:28:00] susceptible to you, you know, maybe this is something this is something that can be in the soil and in water. You know, a lot of patients if you take a history,

they'll tell you that no, no, they didn't travel necessarily, but as a kid, they would be you know, jumping in streams by their house. I have a few patients who are like, Oh, yeah, when I was eight years old, I used to like swim in this freshwater stream by my house, right? This is actually where Cryptosporidium lives.

It's where Giardia, I mean, you can get a lot of these parasites. So, so it just clues me in now, if I see that, or if I do see a number of other parasites on one sample, that there is something wrong. It's less about the parasite and more about the immune system that I need to consider.

Dr. Michael Ruscio: Yeah. I'm so glad you said this because I've made a mental note. I wanted to follow up with you with our data because we have it in a nice table and shoot it over to you so we could compare because I think we might be using the same lab. Maybe, maybe [00:29:00] not. Yeah, this, this is an ongoing challenge, I think is correctly identifying parasites and, and not to go too far afield, but I think it's kind of interesting.

So just really quick, at the last naturopathic gastroenterology conference, I had a chance to sort of huddle with a few of my colleagues and two of them who have fairly big GI clinics, the same suspicion with this lab that it produces a lot of false positives. But I always remain open. So let's, let's pow wow.

I'll send you an email and we can sort of compare

some of our notes.

Dr. Tania Dempsey: Let's do it. Let's compare samples and figure out, you know, maybe we need to do split samples.

Dr. Michael Ruscio: That's what we want to do next.

Dr. Tania Dempsey: Yeah, yeah, I think that's something maybe that we need to start doing to understand this, this problem. But I think that, you know, the way you could think about it is that whether it's parasites or bacteria or fungus, I mean, generally, there are people who have this abnormal imbalance, right. Because maybe, maybe we all have some parasites [00:30:00] and some abnormal bacteria and, and some yeast, right?

But maybe it's supposed to be all in balance.

Dr. Michael Ruscio: Yeah. And I mean, there's a few really interesting things in response to that. A lot of the treatments, at least a non pharmaceutical treatments, have tremendous overlap in terms of they're going to improve immune hosts you know, immune system competency. They're going to be antibacterial, antifungal, antiprotozoal.

So that's why we've progressed to less testing over the years because there's so much overlap with how you treat someone.

Dr. Tania Dempsey: What is your, what is your approach? How do you, what do you use both natural, pharmacologic, diet? You know, what's your approach to a patient who's. Do you suspect SIBO, SIFO, dysbiosis, you know, all the, all the rest.

Dr. Michael Ruscio: I think there's, there's three diets, um, starting with diet, right,

being like a food first healthcare provider, to try to [00:31:00] quantify who we pair it with out of the gate. That's the low FODMAP for bacterial overgrowth type. That's a candida diet, which is lower in sugars and starches and lower carb for the fungal overgrowth type. And then for people who have a lot of symptoms of mast cell or histamine intolerance, a low histamine diet. And sometimes we combine the low histamine with the bacterial or fungal, it just depends on the person, right? Some people, you kind of have to meet them where they are and doing a double diet too much.

But I think that's kind of your, your step one regarding diet. And then with the histamine piece, I'm sure you guys have spoken a lot about this, but if people say really, it's the fermented foods, that can be a really big flag from their trigger. Like, you know, I, I'm try and eat fermented foods, but I notice I get brain fog,

I get a runny nose, I have loose bowels, I get irritable, then that's one of many a clue that there could be histamine intolerance. But that [00:32:00] combined with a good probiotic, and we've been using a formula that we developed called triple therapy. And in many different areas, we see that a dual or a three drug or treatment regimen is better than just one standalone,

right? Dual antibiotics are better for chronic infections, as one example, whether that be for SIBO, in some cases for other vector borne infections, same thing. So we're just taking that same concept and applying that to probiotics. Now with probiotics, if you look at the, the OG, if you will, the, the really traditional probiotic, that's your lactobacillus and bifidobacterium species blends.

So VSL three, Vis biome, these are kind of like your traditional versions of that. Then you have your Saccharomyces boulardii, or florastor, which is the healthy fungus. And then you have your soil base or spore forming with various bacillus species.[00:33:00]

So what we do in sensitive patients is we send them home with the three separate bottles and we have them start one at a time.

So in case there's any one of those that does not agree, then they just don't use that one. So that allows us to personalize. If they're not sensitive. We give them the all in one, which essentially takes 2 capsules from each bottle and puts into a single serving sachet. And that's been really helpful because it allows us to do two things again, the, the really sensitive people, three bottles, take them home. A month later,

if you're on all three and it's easy peasy, then we move you over to the combo formula, or you just only continue with the one or two that you tolerate. And almost everyone tolerates at least one of the three formula types.

Dr. Tania Dempsey: Yep.

Dr. Michael Ruscio: So that's, that's kind of how we start with, with a pairing of, of diet and then probiotics.

Dr. Tania Dempsey: Gotcha, and then and then beyond probiotics, is there anything else? Are there any [00:34:00] herbs or anything else that you find that you need to tap into?

Dr. Michael Ruscio: Especially for the bacterial overgrowth types, and to some extent for the histamine intolerance types, the elemental diet that you mentioned earlier can be really helpful. So the elemental diet is essentially, picture of a protein shake or a meal replacement shake that's formulated to be predigested

and hypoallergenic. And the way I sort of describe this is, it's like giving your gut a rest. If you sprained your ankle, it'd be really hard to heal your ankle if you were running three miles a day or eating three meals per day. So this formula being a complete meal replacement, but it being predigested and hypoallergenic, everything gets absorbed within the first couple of feet of the

small intestine. It will starve overgrowth, and this can be a really easy way to calm down inflammation. There's a bunch of studies showing high efficacy in [00:35:00] inflammatory bowel disease, so Crohn's and ulcerative colitis. There's emerging data on SIBO and IBS. There's only two or maybe three trials but the results there look really promising too.

And then there's, and there's, there's, and there's also herbals, herbal antimicrobials. There's so many wonderful herbs. And the body of literature here is getting so much more impressive. Just as one example, there was a study looking at, this was vaginal yeast, but I think this also applies for intestinal yeast.

Again, because intestinal yeast is much harder to quantify. So you see less research studies because there's disagreement on how we even quantify if someone has intestinal, but vaginal yeast is a much more clear cut, or oral thrush. So you see more studies regarding fungus with oral thrush or vaginal yeast.

So that's why I referenced these, but they use this herb called Horopito. It's a New Zealand shrub. They found better long term efficacy, meaning clearance of the vaginal candida, but then a prolonged remission, when [00:36:00] using Horopito as compared to fluconazole. So there, you know, some really cool studies and a similar study in SIBO found that berberine led to longer time in remission as compared to the antibiotic Rifaximin.

So there, there's a lot of herbs that can be used. Undecylenic acid is another one that's really interesting for fungus. Then you have garlic, oregano, pau d’arco. I mean, there's, there's so many that we actually have a table that we've made that lists out bacteria, fungus, Borrelia, Bartonella, and Babesia, and all these different herbs, and it checks off, does it hit the different pathogens, does it hit the biofilm form, does it hit the cyst or the growth form, and we cross reference that when we're making a protocol for someone just so we can say, well, this person, you know, they have bacterial growth, but I think they also have, or Bartonella, but I think they may also have fungus, cinnamon can kind of hit both, so we're going to use cinnamon.

It's not perfect, but at least gives us an ability to try to [00:37:00] get as much like two or three for one benefit with herb selection that we can.

Dr. Tania Dempsey: I love that. No, that's that makes a lot of sense. I know we have to finish up, but I wanted to ask you know, one of the things that we do see a lot and people ask us a lot about is recurrence. Right. So, you know, you've changed the diet, let's say you've done, or you've done the elemental diet. Maybe you've done, you know, you've done, you've done the probiotics, you've done, you know, maybe you've even done Xifaxan, right?

Or maybe you've done these herbs, you've treated for a while, and then either, you know, you've come off some of the stuff, and then the symptoms come back. Or you know, and it could be coming back right away, or it could come back, you know, at a later date. How often do you see recurrence? And what do you think is really going on?

Dr. Michael Ruscio: This is always a tough one to answer because my suspicion is in a lot of these cases, there's something in addition to SIBO, [00:38:00] but SIBO is what's blamed because SIBO is the most visible. So my strong suspicion is that oftentimes the relapses aren't due to SIBO, it's due to something else, either another infection that they have, or they also have fungal overgrowth, and they just haven't been able to nuance a plan that's going to hit all these things.

I also have observed that there, there's some really incorrect messaging in some of the SIBO circles that people should avoid probiotics. And I think this is one of the reasons why people relapse. The, the frustrating thing about this admittedly is if we're going to have the unifying language of science, it wouldn't matter what our credentials, our training or our biases are, right?

Maybe you prefer medications, maybe you prefer herbs, but if we're all speaking the same scientific language, then we should be in agreement. And the challenging thing here is some big thought leaders, they're violating just normal scientific [00:39:00] discord in the sense that we have a random, we have a meta analysis of over 10 randomized control trials showing that probiotics can efficaciously treat SIBO.

That's the best data point that we have, right? That answers the question. We have people that argue from an observational study or one small clinical trial and or just sort of their own speculation. And sometimes a problem here is people are microbiome researchers and they do this really cool stuff in the lab.

And they say, well, we saw a little bit of a higher level of lactobacillus in SIBO patients. So we don't think SIBO, and this actually happens, we don't think SIBO patients should use lactobacilli. But they, they ignore if we take a group of people with SIBO, we give half lactobacilli and half a sugar pill, the people getting lactobacilli feel better and they clear their SIBO.

All right, so it's that sort of data that should trump the mechanistic and observational data. But that doesn't always happen. So I think a lot of the confusion comes from incorrectly [00:40:00] citing the body of evidence, people not using probiotics and that being one great way, at least in my view, to maintain a healthy gut and to help prevent recurrence.

But coming back to a few of the things from before, they might have low stomach

acid and risk factors for low stomach acid are being over 65, a history of anemia or a diagnosed autoimmune condition. Those three things give you a decently increased prevalence. 20 to 40 percent of people with those risk factors will have low HCL.

And the nice thing about HCL experiment, people will usually notice within a few days, definitely within about a week, they'll have less prolonged fullness. They'll have less belching. They'll have less reflux. So when it hits, when it lands, it really lands. There's the, the tortuosity or the scar tissue, right?

That can be another reason for relapse or recurrence. And then another thing is the mentality that people have. And [00:41:00] sadly, it has been demonstrated that people with IBS or irritable bowel, are more likely to have anxiety. And so what I think happens is you combine the fact that that gut imbalance triggers increased anxiousness, probably via the gut brain connection,

and then these people can end up in a really restrictive dietary pattern. And I think sometimes it's the, it's the worry that's actually where most of the disease is coming from. And it's not actually organic. It's not to say that it's all in their head, but it's saying that the worry in their mind is actually increasing

the reactivity of their gut. In fact, there was one study that looked at blood samples from depressed, anxious cohorts on the one hand versus healthy controls on the other. They stimulated the blood with lipopolysaccharide, and there was a much higher inflammatory reaction in those with anxiety and depression as compared to the healthy controls.

So [00:42:00] part of where the symptoms coming back might be coming from is worry turning up their immune system, causing this food reactivity and the whole sort of cascade of overgrowth and symptoms that can you know, ensue secondary to that. So mindset I think is really important too.

Dr. Tania Dempsey: I, I agree with some of that, but I'm going to provide a slightly different perspective because I think what happens is a lot of those patients have mass cell activation syndrome. They're more prone to a, a more inflammatory state. I think they're also more viscerally sensitive, and I think it's the mast cell interaction with the nervous system.

I think that their nervous system tends to be more in sympathetic drive, like more, they're more reactive. But I think the mast cells are driving it, so I think it becomes a little bit of a vicious cycle. There's an imbalance in the gut. They probably feel it more [00:43:00] because their mast cells have more, you know, activity related to that imbalance.

So, less, less of an imbalance triggers more mast cell activity because mast cells are really, you know, designed to react to change and in quotes change in the environment. Any shift, whether it's a, you know, all of a sudden, it's a little bit less lactobacillus, or it's a little bit more of something else.

I just could be minuscule. Then mast cells get more reactive. And then, and then that I think, and because we know that mast cells line, every nerve in the body, so the mast cells are, are directly impacting the nerve signaling, right, causing inflammation in the nerves, which I then think that gets perceived as anxiety in some patients, because it's like the nerves are, are very heightened.

And then that, that sympathetic drive, that anxiety, all that, [00:44:00] then feeds back obviously making mast cells even more reactive. And then it becomes like a vicious, vicious cycle. So what I think works, tends to work well is things like limbic retraining, you know, those programs...

Dr. Michael Ruscio: Fully, fully agree. And this is just really good. This, so that's the one thing I'd want to bring people to with my, with my diatribe from a second ago is for some people, they just need to do some of that mindset work and it has a tremendous benefit for them.

Dr. Tania Dempsey: So, you know, DNRS, Gupta. I think there's a new program, Primal Trust. I think there's one more program that I'm that I'm forgetting.

Dr. Michael Ruscio: There's one I heard actually, because I had just one of these cases the other day who, you know, and I'm sure you hear this periodically, Doc, I did DNRS and it changed my life. And he had done DNRS plus this other program called Curable, which is a new one I just heard of, and we're going to be looking into that.

There's that, There's there's a, there's an, a cognitive behavioral therapy app [00:45:00] too called Clarity, which is really nice for people who tend to catastrophize. I had some food, I'm having symptoms, and all of a sudden this thought cascade. Oh my goodness, my mast cells are activated, it's causing inflammation,

it's causing a leaky blood brain barrier, it's causing leaky, right? Like this whole worry cascade. Clarity is really nice in helping to sort of disarm that runaway thought cascade.

Dr. Tania Dempsey: And to and to be clear, you know, again, like, these are these are all helpful tools. Right. And I, and I want to be clear with with people listening. You know, we're not saying that it's in their head at all. Right? Because we want to be careful because unfortunately, conventional medicine has really sort of, you know, really gas lit a lot of patients to really say, it's not about that.

These are physiological changes that are occurring, but it can go into this loop, which really can be you know, very disabling. [00:46:00] So it's about trying to figure out, okay, we're going to address the gut imbalance. We're going to address whatever else we think is going on. We're going to try to stabilize mast cells.

And we're going to look at this other piece to try to calm down the limbic system and the, and the, and the autonomic nervous system. And it, right, and it has to be that really comprehensive approach. Right.

Dr. Michael Ruscio: Yeah. And I think there's a really important distinction between it's in your head, go away, see a psychiatrist versus there's something in your head and here's what we can do about it.

Dr. Tania Dempsey: And it's really also in your body. The mind, the, the, the gut brain connection is just so tremendous. It's even, you know, there's so much literature on it, but you know, it, it clearly is a important.

Dr. Michael Ruscio: Oh. And one thing I should mention really quick is low dose amitriptyline. So a tricyclic antidepressant. We had Alex Ford on the podcast, who's from the [00:47:00] University of Leeds. He published a meta analysis in the Lancet, really demonstrating pretty impressive efficacy for IBS with low dose amitriptyline.

So it's something else to consider for people. And that might be modulating both brains, if you will, by increasing serotonin level, probably morely in the gut. And it's a low enough dose that it's not going to have a antidepressant effect, but it does seem to have some sort of positive impact in the gut, probably through some of these serotonergic or, you know, gut brain feedback loops that we've been discussing.

Dr. Tania Dempsey: No, absolutely. I mean, that's been a tool, but that, you know, I've used in some patients, but I'll tell you another really cool tool is Cromolyn.  Cromolyn. It doesn't it doesn't work for everybody. But interestingly, it is a drug that's not absorbed into the system at all. It really just deals with the mass cells in the gut.

But, because of the mast cells, I believe, I don't think anyone's [00:48:00] really studied this yet, but I believe that that the mast cells in the gut are basically talking to mast cells elsewhere in the body. And because of all the nerves in the gut, those nerves are also interacting with other nerves in the body.

So, sometimes if you use Cromolyn for the right patient, and it calms down the gut mast cell activity, then it also seems to impact and decrease anxiety, and decrease visceral sensitivity, which is really, really fascinating, you know, and I've seen that, I've seen that quite a bit.

Dr. Michael Ruscio: It's something a little bit similar to that I should also mention is aminoglobulin therapy or aminolin.

Um, you know, these bind to the LPS fragments in the gut. And the way I describe it to patients in the clinic is picture if you were to swallow shards of glass. Those are going to be triggering as they make their way through your intestinal tract.

But if we could dip those shards of glass in wax so they had soft edges and they would no longer [00:49:00] trigger your immune system, that's kind of what the immunoglobulins do is, is they, they neutralize some of these LPS and toxin fragments from stimulating the immune response. And then kind of to your point, it can interrupt this, this cell perpetuating feed forward cycle

of wind up. So for some people and specifically with those with histamine intolerant symptoms, that can be a game changer when they get on a good dose, at least five grams per day. And some people, what they'll do is they'll, they'll buy a bottle online and they'll do like two or four capsules, which gets you to about 2.

5 grams. And for some people that's just not enough, they really need the five or in some cases, the 10 grams per day, which can be a lot of pills. I think that's 16 pills per day, but nevertheless, you know, it clearly can be helpful.

Jill Brook: Well, I love all this information

and thank you so much and Dr. Ruscio, I just want

to also say that I love your

podcast and I would encourage our listeners to listen to it because you do so many very deep dives on [00:50:00] all of these things and I so appreciate that you're bringing the evidence, and making it available to everyone.

But my big question is a lot of our audience has dysautonomia, and we know that dysautonomia can come with a lot of gut motility issues, and so I know we need to be quick, but would you mind just saying a couple words about how that can affect the SIBO picture?

Dr. Michael Ruscio: Yeah. Well, you know, credit to you, Tania, because one of the things you've helped me to better understand is a connection of some of these vector borne infections, to the nervous system, dysautonomia and then to the gut. So certainly when I see dysautonomia, one of the things I'm a little suspicious of is some sort of vector-borne infection, Babesia, Bartonella, Borelia, or some of the other cohorts, if you will, but also we've been experimenting with this thiamin protocol, vitamin B 1.

We recently had Elliot Overton on the podcast who's essentially dedicated his life to vitamin B 1 research and his, his theory on this and he makes a pretty good case is that some [00:51:00] dysautonomia and corresponding dysmotility might be due to thiamin insufficiency. And I do wonder with, you know, with, with processing of food, that's one of the ways thiamin is going to get taken out of the food supply.

A lot of the thiamin research goes all the way back to Japan when they started fortifying or fortifying, excuse me, the rice, removing the, the fiber and the thiamin and the white rice was creating population wide thiamin deficiency. And in some of these people, thiamin does seem to sort of unlock sort of slowed intestinal motility.

So we're still playing with it, but I can say I've seen enough people who, you know, when someone comes back, you kind of get one of a few responses. Negative reaction, I'm not sure if it helped, maybe it helps, it really helped. And I've seen a few people who've said it really helped [00:52:00] and when I have a few of those, I kind of perk up and say, okay, there's something here.

So that's something for people maybe to think about one of a few things with dysmotility and also the, some of the basics, like getting in adequate salt. Sure. But the, the vitamin B1 deficiency is something that is notoriously difficult to test for. So, this is where an empiric trial of just going on the vitamin for about a month and then seeing do things move literally could be worthwhile.

Dr. Tania Dempsey: We have to have that guy on to talk about this.

Dr. Michael Ruscio: Yeah, he's, he's a good, he's a good

interview.

Dr. Tania Dempsey: It's very cool. Michael, thank you so much for being here. This was I mean, we can talk for hours and we can. So, so where can where can people find you.

Dr. Michael Ruscio: I'm at drruscio. com, D R R U S C I O. com. They can plug into the book, the podcast, YouTube, our supplement line, clinic, everything is hubbed there.[00:53:00]

Dr. Tania Dempsey: That's great. And I can, I can attest to your excellent podcast. I've been a guest a few times.

Um, so thank you. And we're excited to have you here today. So, thank you so much. And any, any last words.

Dr. Michael Ruscio: It was great. Thank you for having me. And, and the, uh, the, what I'd want to close with for people is don't give up hope, right? People have, almost everyone's experienced a winter of their life, so to speak. And it stinks when you're in that winter, but every day also, people can come from winter to spring and then to summer.

There's a great quote by Nietzsche that I like, which is something along the lines of for the branches of a tree to reach the heavens the roots must reach hell.

So you may have to really go to some deep dark places on your healing journey to eventually be able to extend your branches to the heavens where you feel great.[00:54:00]

So you're not alone. There's a lot of, I'd like to think great minds working on this to try to help. And just don't, don't give up faith and hope that you can heal.

Dr. Tania Dempsey: Agreed. Great. Thank you.

Jill Brook: Wonderful last words. Thank you. Okay, listeners. That's all for today. We'll be back soon with another episode. We do receive your requests and we're working on them, so stay tuned for next time. And until then, thank you for listening, remember you're not alone, and please join us again soon.