How to Have a Healthy Gut [transcript]

Written by Christopher Kelly

June 27, 2018


Tommy:    Hello and welcome to the Nourish Balance Thrive Podcast. My name is Tommy Wood and today I'm joined by Dr. Michael Ruscio. Hi, Michael.

Michael:    Hey. Thanks for having me.

Tommy:    Thanks for joining me. I don't really think that you need an introduction. So, we're just going to dive straight in. We'll obviously link to all your stuff in the show notes, but one of the reasons why I want to talk to you was because you recently published your book, Healthy Gut Healthy You, which details a lot of the methods that people and their practitioners can use to help address gut issues and some other things.

    I know you talked a lot about the book on your own podcast and elsewhere and I really highly recommend it. I think it's great. But to stop you having to cover the same ground again and again, as I know you've done in multiple places, I thought we could sort of go in some more expanded topics. So, maybe we can start at the end. The book is a great self help guide and I really encourage people to work through it in a methodical manner if they think that they need some of these aspects of fixing their guts. But at what point should somebody admit that they need help with their gut and where they should they go?

Michael:    Good question. Well, I should first say I'm learning as I'm interacting with people on our comments forum because we have a comments forum for every step of the book protocol. So, there's eight steps so there's eight little forum -- or I should say there's eight comment threads where people can read other's questions and answers and try to obtain some support there.

    One of the things that I'm figuring out is that people, and I think this is human nature, but they doubt themselves and they doubt the protocol. I would say the first thing to do is don't jump ship before you even set sail. You got to sail through the whole protocol and go through the steps and oftentimes you'll be contending with stuff that you read or preconceived notions that you have in your head.

    And that's all fine and good but you've got to throw all that out and follow the protocol because the protocol is essentially what I do with patients. It is an algorithm. So, we do check in along the way. If you're not better at step two, that's okay. We have eight steps to go to get there. It's important, firstly, to follow the protocol, not overcomplicate it and realize that that protocol is a desolation of about seven to eight years of very methodical and thoughtful clinical practice combined with just under 1,000 medical references to create an approach that should help the vast majority of cases get there.

    I'm not talking about, and I'm sure you know this, Tommy, after reading the book and it will be evident for anyone who does read the book, this is not a simple starter's guide. It can function for someone as a starter guide only needs simple solutions but the protocol is adaptable to be able to offer you progressively more advanced treatments if you have more advanced needs.

    The first thing I would say is truly follow the protocol, go through all the steps and don't let stuff that you've read or heard other where throw you off following through with what's in the book. But now to your question more directly, I would say if someone has gone through the protocol in the book and they don't feel like they have achieved at least 70% overall improvement, that's a good time to think about bringing in a provider.

    There's maybe one caveat I should mention, and this is also outlined in the book, if you're at 70% improvement or let's say you're at just south of that, let's say you're at 65% but you feel like you're trending in a positive direction, give your body some time because sometimes people will see a notable level of improvement at the start of a process.

    Maybe it takes them -- That's a self help plan in the book. Maybe it takes them three and a half or four months and they improve 60% in three months. That's pretty darn good. And if they feel like they're continuing to improve, even if it's a slow but steady improvement, give your body some time because sometimes that last bit of improvement is accrued with time.

    But if someone has done that and they still feel like there's this chunk of 30% improvement that they're not able to get, that would be a good time to reach out to a provider because there are things that sometimes require a little bit deeper of a dig. Sometimes there may be true hypothyroidism that's present that needs to be treated.

    There may be a high degree of histamine sensitivity that has to be worked through. There are definitely other things that can be present if you have them methodically and going through the process and you bring your notes and observations to your provider, you will give them some very important foundational information to work with as they start you in on the clinical process. I know I give a lot there. Hopefully, at some point, I answered your question.

Tommy:    Absolutely. I'm really glad you went back to the principles of actually working through it and sticking with the program because it's so easy with the amount of information that people have access to just jump from ship to ship and never really stick with one methodical process and then you never really know what it is that will help or whether you're getting benefit from something. I think that's the perfect place to start and, hopefully, people will take that to heart.

Michael:    And just one thing to piggyback in there. The people who have negative reactions are the ones that find it most challenging. I get it. You're doing something, you're feeling only 20%, you start doing something and now you feel like you're at 1%. That's a very disheartening feeling to experience but that's part of the process.


    Whether you work with a clinician or do it yourself kind of protocol, sometimes setbacks are you lose the battle but you win the war. So, for the people that have had setbacks that it's the hardest to do but probably the most important because if you have a setback and then you jump ship, it's going to be very difficult to get any traction going. So, yes, especially for those who had a setback, don't be demoralized by that. Keep your gaze forward and work the process and you'll realize that sometimes the setbacks are just part of getting healthier.

Tommy:    Yeah, that's great advice. Then moving into the sphere of practitioners, one of your, I guess, cries in this space is that the volume of testing that a lot of practitioners are doing. Maybe you could tell us a little bit about your algorithm for testing. If somebody comes to you, when might you try empirical interventions without testing first and what determines whether you do some kind of test be it gut or stool or blood or breath test or something else?

Michael:    Great question. One of the things I look to is what the patient has done already. If someone hasn't even done a Paleo diet then I'm not going to do much testing right out of the gate. Depending on their age and family history and symptoms I might do a blood panel to rule out something like hypothyroid or very high lipids or diabetes.

    So, it depends on who walks in the door. But essentially, the less they've done the less testing I'm going to do because there's a good chance, even if someone does have high blood sugar, if we put them on a Paleo diet, we're going to see remarkable improvement in that in only a month or so. So, the less someone has done the less testing I will do.

    In opposition to that, the more someone has done in terms of, maybe they've done Paleo, maybe they've done Low FODMAP, maybe they've used HCL and they've used probiotics, and they've even done a course of antimicrobials, the more they've done the more testing I will do. And there's also a component of this where I ask people in my intake paper work if they prefer to be conservative or aggressive.

    Part of that is just trying to keep someone feeling like the process is crafted to them. If you have someone who is an engineer type and they love data and they love numbers and they have a hard time doing anything without having some kind of objective measure to guide it, then they may want to do a SIBO breath test even though I may not say it's a necessity.

    I also factor that in but at the same time it's important to be able to reign someone in if they've been fed this excessive functional medicine testing model to try to help them understand, okay, this is a potential but these other three things that you want to test are just absolutely wasteful and there's no data to support testing them.

    It's not to say I humor someone in wasteful use of the resources. Within reason, within things that are effective and have some validity to them, I will work within someone's preference of how conservative or aggressive they want to be with the testing. And then in terms of what I start with, and this list is actually shrinking every few months, I often will do a SIBO breath test and I will often do one what you might call expanded ova and parasite analysis where we'll test for some dysbiosis markers in addition to ova and parasites.

    So, we look at your H. pylori, your candida, all of your worms and amoebas and blasto and essentially that lot. Some of those panels will include microbiota assay to give you microbiota mapping, so to speak. In my opinion, that information is fairly close to useless. Unfortunately, not everyone has keyed in on that. For example, showing that you have a low level of Lactobacillus acidophilus in your stool, I have not seen one study showing that that has a positive productive value for someone responding to Lactobacillus acidophilus probiotics.

    So, I'll run those two and then oftentimes I'll run a blood panel either CBC or CMP which looks for liver and kidney function, screens for anemia, looks for basic metabolic imbalances. And I'll include with that TSH and free T4 plus or minus potentially a free T3 and thyroid antibodies depending on if I'm suspicious and also if they have insurance or if they don't have insurance. If they don't have insurance and they're paying cash I'm going to do much less.

    And then we include in that some expanded iron markers, sometimes hemoglobin A1c and fasting insulin. Sometimes, some inflammatory bowel disease markers if we're thinking about that. I may be missing a few things there but that's kind of where we start. It's not overly elaborate but it's enough to give us some hints in terms of where to go.

Tommy:    Yeah, absolutely. That makes a lot of sense. Then once you do start down the path of some kind of protocol, how are you tracking responses to therapy?

Michael:    The main measure I'm using, it depends. If you're tracking thyroid hormone then there's not a good symptomatic gauge for that. So, if someone's starting a medication, you're trying to optimize thyroid hormone medication then, of course, testing is needed. If you're trying to track something like diabetes that has very simple straightforward lab testing then you can use the fasting blood glucose, maybe a hemoglobin A1c but the hemoglobin A1c can be confounded by things like hypothyroidism so you have to be careful about how you much you read into the hemoglobin A1c by itself.


    But if there are more, I would say, traditional medical conditions that have very well established testing markers to monitor then I will use those. If it's something like IBS and SIBO I actually am doing much less SIBO testing and I no longer advocate the SIBO test-treat-retest and then proceed algorithm that's more so supported or endorsed by Pimentel. I think that's a wasteful endeavor.

    If you look at the North American consensus, the expert consensus on breath testing, they recommend more liberal use of SIBO breath testing. Whereas the Rome Foundation, arguably the leading body in gastroenterology in the world, has a much more conservative position. They've recommended for SIBO breath testing using an only in select cases essentially.

    If you split the difference between those two, you arrive at the conclusion of one systematic review which was published, I believe, in 2012. It's a little bit older but they essentially concluded start off with SIBO breath testing to identify if that is an issue that you're going to be grappling with and if it is present, from there, just treat based upon empiric response, and that's essentially what I do.

    We may do a, if we're struggling to obtain the response that we're looking to get symptomatically, after a few rounds of treatment, if they're still unresponsive, we may do another SIBO breath test to see if we've eradicated SIBO, and their symptoms are still present indicating that there's something else we should be looking at, or if the patient wants that verification and they would feel better if we perform a retest, I'll retest in those cases.

    There are so many, many variables there along the clinical process but those are some of the broader strokes. And then for findings on a traditional stool test like H. pylori or candida, I essentially follow that same process where I will get a test at baseline to determine what we're dealing with and then I treat and modify the treatment or use entirely different treatments based upon their symptomatic response. And we keep treating them until we get the response we were looking to get.

    We may, if we're struggling a little bit, test along the way but in most cases after you've modified your treatment approach a few times you usually get to an acceptable level of improvement. And once you're there I find most patients are much less motivated to perform testing. At that point it's more of an optional. If they want to do it we can do it. If they don't want to do it, I oftentimes don't feel the need to do it with the exception of a handful of pathogenic infections.

    If it's something like an Entamoeba histolytica then I am very vigilant in retesting that because that is not something to be trifled with. Whereas if it's something like candida, it's not to say that some person may not have some candida on culture and could be perfectly healthy. So, quantifying that we've got them to zero, I'm not sure if that adds any clinically. That's just a couple of things that come to mind.

Michael:    That makes a lot of sense. I'm wondering now how closely you're following some of the other things that people are talking about that it might be important to measure in the future. So, I know Pimentel has been talking about hydrogen sulfide and things like that. Is that something that you think is going to be worthy of our time in the future or is that sort of a bit of a SIBO navel gazing?

Tommy:    I think if we can get the hydrogen sulfide SIBO testing accessible, meaning not very expensive and if it could be done via breath analysis, which has been done, there has been one study done using a breath analysis for hydrogen sulfide SIBO, and they did show that symptoms correlated with the test results and that post treatment symptomatic improvements, correlated improvements on the retesting, that's been validated at least in one study and there's been one other study showing that symptoms correlated with hydrogen sulfide but there is no treatment in that study.

    If it could become something that could be done fairly easily just like a take home lactulose or glucose hydrogen methane SIBO breath test then I would be fine with it. Certainly we have some data to show that that's a player but I would see it falling in the same kind of approach that I outlined for the normal SIBO test that isn't practiced right now which would be you can test to get a baseline and then steered empirically from there, potentially retest once you got into a symptomatic position or retest along the way if you're a little bit unclear as to why someone is not responding to therapy.

Tommy:    And what about general symptom control? So, I'm thinking about a lot of the work that we do through NBT and then some of the other positions that I have work with the athletes and a lot of them have gastrointestinal symptoms either because they get exposed to things when they travel or some other underlying problems. But these guys, their racing pays the bills and they often have to race every weekend or every other weekend. [0:14:56] [Indiscernible] have the time to invest in a full kind of algorithm treatment protocol.


    Do you have thoughts about controlling symptoms in anybody in acute periods of pain and people with IBS type symptoms, for instance, if you sort of like need to get them to a race or back to performing as quickly as possible?

Michael:    Sure, yeah. There is a number of things that can be done as a palliative measure for if someone has an IBS or IBS like flare. One is fasting. Someone could just do a one day strict fast on water or if they need some kind calories, and we talk about this in the book, they can use a modified fast using something like bone broth or the master's cleanse which is a cleansing lemonade or even some kind of juice fast, they could also use an elemental diet if they have a fairly high amount of caloric needs, they could do a liquid pseudo fast on an elemental diet.

    All those can be very helpful and they can be implemented very easily. The utility of those, I think, should be really emphasized because some people need to take something. There's this ethos in natural medicine of needing to take something to fix a problem but sometimes doing nothing is actually the best thing that you can do for someone especially if someone has a history of being reactive.

    There's kind of a coin toss on whether a new agent will help them or may flare them even more if they have a history of being very reactive. But those are a few. And then also tightening up their diet. A low FODMAP diet is a great place to go for if someone has a flare. A dose of probiotics can also be helpful. If they're taking a probiotic they may want to up their dose. If they're not taking a probiotic, they may want to simply take a high dose probiotic for a few days to help calm things down.

    Peppermint, there's also a few promising trials with peppermint. I think the data on peppermint oil does suffer from a degree of selection bias. I mean, there's only been a handful of studies and so you're seeing -- they report a fairly low or good number needed to treat in some of the analysis on peppermint. I believe the number needed to treat with peppermint is two to three and the number needed to treat with probiotics is eight to nine.

    The number needed to treat means if you treat patients after you've treated this many you will see one who has a positive response. So, you'll see one positive response for peppermint oil every two to three people you treat, with probiotics will be every eight to nine people. But there have only been, I believe, four studies on peppermint. There's been about nine of these studies on probiotics.

    So, when we're initially studying something there's a selection towards studies that you'll benefit because those may be the only ones that get anywhere and there may be pressure to publish positive findings and build up some excitement before the negative ones are actually published. It's unfortunate but it is identified in many studies we'll look at bias as part of their reporting for the waiting of a finding.

    Peppermint oil may also be one. I've heard some good things about charcoal. I haven't experimented with that myself. I'm certainly open to it. There's also the potential of some anti-inflammatory compounds like ginger or using something like glutamine or aloe. I haven't used a lot of those either but I'm open to those. But that's a handful of things that can be helpful for people to calm things down in the short term.

Tommy:    Yeah, that's great. Would you say a sort of a similar approach for maybe some people after some kind of viral or bacterial gastroenteritis, some traveler's diarrhea or something? If they have some ongoing anorexia or bloating or abdominal pain, would you sort of use some similar approaches then?

Michael:    Yeah.

Tommy:    Great. So, I am going to change track slightly, mainly to sort of talk about your model as a practitioner. I think you're one of the best examples of sort of the modern day practitioner who always has to be half clinician and half entrepreneur. You sort of have your practice but then you have the podcast as well, you have a subscription model of teaching practitioners through your feature of functional medicine review, and I think a lot of people listening to this are going to be interested in sort of building a practice or becoming a practitioner. Do you have any tips on how people might want to do this? Should all practitioners be trying to follow sort of an online content base model to try and fill their practice with clients?

Michael:    That's a very good question. I mean, it certainly will not hurt you to try to build an online presence in order to fill your clinic. It certainly has helped my clinic. But in my opinion, if you focus on marketing without focusing on having quality information, you'll hit a very low ceiling. And when I graduated now eight years ago, you have friends who you went to school with, and everyone's a little bit different.

    Just like we all look different, people have different minds and mentalities. I watched. I tried to be observant. I tried to be a good student of life. Some people hit the ground running and they were great at marketing, they blew up very quickly but now they haven't grown anymore since they've been out of school for three years.

    Because it was this poor level content that was marketed very well. So, they got somewhere quickly. It's almost like building a shitty boat. You'll get out into the water quickly but you're not going to be able to go too far out into the ocean without sinking. Whereas if you take more time to build a great ship, it will take you a lot longer to leave the harbor but you're going to be able to sail around the world.

    So, it depends on what you want to do. Some people don't care to be the expert. I was always bugged when I didn't know the answer to a question and I always kept asking why, why, why, and that pulled me deeper and deeper and deeper into developing expertise.


    I didn't set out initially with the objective of developing an online platform. I just have a lot of questions and I had a lot of grievances with the way things were done. For me, it was really more about just trying to find the answers and then I kind of stumbled my way into the online platform because I just needed somewhere to tell people these things that I was thinking.

    That's why I started with the podcast because I just needed an easy way to share my thoughts and ideas and then when I started doing that I realized, wow, there's a lot of people out here who are seeing these things as legitimate issues and need guidance with this. And so that kind of fueled everything else. But in my opinion, to build a successful content platform the right way with high quality information, you've got to be the one to work really, really hard because you not only have to build a clinic, and if you do a clinic the right way you have to have good clinical systems, you have to have good business and logistics systems and then you have to have this whole other business that you work on which is educational business.

    What's challenging there is it's not like we make some kind of widget and then the business just sells the widget. The widget is constantly demanding research, education and updating. It's not only the business but you also have to be at the cutting edge of the science. So, it's almost like three jobs in one. It's the clinic, it's the information acquisition, and then it's also the business of the disseminating the information.

    So, I think it can definitely be helpful. In my opinion, you've got to be able to work really hard. You've got to have an exceptional ability to organize and to work with people and systems. And you have to have the desire to do it. You have to feel like there's something wrong that needs to be fixed or an important message that needs to be shared to drive that.

    I think it was Nietzsche who said he who has a why can overcome almost any how. So, you have to have that burning drive in why. Now, if you're not in that group of wanting to go to that extreme, I do think having a reasonable online presence is totally advisable. You may want to have a website that shares some simple information and is a way of making people aware that you exist and that you're out there. It's just important, I think, not to compare yourself to someone who is doing that as a primary business compared to someone who's just doing that to make people aware of what they're offering.

    Because they're two different animals. One can be done with a small team and minimal investment and the other requires a maximal investment and a team of people and a lot more time and work. Part of that, I think, starts with a self assessment in terms of who you are and what excites you and then determining what path you go down from there.

Tommy:    That's great advice. The next question I have based on that was something that I know and I'm sure you thought about a lot because if you are somebody who decides to build an online content based platform and start a podcast, that time you're not being remunerated for if you're investing a lot of times. So, can you give some thoughts on podcast sponsors particularly people working as practitioners or health related organizations? How do you balance the potential conflict between being sponsored by testing or supplement companies with trying to produce like a completely objective podcast which is for objective content?

Michael:    That's got a very easy answer. It's a great question. It's got an easy answer. But there's one other thing I should mention because this kind of is an adjacent issue to think about which is if you do want to try to build up an online platform, realize that you may have to work very hard and take all the money that you're making and pour it into this platform for years before it's going to provide you any kind of profit.

    That's one of the biggest mistakes I see people make when I'm interacting with employees or contactors or other people in this space, they can't conceive of not getting paid for their work right away. It can be years and years where you're making almost nothing but working your butt off until you get a return. You've got to have that long term vision.

    But then regarding sponsors, we only allow someone to sponsor the podcast if I personally approve of them. If I don't like the product or the service then they can't. It's as simple as that. And the way I look at it, there are definitely a handful of good products and services in any given area. And so those are the ones that I would align with. The ones that I use, I recommend, or if it's something that I don't typically use like some of these coffee products that maybe I don't use on my day to day but we researched them, we like the product, the product tastes good, it's clean, I have no problems sharing it with our audience.

    It's just a simple -- it should be simple, which is you only allow people to sponsor products that you would personally use or endorse. The challenge comes when you need money and you're tempted to take money from someone that you wouldn't otherwise support. You just have to have good morals and not compromise on that and it's, obviously, something that I thought about and when I thought about it I said to myself, what's more important, making a little bit of money from a sponsorship or ruining your reputation?


    Obviously, your reputation is the most important thing. Giving people competent advice is what I am essentially all about. I think, if you boil it all down, that's the one objective I try to always hit which is giving people competent advice. If you're going to compromise on your morals for money then you're going to ruin it. Unfortunately, I think there are people who do do that. In fact, I could tell you some disgusting examples of people who've done that.

    I think that's terrible. I think it's part of the reason why there's so much confusion in this space because people are either honestly, ignorant, or they're fairly maleficent. I don't know which. I like to think that if someone is committing an error it's out of ignorance not out of malice. And that's probably the majority of people, are probably are honest ignorant and minority are probably malevolent. But there's also that small malevolent group and collectively I think they definitely are hurting people and hurting the field and I didn't want to contribute to that. In short, I'm sorry, for even putting in on here. In short, you just can't compromise on your morals.

Tommy:    Yeah, absolutely. I suddenly wonder if you have any tips, say, for listeners who are going to be probably consuming quite a lot of content. Is there anything that sort of makes your Spidey senses tingle and think maybe this isn't a true endorsement, this is just something that maybe somebody is doing for money? Is there anything that sort of immediately makes you think something like that?

Michael:    I think there are ways of examining the individual that would give you indications if they're truthful or biased. I think you can use that to extrapolate to the other areas like how legitimate their sponsors are. I look to how passionate someone is. If someone is too passionate, it almost always clouds their objectivity. And this is something I struggle with early in my career.

    One of the gentlemen that I lectured with right when I got out of school who was kind of a mentor to me when I was starting out said, "You've got to be more passionate. You got to be really excited." And I would look at people who lectured like that and think to myself this guy is just totally -- not my mentor per se but people who came off very, very passionate are totally unwilling to look at the contradictory evidence to the position.

    And the problem with that is that gives you someone who is ignorant. I've quoted before that dogmatism can only exist in the presence of ignorance. Someone has to be ignorant to the contradictory information to their point to be so passionate about their point. So, I look to people who are overly passionate. That's one dead giveaway. Along with that, you look at the type of language that they use. Always works. Incredible results.

    If you're hearing this strong language that accompanies passionate speaking or passionate tone, then they are almost certainly going to be inflating the claims that they're making. So, look for conservative language. Look for cautious thoughtful communication and crafting of an argument and also look at their references.

    If they're referencing animal model studies compared to human model studies, then that's a dead giveaway because you can find the mechanism or an animal model to support almost anything. But you have to be a disciplined scientist to only use clinical trial or predominantly use clinical trial data. And you don't have to be a science geek to figure this out. But if you look at the references and you lick through and it takes you to a page of PubMed or whatever it is, and you just read a little bit, and if you see mouse or Petri dish or cell line or cell culture, if you see that and you don't see in humans, in 35 women, 79 men, 122,000 people, if you don't see the research being done in humans but rather you see cells, animals, cultures, Petri dish, it's predominantly that Petri dish kind of citation and there's little to no human data, then that's almost always a dead giveaway that someone is just trying to find any fact they can to scientifically footnote their position but they're unwilling to say, "Okay, this study with the magical weight loss fiber showed a reduction in inflammatory compounds that correlate with weight loss. But when we give this magic weight loss fiber to a group of people they lose half a pound."

     So, that's another thing that I think can be helpful in trying to navigate that. I lay out some guidelines for that in the book. But that's key. If you can figure out some ways to tell if a given person is someone you should or should not listen to, that can help you from getting pulled into someone's ill thought out ideas and preventing you from getting pulled into some quackery or whatever.

Tommy:    Yeah. It actually transitions very nicely to the next question I had which is somebody listening to you know or has listened your podcast or get your newsletters will know that you frequently quote from the scientific literature. I think all of the people that are increasingly interested in digging down into this and trying to understand these things better. So, can you talk through your approach through assessing a paper for quality to figure out what the data is really telling you?

    Because often the abstract on PubMed is biased or simplistic. It doesn't really tell you what the data is telling you. So, do you have some tips on how people can really dig into a study and figure out whether it's telling you what you think it's telling you even if it's in humans it might not be, but the abstract is absolutely tell you all the truth.

Michael:    That's a great point. There's kind of a macro way of evaluating this and a micro way of evaluating this.


    From a macro method, if you find a paper that you're not sure if this paper is on the mark, so to speak, you can compare and contrast that with other similar, let's say, clinical trials because we should be holding our self -- this isn't an absolute rule but if we're trying to decide what to do with the patient we should be looking at clinical trials at least or higher in terms of evidence on the scientific evidence hierarchy.

    So, you can first look to see what other clinical trials show to see if this one result was an outlier or it was potentially misquoted or misinterpreted. And then you can also look to systematic reviews and meta-analysis because these will oftentimes look for bias and sometimes they actually go through special calculations to calculate for bias and they'll also have selection criteria that try to weed out studies that were ill done. They had poor parameters or poor selection. So, that can be one method.

    If we go to the micro level, you can read the paper itself and sometimes what you see in the conclusion doesn't fully match the results or something in the results may have been left out or the results could have been interpreted one of two ways and what you see in the abstract doesn't really match the results. So, as you start drilling down and you go from the macro, which first you just attempt to get an assessment of the trend in the data, then as you start getting into the micro and you start reading some of the papers, then as you read the papers some of these things just jump out of you.

    And then you if get even more detailed you can look at things like confidence intervals and P values. But most of that will be sussed out in any peer reviewed paper. If they haven't done a good job of setting up some of the statistical parameters a lot of that will be done as part of the peer reviewed process. That's a way that you can simplify your life and not have to get overly wrapped into some of these statistics.

    But I will say start macro, start with looking at what a number of clinical trials are finding and the you can look at the summary of the clinical trials and the systematic review or a meta-analysis. And then as you're trying to get more sophisticated in your understanding of that body of literature then you start reading the full papers, and as you read them a lot of these things will start popping out of you.

    Meaning, when we actually read the result section, here's what we see. And when you read some of the tables and start reading these things you may catch what doesn't happen often but does occasionally happen, the fact that what you see in the abstract may not be fully representative of the actual results. Those are some ways you can come at this more broadly macro and then kind of come down to it in a more micro level.

Tommy:    That's great. Thanks. And then that sort of brings us on to maybe some of the things that are done in the functional medicine community that don't have as much evidence behind them. I'm sort of thinking about in the book, you mentioned adrenal fatigue. I know you talk about adrenal glandulars, adrenal support, which don't necessarily have that much evidence behind them. Can you talk about how you balance the scientific evidence versus things where the evidence just isn't there yet but you feel it's still giving some benefit and how do you -- if you have tips on practitioners on sort of how to navigate these things?

Michael:    Yeah. That's, I think, a more challenging question to answer. The way I describe that is being evidence-based but not evidence limited because there are areas where the clinical science is ahead of the evidence and so we want to remain open-minded. One of the things that's helpful, and I also discussed this briefly but I discussed it in the book, is that we want to first look to see if the clinical trials in a given area have been done.

    And if they've been done we use those. Those become our guiding principle, our guiding north star, if you will. But in the absence of clinical trials then we can look at anecdotal evidence. We can look at these lower levels of evidence in the evidence-based hierarchy so we can look at observational trials, we can look at mechanism, and I will compare and contrast that with how expensive the therapy is and any potential side effects that the therapy has.

    So, looking at the adrenal glandular as an example, there is very sparse evidence supporting the use of adrenal glandular. I did some clinical experimenting with them and personal experimenting with them and they do seem to provide some type of benefit. They're fairly inexpensive. I know of no negative consequence of using those. And if we put some glandular in with some herbals which have been very well studied then I think we have a reasonable method of providing a formula that is predominantly evidence based but also has another form of support that at least anecdotally seems to help people.

    The big thing here is there's no negative reaction that I've seen with those and they're very inexpensive. So, those are a few of the things that I look to to help guide me when there's not the luxury of having clinical trials present. We should really underscore that oftentimes clinical trials are present and people just aren't looking at them and that's one mistake we definitely want to try to avoid.

Tommy:    Yeah, absolutely. I think your point is a good one, that when you don't have the information then going for low risk high potential benefit low cost interventions and even if you don't have the data available that's still worth trying to discuss those both amongst their clinical team as well as with the patient. I think that's going to get you out most of the way. I completely agree.


Michael:    Exactly. And I'm sorry to cut in, Tommy, but one of the things, just before I leave that, is also you can position that in a treatment hierarchy where you use the more supported therapies first and you leave the more experimental, for lack of a better term, therapies for further down the line if you're not getting the response that you'd like to have obtained with your frontline therapies that are more evidence-based.

Tommy:    Yeah. And that's a great approach too. No need to wrap up quickly but sort of that transition into questions about studies that you're ordering. I know you've talked a few times about doing studies on various protocols, studies on biofilm disruptors in the clinic. I think practitioners such as yourself, you have this great body of data that's sort of siloed and other people don't necessarily have access to finding ways to do studies and then publish that is probably going to be a great way to sort of broaden some of these functional medicine approaches out into the more general medical world to make them more accepted. So, can you tell us a little about how your trials are going and what you've done to make sure that that's going to be data that you can then publish in some way to sort of help spread the word?

Michael:    Absolutely, yeah. It's a great question that you asked. One of the things that I wanted to try to do at some point over the next couple of years is really get practitioners a hub that they can plug into where we would be the lead clinic in a multicenter study where we would provide all of the guidelines and the protocols and the questionnaires and the paperwork and the parameters for other patients to use a treatment protocol in their office so we could amass that data and instead of having a sample size of 22 we can make that 845 or what have you. That's one of the things I'd like to work toward. It's a little bit out of my reach right now with the current level of resources that we have but I do think we'll be there within a couple of years.

    Regarding the research, there's a biofilm study which I'm sure you've heard me mention which we haven't published yet. I had to put a number of things in the back burner to get the book out there. It was more time and energy than I thought was going to be required to take the book from semi finalized manuscript all the way through what someone may be holding in their hands.

    So, I had to just put some of these things on hold but we will be publishing the SIBO biofilm study at some point in the very near future. We have had IRB approval for a randomized placebo controlled trial in looking at a natural prokinetic versus no treatment in preventing SIBO relapse. But we were throwing some challenges there. We were initially going to study Iberogast and then that got taken off the US market. So, that caused us to try to find another compound.

    We've identified a compound that we want to study but we've been having a very difficult time being able to obtain placebos for that compound. I think we'll be able to obtain those but it's actually been surprisingly difficult to find placebos for this particular setup. But all the parameters there are locked in and ready to go and everything's been approved. And now that the book is out there, this is one of the things I plan on picking back up.

    We've also been collecting some data on the compound Atrantil. We've collected data with Atrantil compared to one of the standard herbal antimicrobial protocols that I've used and we have a, not enough in the data set now to publish it but we will have in probably not too long a data set that gives us enough of a sample to have statistical significance and when we reach that we'll publish on that also. So, those are the next two things that we'll publish on.

    The thing that I'm most curious really to dig into is the utility of prokinetics, natural kinetics in treating SIBO relapse. My suspicion and I'm happy to be proven wrong on this when we have data that more definitively answers the question, my suspicion is that the importance of motility in SIBO I think has been overstated. I do think it is a factor for some people but I think that's more like the most severe perhaps 20% rather than it is for the majority.

    I think part of this is because one of the quintessential researchers in SIBO is a motility specialist. So, I think you see a biasing of a lot of opinions in SIBO as derivative of that. I don't think it's done in any malicious way. I think if you ask a plumber for a philosophy on life, you're going to get a plumber-centric opinion. I do think the utility of prokinetics and motility has been overstated. It's important to remember that there's only really one good study, maybe a second or third that are more very select sub-groups of patients, but really only one good study that showed a benefit with prokinetics.

    And the question is, is taking something like Tegaserod which was the most well performing study, but that's a medication that may cause cardiovascular complications, is that going to benefit someone more to potentially using a low FODMAP diet, probiotics or a repeat round of herbal antimicrobials.


    In my opinion, I think the other therapies that are non-prokinetic in nature will actually work better for the prevention of SIBO reoccurrence or simply touching up and retreating a mild case of SIBO reoccurrence which isn't the end of the world although it's portrayed as such on the internet. I know I did get a little bit off tangent there but that's a question I really want to answer.

Tommy:    Yeah, that's great. I think there's a number of important points there about if you're trying to do studies, which I think absolutely people should, but making sure you're getting enough data, you're setting the study up properly, having institutional review boards cover your ethics so you can then publish it, all of that is super important and having people like you doing that and showing that it can be done, I think, is super important and, hopefully, other people will follow suit or perhaps sort of take part in the studies that you're running. I think that's great.

    Well, this has been fantastic. I would love for you to tell people about the book, the podcast, the website, all of those things, where they can find you and get more information.

Michael:    Thank you. It's always a pleasure chatting, Tommy. I wish we had the opportunity to chat more but, busy schedules don't tend to align very well. The book is called Healthy Gut Healthy You. It's available on Amazon. You can also go to to find out more about it. I think it's the best offering for a self help protocol for improving one's gut health that's available today.

    I don't say that lightly. There's a lot of work that went into this book and I tried to write a book that could help people but not indoctrinate them and make them feel dependent upon supplements or afraid of food and to really make people feel empowered and get them to a point where their health is very resilient both physiologically and psychologically. I'm very excited about the book.

    Everything really can be plugged into from which is D-R-R-U-S-C-I-O dot com. You'll see a banner there about the book. I also have a weekly, actually a bi-weekly, podcast and a weekly video and we have, now that the book is done, I'm writing more articles. I originally released one that's gotten fairly popular about SIBO. One author wrote an article saying that SIBO was not a real condition and it was a very poorly written article by someone who's not familiar with the body of literature who cited six references in trying to say that the condition does not exist.

    There's an old saying let the fool speak so that he may reveal himself. I think that was the case, unfortunately, with this article and I wrote a response article that had 106 references and I think that did a very good job of establishing what SIBO is and what SIBO is not and how we should look at that. Anyway, we have articles coming out. And then if you're a practitioner and you want to get some case studies and relevant clinical research studies, we have a monthly research newsletter that's entitled The Future of Functional Medicine Review and you can plug into that in our home page. That's the lion share of what I have going on.

Tommy:    Only those small handful of things that you've got going on. That's great. Absolutely encourage everybody to investigate all of those, listen to the podcast and get your newsletters and also get the Future of Functional Medicine Review and have the book. That's all of those things. So, absolutely, everybody go on and check those things out particularly if you're interested in all these things gut related. But thanks again, Mike, for your time. This has been fantastic.

Michael:    Yeah. Thanks for having me on.

[0:43:14]    End of Audio

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