Healthy, Happy Gut Summit™

Everything You Need to Know About Probiotics

Michael Ruscio
Steph: Hello and welcome. I'm so excited to introduce Dr. Michael Ruscio. He's a
functional medicine doctor specializing in all things gut and thyroid. He is the
author of Healthy Gut, Healthy You. He podcasts, he writes and speaks regularly,
educating us on how to best take care of our health. He's based out of Walnut
Creek, California. Hello, Dr. Ruscio. Thank you for being here.

Michael: Hi. Happy to be here. Thanks for having me.

Steph: Yeah, thank you. What interests you in gut health in the first place?

Michael: Good question. It goes all the way back to a personal health experience which I
think a fair number of us who maybe started off the aspirations or plans to go
into conventional medicine then have had our paths diverted by our own
personal health experience. In my case, that was pretty much what happened. I
was planning on going into orthopedics. While I was in my sophomore year of
college, I fairly abruptly went from being a robust, young, healthy, college-
lacrosse playing guy to having semi debilitating insomnia, brain fog, fatigue and
depression. I figured, well, this will be an interesting experience for me. I'll go to
a doctor. That's what doctors fix, and I'll get all fixed up. This is going to be my
first foray into actually the experiential side of what I want to do as a vocation.

Steph: Sounds good.

Michael: Yeah, good in theory. Sadly, after seeing a GP, an endocrinologist and an
internist, they didn't have any diagnosis or any help to offer me. I want to be
clear in saying just out of the gate just to be cautious that I have no animus at all
for the conventional medical system. The doctors that I saw, I feel, were doing
everything that they could do. But as I recommend to my patients, I do think it's
good to have one provider on each side of the proverbial fence, if you will. One
conventional provider, one either integrative or alternative provider so that

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you're getting two different vantage points because we all have our strengths
and our weaknesses, and there are certainly some things that conventional
medicine is much better suited for. There are other things that integrative or
alternative medicine appears to be much better suited for. After seeing three
doctors and having no diagnosis but this continual perpetuation of my
symptoms, I turned to this alternative realm where I was studying nutrition with
some of the kind of side hobby learning that I was doing.

Apparently, there was a doctor everyone in the community saw, who was a
functional medicine doctor. I said, okay, I've never heard this before. But at this
point, I'm pretty open because I've got seemingly not much to lose. I did an
appointment with this clinician. He proposed and he thought I may have had an
intestinal parasite. I remember remarking to myself, "This guy is got to be crazy."
Because I had no diarrhea, no vomiting, throwing up, constipation, abdominal
pain, all the things that one would expect to accompany a parasite. I thought on
it for a little while and then I said, "Well, what do I really have to lose here?" I did
a stool test. It turns out I had a pathogenic Entamoeba histolytica which is one of
the most virulent damaging pathogenic organisms one could be inhabited by.

I should also maybe take a small step back and say leading up to that, I had gone
on the internet and pseudo self-diagnosed myself with adrenal fatigue,
hypothyroid, low testosterone, mercury toxicity. Before I actually did the stool
test, I really spun my wheels, and none of those supports really helped me. It
wasn't until I addressed the problem in my gut that I finally saw my symptoms
clear. That was a powerful lesson for me because it taught me thyroid, metals,
toxicity, adrenal fatigue. Not to say that those never have a time in a place, but I
do think people are pursuing those, putting the cart in front of the horse so to
speak. My case is the same thing I see in a number of patients. In fact, we just
released on our website a case study with one of our patients in the clinic named
Amy who was incorrectly diagnosed hypothyroid and was treated with various
thyroid medications for a year and a half, never seeing her symptoms improve.
Literally, in two months after being in my office and just going through fairly
straightforward gut supports, her symptoms were all gone. I see this more often
than I'd like to admit.

I carried my own experience forward. Now, part of what I do with the research
and the publications and the writing. Is try to bring to people this balanced
narrative, where we have a lot of great stuff to offer in natural and alternative
medicine. But there's also some dogma and some incorrect beliefs that modern
science is challenging. We should embrace that challenge so we can cut out of
the model of things that don't work and focus on the things that do. I try to
really be a patient advocate in that regard where we're going to leave dogma at
the door. We're going to always be open learning and growing. If we can get this
balance right, like this patient example of Amy, and not overzealously reached

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 the thyroid as the diagnosis, but rather not lose our bearings and remember how
pivotal the gut can be and start there when it's warranted which oftentimes it is,
we can get people well when they've been struggling for quite a while as I was,
as Amy was and as many people are. That's a very short synopsis of what's been
a long but really meaningful career in trying to help people in a multitude of
ways.

Steph: Yeah, that makes so much sense. I really hear what you're saying about how it's
like if you only have a hammer, everything looks like a nail. You go see some
folks and they'll say everything is heavy metal toxicity and you go see some.
Then you can be just kind of ping-ponging around looking for answers. But no
matter what, optimizing your gut health has a positive effect like for Amy.

Michael: True. I would hold gut therapies to the same criticism, where if they do not
appear to be helping an individual after two weeks to two months, then we
should look elsewhere, and there are cases of that. But again, what does seem to
happen way more off than it should is the gut is looked at as one of the last areas
to venture into, or someone is given off-the-cuff well, try the Paleo diet. Oh, the
Paleo diet didn't help you, then it's not your gut. Or try an elimination diet. The
elimination diet didn't help you. Try a probiotic and didn't help you. I appreciate I
guess the mention there, but that certainly wouldn't be rolling up your sleeves
and digging in on the gut. But yeah, we don't want to paint the gut as a panacea,
but we do want to give it its fair trial.

Steph: Yeah, that makes sense. One of those things is probiotics where it's like, "Oh, just
take a probiotic." Then it's like, "Oh, that didn't work for me. It made me feel
worse," whatever or whatever. Then we just kind of quit on the whole thing.
What are some signs that we could benefit from taking probiotics?

Michael: I echo that probiotics can be very helpful, but it's also important not to lose sight
of a larger plan where at least in my estimation, of course, there's not going to
be anything published to support this. But just in the clinic talking with patients,
talking about their experience with their prior self-experimentation, their prior
experience with other clinicians, there does seem to be a degree of if this one
thing didn't lead to a massive improvement, then we stop doing that one thing
and we look for the next one thing that will lead to a massive improvement.

Steph: Exactly.

Michael: Yeah. The one thing that's a homerun happens rarely. It's awesome when it
does. Don't get me wrong. When somebody comes in and they're in no dietary
plan, you put them on low FODMAP, and a month later, they come back and
they want to kiss you. That's fantastic when that happens. But more often, what
ends up happening is the dietary aspect of the whole healing hierarchy may lead

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to a 30%-ish improvement. Then we'll administer probiotics, and that may lead
to 20% to 30% additional improvement. Whatever the next intervention may be
and then we get another 30%-ish, and now we're at 90%. It took kind of a long
gamut perspective and not the expectation that one thing was going to be this
huge cathartic, but rather understanding that it's almost like a Rubik's cube
where we have to find the right succession of twists and turns to get all the
colors to match on the one side. Then once we do that, now we found the plan
that will ideally support someone's gut.

Then regarding probiotics, in my opinion, these are one of the least appreciated
therapies that can really help move the needle with one's gut health. There are a
few caveats that I think elude people. One we just touched on which is we
shouldn't look to probiotics to be this one thing that changes everything. It's one
of a couple things that may be needed to be used in conjunction to get someone
to an acceptable level of healing or some amount of improvement. But within
probiotics themselves, what is sometimes an issue is people will look at one
probiotic formula and only use one probiotic formula, not realizing that there are
different types or what I described as categories of probiotics. For whatever
reason, this has made its way into a handful of research papers where there's
this delineation between really for common conversation, I'd say there's three
categories. If we wanted to be technical, maybe there are four, but the fourth
isn't really available to people in the US so I just focus on the tools that are able
to be used, hence the three categories. There are differences between these
three different categories of probiotics. There's something different. The studies,
the clinical trials tend to break down using one of these three different
categories and they all tend the show benefit.

The analogy I like to use is if there was a stool that you sit on. I need to clarify
that because we're talking about gut because I don't mean a bowel movement,
but I mean a stool chair. A one-legged stool would be a little bit wobbly. That's
akin to one probiotic protocol. It can support balance in the microbiota, in the
world of bacteria in the gut, but it can be a bit wobbly. If we rather use all three
categories at the same time, this can actually be the difference between
someone saying, "Uh, probiotics help me a little bit or not at all," versus "Wow, I
really notice a notable, in some cases a remarkable level of improvement from
using all three in conjunction." It makes sense. If we know that taking a very low
dose of probiotic may not be as effective as taking a higher dose of a probiotic,
then it would make sense that taking these three different categorical types all
together and providing these three pillar legs of the stool, that would also be
more conducive to balancing out and healing the microbiota. The way these
categories break down, category one, two, three, category one, these are lactic-
acid forming bacteria and these are mostly various strains of Lactobacillus, the
Lactobacillus acidophilus is one example, and Bifidobacterium. Bifidobacterium
infantis, that's another example. Now, here's a crucially important point.

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 The probiotics here vary from study to study, but they have this trend of the
cocktail of probiotics used in the formula is predominated by various strains of
Lactobacillus and various strains of Bifidobacterium usually anywhere from
maybe seven strains to maybe 15. Why this is so empowering is because it
doesn't mean there is one formula that is the best. Let's take one model where
there have been a few studies, depression and anxiety. There have been a
number of clinical trials that have shown benefits to mood, depression or anxiety
with probiotics. But the strains used have varied from study to study to study.
Same thing with constipation, there have been, I believe, four trials showing that
probiotics can improve constipation, but it's not just this one special blend.

Steph: Yeah, all different species.

Michael: Correct. What's really more important in my mind, to simplify this because
there's oftentimes this impetus to make things more complicated, you need to
have the research validating strains. Well, just because you have one study
showing that a probiotic improves mood, it doesn't mean that that is the best
probiotic for mood because there are other studies with different strains also
improving mood. But that's oftentimes not disclosed by someone who is
marketing a given probiotic. This creates a flood of contradictory claims on the
internet, and then the consumer can do nothing other than just try one
probiotic, try another probiotic, try another one. They have no guiding principles
or philosophy to help them adjudicate or just kind of parse. The category one is a
mixture of Lactobacillus and Bifidobacterium strains.

Category two, Saccharomyces boulardii which is a healthy fungus. Then category

three, sometimes known as either a soil-based probiotic or a spore-forming
probiotic, these are various Bacillus strains, Bacillus subtilis, Bacillus clausii,
Bacillus licheniformis, Bacillus coagulans. Now, category one has over 500 clinical
trials that support use. It is the most popularized or most researched type. It
doesn't mean it's the best, but researchers have been doing studies on this
categorical type for longest. Category two has just over 100 clinical trials. This is
the Saccharomyces boulardii. Then category three has 20 to 40, depending on
the exact mixture of different strains that you're looking at. These three
categories have all shown various benefits with much overlap. Many of the
research studies have shown any one of these can improve IBS, any one of these
act to be antibacterial and combat SIBO as an example, antifungal, to reduce
leaky gut, to help with motility. Sorry for the long explanation here, but there's a
lot to this.

Steph: It's great, yeah.

Michael: Because these probiotics all show very similar benefit, it tells us a good thing,
which is that if a probiotic can improve a core issue, someone's gut, then that

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 can lead to improvements in digestive symptoms, improvements in non-
digestive symptoms like depression and anxiety we talked about a moment ago.
It may help with skin health. There's some research suggesting this. It may help
with joint health. There's some preliminary research suggesting this also. It may
help with sleep. There's varying levels of evidence for all these things so I don't
want to paint too strong of a case, but the philosophical point I'm hoping to
articulate is that when we look at all these studies, we see there's a bunch of
research on probiotics. We can organize this into these categorical types. We can
also see that probiotics tend to have similar effects irrespective of the exact
mixture. So then rather we can recommend someone tries all three categories
together. That may be, at least right now, it seems to be the best most
comprehensive probiotic approach we can offer someone. With one small
caveat, the reason why I, in part, break these categories out is so that if someone
is sensitive and they react to a certain categorical type, they can try the probiotic
formulas one at a time and then not include that leg of the stool, so to speak. It's
fairly rare, but some people will react to probiotics, and that's where having
these three formulas broken out into capsule one, capsule two and capsule three
rather than everything in one capsule allows someone a personalization of a
protocol to their specific gut.

Steph: That makes sense, having them separated. There are a few different reactions to
probiotics like you're saying that it's rare. It's different, I think, like the gut
reacting to just feeling getting gas and bloating from taking a probiotic versus
your immune system going, "Hey, that's a yeast. Get out of here." What kind of
reactions to probiotics are you talking about?

Michael: Sure. That's a great question. Again, I don't believe this has really been
researched robustly so this is just more of a clinical reflection than anything else.
But I think we can use time of reaction to dictate if this is either an adjustment
reaction, which is temporary and usually occurs on your way to feeling better, or
an intolerance reaction, meaning body just does not like it. The adjustment type
reactions, whether it be I had really big voluminous stools or I got a little bit
backed up or I felt a little bit bloated or my skin broke out a little bit, those tend
to roll on and roll off over the course of a few days, maybe a week max. You may
start noticing the second day a couple of symptoms kick up. Third day, fourth
day, fifth day, they're starting to abate. Sixth day, seventh day, they're gone and
hopefully you're starting to even feel better. But if the reaction, whatever the
reaction may be because people tend to react in unique ways, if that persists
much over five six, seven days, then that's much more strongly indicative that it
may be an intolerance reaction in something that your immune system or your
gut just doesn't like. Then you can put that one on to the side.

Steph: Right. That makes sense. Something is going on for more than a week, it's not
just our body adjusting to something usually.

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Michael: Right. It seems to be a pretty good time gauge in terms of a week. But really
what you're looking for is if these symptoms come on and never go away, then
that's an intolerance reaction. Usually, when people had this adjustment
reaction, we see this in the prebiotic literature where I don't want to say it's
common, but it's fairly commonly observed that someone may have some GI
turbulence, some gas and some bloating as their body is adjusting to the
prebiotic. That usually tends to abate after about a week. I think a week is a good
benchmark.

Steph: Okay, that's great. With the prebiotic, because yes, sometimes you'll get like gas
and bloating when they take a prebiotic. It's just like they just don't have enough
of the balance of bacteria to metabolize those gases. That can change in a week.

Michael: Well, it's not to say that that will be gone in a week, but you should start to see a
real reduction and lessening and be able to say, "Okay, I was the worst day four.
Now day six, I'm getting noticeably better." Maybe there's a bit of residual gas
that trickles along a little bit afterwards, but you should be able to identify this
kind of rolling on, rolling off pattern. Probiotics, I think the adjustment time, at
least as best I'm able to tell, seems to be shorter perhaps than it does with
prebiotics. But even with prebiotics, it's not a long adjustment period. The gut
microbiota tends to change to foodstuffs in the diet fairly rapidly I believe even
within hours, definitely within days. That community down there is pretty
responsive to the food that we give it.

Steph: This is awesome. This is really hopeful news. Thank you. I want to just tie some
things together. Probiotics, you've talked about, are relieving some symptoms of
depression, helping reduce inflammation in the gut. How can probiotics help our
thyroid, for example?

Michael: Great question. I think this is a very important question and one that is not really
given the attention that it deserves. Now, I just want to lead with something that
I see in the clinic which is, again, probably well-intentioned clinicians, but it's
become fairly endemic that clinicians of some trainings are now reaching to the
thyroid as a cause of almost every symptom, even in spite of any compelling
laboratory evidence to support that. What's upsetting about this is the
diagnosed hypothyroid, we've got pretty darn good data and there's a pretty
clear diagnostic criteria. We've even gone so far as to have a number of studies
saying, "Well, what about these people who don't quite fit the diagnostic
criteria? What if we give them some thyroid hormone? Will that make them feel
better? Will their symptom inventory improve?" The overwhelming totality of
the data there shows no, they will not improve.

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But for some reason that I can't quite understand, clinicians are reaching for a
thyroid diagnosis even when their TSH is in the normal range and their T4 is in
the normal range. Oftentimes what may happen is "Well, we want you to be not
just in the normal range for TSH. We want your TSH to be in the lower half of
normal. If you're not in that lower half, then you might be hypothyroid. We want
your T4 to be in the upper half. If you're not in the upper half, then you could be
hypothyroid. Or we want your T3 to be in the upper half. If it's not, then that
could indicate that you have to have this conversion." But we've done many of
these studies and we haven't found that patients report benefit. Now, some
clinicians will retort with, "But my patients tell me they feel better when I give
them thyroid hormone." Yes, on the one hand, it is very important to listen to
patients. I fully agree. It is important to be willing to experiment on a patient's
behalf. You have my full support there. I am a patient advocate 100%.

But placebo makes a difference. We've done studies where we don't even
change a patient's medication. They just enter into a study that's blinded. Their
levothyroxine is taken away, and they are given a white labeled box or bottle of
pills and they don't know what it contains. Just a perception that their
medication might be changing, even in those where the medication they're given
back is exactly the same report symptomatic benefit because of the expectation,
the placebo effect. That benefit is attenuated by six months and these patients
are right back to square one. But this is why it's travesty when we overlook the
fact that thyroid symptoms may come from the gut. Just as Amy's case study
that I opened the call with illustrated, a year and a half on different thyroid
medications. Her TSH was I believe 4.3 and her T4 was right in the middle of the
range. It's not a surprise it didn't benefit from thyroid hormone. This is really
important because when patients don't get to the right area expeditiously, they
flounder.

In the past six months, we've released at least three case studies of this same
type where patients were chasing down thyroid and it wasn't the thyroid. In our
clinicians' newsletter, we've had two doctors submit case studies of their own
after reading my newsletter where I talk about this. They found the same things
in their practices and now they've submitted case studies correcting the same
problem that they're finding in their practices also. It is an endemic problem. The
gut-thyroid connection is interesting. I think the most relevant is really twofold,
and it's probably going to be opposite of what people expect. When people do
not have healthy small intestinal function, they may malabsorb their thyroid
hormone because thyroid hormone is completely absorbed in the small
intestine. This may be why one preliminary, so I want to be cautious not to
oversell the implications of the study, but one preliminary study using a category
one probiotic did find that using a probiotic actually stabilized TSH and I believe
was also found to allow patients to take a lower dose of thyroid medication.

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 We do see this occur when H. pylori infected, or colonized patients clear their H.
pylori. There's a number of studies showing a lower dose of thyroid medication is
needed not because there's this, "Oh, you've sealed your thyroid." That's how
these things are sometimes portrayed. That's inaccurate. People are better
absorbing their medication, and oftentimes because they've addressed this
inflammatory issue in the gut, they feel better. But it's more so the gut rather
than, "The H. pylori was causing this autoimmunity. That autoimmunity was
damaging your thyroid, and now you need less medication and that tells us your
thyroid is working better." I wish that were the case, but that would be telling a
patient what they want to hear but not telling them what the truth actually is. I
think the two fundamental ways in which improving gut health with the thyroid
is, one, through absorption of medication. Then two, through helping to remedy
the underlying cause of the "thyroid symptoms" like potentially fatigue or
potentially depression which can also be driven by the gut. There's other tie-in of
autoimmunity, and this is where the case is probably the least strong, but
probably the most ecstatically emphasized online.

Steph: This is popular, yes.

Michael: Yes, yes. As a gut geek, I would love this to be more true than it is, but I'm also
unwilling to compromise the truth based upon what I would find convenient to
be true. There is data associating H. pylori with thyroid autoimmunity. H. pylori is
the bacterium that we have the best evidence on. Please don't, everyone with
hypothyroidism, rush out to test H. pylori. I use this example because it's the one
we have the best evidence on, but I don't want to paint this picture that
everyone needs to be robustly screened for H. pylori if they have hypothyroid.
This is where the details matter. There is an overall association between H. pylori
and thyroid autoimmunity. But when you break it down and you look at Graves'
autoimmunity compared to Hashimoto's autoimmunity, Graves is hyper,
Hashimoto's is hypo, the relationship exists for Graves, but it doesn't seem to be
strong or significant for Hashimoto's. That isn't something that many of the
people on the internet want to point to, but there it is, nonetheless. Now, there
was a one study done in Italy that was exciting and that did show that treatment
of H. pylori actually lower thyroid autoimmunity. It's probably still not a bad idea
to treat an issue in the gut, but it may not be highly associative to improving the
condition of one with thyroid autoimmunity. There's also small intestinal
bacterial overgrowth.

There is an association, although very mild, that small intestinal bacterial

overgrowth tends to associate with a milder degree of thyroid autoimmunity.
Also, there does seem to be a fairly strong correlation between having SIBO and
being hypothyroid. There are a couple mechanisms here that I've been
proposed. I think one that makes the most sense could be about 30-ish percent
of people who have thyroid autoimmunity, they also have autoimmunity against

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 their parietal cells which make hydrochloric acid. They may be low in stomach
acid which opens the door to small intestinal bacterial overgrowth. I think that's
the most likely mechanism. But when we zoom way out, irrespective of what
direction the causality is going, we can I think make a pretty tenable case that
gut health is very important for thyroid health. If we want someone to have little
to no symptoms, it's very important we make sure that their gut is functioning
appropriately, whether that be to better absorb their thyroid medication to
address the symptoms one thought where a thyroid symptom or to potentially
help with thyroid autoimmunity. It doesn't really matter. We still want to go
through the same process of clinical interventions to improve one's gut health.

Steph: Yeah, this makes sense. This makes sense. Also, the absorption of our nutrients
that we need for conversion and everything and reduction in inflammation in the
gut. This makes sense. Even if we can't figure out who caused what.

Michael: Right.

Steph: Yeah, I like that. Thank you.

Michael: Wherever I can try to dispel some of the confusion here, I'm really happy to
because there have been, like I was saying a moment ago, at least three cases in
the past six months who were just force-fed thyroid hormone. I'm talking about
at least for a year. We get them over the symptomatic hump in a number of
months, and it's like, gosh, these people don't need to suffer this long if we could
just get them some competent advice."

Steph: Right, thank you. Okay. What's your gut health maintenance routine?

Michael: Good question. My road was a somewhat laborious road. I was tackling this issue
when I was in college and then graduate studies. I really did not have the
financial resources. A $350 stool test to me felt like buying a house. I was really
probably the best patient that I could have been. I also think between then and
now, about 15-year delta between these two time points, we have learned a lot
more about how the gut works. Finally, I've ended up in a really good place gut-
wise, but it did take me a little while. What I do now is I eat I would call it a Paleo
diet, but I have dairy and I do have gluten-free grains, a Paleo-like diet, and I eat
dairy. I have gluten on occasion. I think I may have a mild reaction of gluten
where I can have it here and there. But if I have it days in a row, I think I will get
a light degree of joint pain and depressed moods. I still have to be better able to
tease that out because sometimes in my case, gluten accompanies drinking,
staying up late and eating otherwise unhealthy food. This is, I think, very
important for people to understand. I think people are over assigning blame to
gluten and they shouldn't. I'm sorry, this wasn't your question.

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 But the best evidence we have shows that non-celiac gluten sensitivity by a study
at the University of Bologna by Volta, looking at over 12,000 patients and really
looking robustly a 60-point assessment found about a 3% prevalence of non-
celiac gluten sensitivity. Three percent is definitely something. We can point that
yes, this is real. Yes, this affects people. Yes, it affects them both gastrointestinal
and extraintestinally joints, brain, skin. But it is not 100%. In fact, only 9% of the
patients who are non-celiac gluten sensitive had thyroid autoimmunity. It's not
to say there's this 100% association between gluten and thyroid also to bring
thyroid back in. I'm trying to be, myself, objective about gluten and not make a
fall observation, which has been biased by the thinking in the community that no
one should eat gluten ever to expect the gluten reaction. I'm still evaluating that
about essentially a Paleo-like diet with gluten-free grains most of the time and
dairy. I also take all three categories of probiotics every morning and a
compound called Gut Rebuild Nutrients that contains glutamine, aloe, zinc. That
for me has got me from feeling good to feeling I guess you would say great.

This is something I think more so from the perspective of what do we do for

longer-term maintenance of the gut is important to mention because I would
have been fine without those supports. I wouldn't say I needed them, but I'm a
bit more impervious to not eating the best foods, getting a bad night's sleep,
travel, stress, the occasional alcohol. I notice I don't really feel a digestive or
neurological impact from those things how I would used to. They were fairly
slight before, but now they're nonexistent. I've also been playing around with
prebiotics and fiber, and I wasn't really able to tolerate those until I added in and
was using the three probiotics and the Gut Rebuild Nutrients consistently. I think
that for, and this is something I write about in Healthy Gut, Healthy You. That we
have to get someone's gut healthy enough to be able to well tolerate prebiotics
and fiber. There's a decent body of evidence to support that. If someone has
inflammatory bowel disease and they're flaring, you cannot give them fiber. But
as someone gets healthier, then the higher amount of fiber and prebiotics may
actually help promote health. Those are the general practices that I'm currently
employing for my gut health personally.

Steph: Awesome, awesome. I like your three categories of probiotics. It's something
that we can think about right now, we can do.

Michael: Yes. I would really recommend people try using all three because there are
cases. We published a case study in our website with Phyllis. If someone
searches my name and Phyllis, they should see it come up. She had been on low
FODMAP for either a year or a year and a half. She had used various probiotics
prior and hadn't really gotten much traction. When we put her on all three
probiotics at the same time, all of her symptoms went away, and we didn't need
to test. She either had SIBO positive or potentially Candida positive. We did the
stool and breath testing on day one, put her on the three probiotics while we

Healthy, Happy Gut Summit | Michael Ruscio | p. 11

 were waiting for the results to come in, followed up about a month later. At the
follow-up, we had to treat any of those lab findings and her symptoms were
gone. This can be quite effective. Again, it's not a cure-all, but I would certainly
say, if you want to execute a good probiotic protocol, try the three categorical
types at once, the Lacto-Bifido Blend, the Saccharomyces boulardii and the soil-
based and reevaluate after a couple weeks.

Steph: Yeah, awesome. Thank you. How do you see probiotics changing the face of
chronic care? How do you see that?

Michael: Well, right now, I'm not as excited about them as I'd like to be not because of
lack of effectiveness, but because many conventional gastroenterologists seem
to shy away from recommending them. There's a lot of hand-waving and
hemming and hawing. We recently released an article where I discussed this. If
you search my name and probiotics, you should be able to find your way to a
bunch of information including this. The most common criticism by conventional
gastroenterologists is we don't have enough research and the studies are
inconsistent with the probiotics that have been used. That is not an inaccurate
criticism, but the details here make a fairly notable difference. Now that we've
already covered the fact that the types of probiotics have differed, you can look
at that in two ways, a disempowering way or an empowering way. The way I look
at that is that okay, great, that tells us, kind of like using antibiotics to treat SIBO,
multiple different antibiotics have been shown effective.

I don't see gastroenterologists hemming and hawing about antibiotics for SIBO
nor should they. We have good evidence showing that different types of
antibiotics can all help. Yes, so we have a menu. To the other point, we need
better data. The analogy I used in the article is that's akin to saying you have a
Porsche; you don't have a nice enough car. You could have a Ferrari. We outlined
the 500 clinical trials for category one, the 100 clinical trials for category two and
the over 20 for category three. There are a number of meta-analyses that have
summarized these studies. We have gold standard level data. Now, we could
have larger clinical trials. That's the main criticism, that these clinical trials are
between ten and 100 subjects. We'd like to see them be more akin to a drug-
funded study of 1,000 or higher subjects. But when you look at all this evidence
that we have, yes it could be better compared to one of the other options,
tricyclic antidepressants.

Steph: What are the risks too?

Michael: Yeah, antispasmodic agents, laxatives. I think it's fairly safe to say, okay, let's find
a quality probiotic that fits the appropriate safety criteria and have our patients
try this. If it doesn't help, then we can fall back to antibiotics, antispasmodics,
various motility agents or laxatives of various sources, your linaclotide, Linzess.

Healthy, Happy Gut Summit | Michael Ruscio | p. 12

 No overt problem with those, but certainly, I think, especially because we see
other side benefits from probiotics, a minor ability to lower blood pressure, a
minor ability to lower blood sugar and blood cholesterol. Again, very small, not
really clinically significant, but that's been documented and those are good
things, the ability to lower inflammatory cytokines and those with
neurodegenerative conditions and even the ability to potentially improve their
cognition or at least brain fog in some of those models. That compared to a
medication seems like it doesn't have to be one or the other, but we could assign
earlier in the hierarchy the probiotic and then fall back to these other things.
Because there's this resistance from conventional gastroenterologists, it makes
me a bit tenuous about where we're going. But with every day, there are more
and more studies documenting the power of probiotics and in an increasingly
wide array of symptoms and conditions which makes me very hopeful for the
future. I guess I have mixed emotions here about the road forward.

Steph: I like that though. That's true. I do hope that we become more open minded. But
studies will help. I think that it is going that way, however maybe a bit slower
than we want. But yeah, I think you're right about that.

Michael: Also in the conventional gastroenterologist defense, I wouldn't necessarily

consider probiotics something that are squarely in their purview. We'd like to
think that every doctor knows everything about everything all the time. But
that's an unrealistic expectation. This is a good example of why I make the
remark I mentioned earlier to my patients which is have a doctor on each side of
the fence because there are definitely things that a conventional
gastroenterologist is going to do that an alternative provided like myself is not
going to be doing. I'm not going to be looking at your family history and your
medical history and trying to determine are you within the criteria for colorectal
cancer screening. That's one example. That's not in my purview. I also want to
give them a little bit of empathy here that they're looking at a lot of diseases and
trying to screen and manage those as best they can. These other nuances of diet
and probiotics aren't necessarily their chief focus and it may be a little bit
unreasonable for us to ask them to do that. This is why, again, have one
competent provider on each side of the fence and look at both opinions, discuss
them over, think them over and then do what feels best to you.

Steph: Yeah, that makes a lot of sense. That gives us something to do. That gives us a
course of action. I like that one provider on either side of the fence, try out the
three different categories of probiotics at the same time which I think not a lot of
us are doing. In closing, is there any other kind of guiding principle that you'd like
to leave us with? I think this is really great.

Michael: Well, thank you. I guess in closing, a couple things. One, don't be fearful. I know
it may be easier for me to say that than it is really able to feel that way. But

Healthy, Happy Gut Summit | Michael Ruscio | p. 13

 especially regarding diet, oftentimes the narratives people are given are very
fear-based and very extremist.

Steph: So much.

Michael: You can't have any of this. You can't have any of that. That really, as someone
who day after day, I work with patients, I work with sensitive patients, I work
with some chronic patients, those patients oftentimes do not need to be super
strict. In fact, sometimes they have the most improvements when they ease up
on themselves a little bit. Yes, aim for a healthy diet, but realize that we all will
fall short occasionally and that's okay. You may feel a little crappy, but it doesn't
mean that anything is irreplaceably damaged or broken. It's part of the human
experience, even the people I know who are the healthiest. Triathletes who are
in phenomenal shape have some good days and some days that aren't great. Be
okay with that. Be a little bit empathetic. I would also say that you have more
power than you may think. This is an example as to why I wrote Healthy Gut,
Healthy You was to really give people a reasonable narrative, a non-fear-based
narrative and a series of steps that they could walk through to reclaim their gut
health without feeling like they had to spend thousands of dollars on testing or
like they had to go to a doctor as a purveyor of all the knowledge.

Especially with natural medicines, there's a lot of wiggle room. They're very safe
and they tend to be effective of course also. If you have the right guide, there's a
lot you can do on your own to improve your gut health. Of course, don't stop
seeing your doctor. I would definitely recommend keeping your doctor in the
loop, especially conventionally speaking. But there's also a lot you can do just to
countervail the narrative that if you're not feeling well, you've got to do a bunch
of testing, you've got to have a long-term restrictive diet. Not really the case and
there are definitely resources out there that can walk you into this realm of
empowering care. I hope people will take action on that. Because once you get
the right approach, then people can heal pretty quickly. Hopefully all that
resonates and provides people with some next steps.

Steph: Yeah, concrete steps and concrete hope. I really like that. Thank you.

Michael: Yeah. Well, thank you.

Steph: Yeah. If we want to learn more, we can go to drruscio.com. We can check out
your book Healthy Gut, Healthy You. Anything else? Podcast.

Michael: Yeah, podcast also and articles and videos. If there are any clinicians listening to
this, we also have a clinicians' newsletter. But everything can be found at that
drruscio.com hub. That's where you can plug in to pretty much everything else.
Yeah, I invite people to have a look and happy to provide some progressive but

Healthy, Happy Gut Summit | Michael Ruscio | p. 14

 also evidence-based and well thought-out information to guide people along
their healing journey.

Steph: Yeah, thank you for that. Your clinicians' newsletter is fantastic. I highly
recommend it. Thank you so much for taking the time to come and talk to us
today. I learned a lot.

Michael: Yeah, it's been a pleasure. It's been a pleasure. Thank you for having me.

Steph: Yeah, it was really empowering and hopeful, and I really appreciate that.

Michael: Well, thank you.

Steph: I'd like to thank each of you for coming as well. I'll see you next time.

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Healthy, Happy Gut Summit | Michael Ruscio | p. 15