The elemental diet is the most impactful data-backed treatment for SIBO. And yet, it’s often misused, misunderstood and generally met with last resort trepidation. Today on the podcast, I’m joined by Dr. Michael Ruscio to demystify this approach and talk more about how he uses it for SIBO treatment, IBD, celiac, and other cases involving a highly-damaged gut.
For those who thought you could never last two weeks only drinking your calories (ahem, I get it), Dr. Ruscio provides plenty of flexibility and advice on using the elemental diet as a meal replacement supplement. You guys have been asking for this episode, so I’d love to hear what you think!
A quick taste of what we’ll cover:
- How the elemental diet works to treat SIBO and the healing potential for leaky gut
- What should you look for when picking a formula and what to avoid?
- Risks and side effects to watch out for
- Myth busting the Candida issue
- Die-off versus negative reactions to a treatment – how you can tell the difference between the two
- How to pair the elemental diet with other SIBO treatments
- The best methods for reintegrating food back into your life and how a low FODMAP elimination plan can overlap
- Keeping your blood sugar stable and other troubleshooting while on the diet
- And so much more…
Resources, mentions and notes:
- Dr. Ruscio’s website and podcast
- Dr. Ruscio’s book, Healthy Gut, Healthy You
- Dr. Ruscio’s Elemental Heal formula
- Physician’s Elemental
- Three probiotics that Dr. Ruscio rotates: Lacto-bifido blend, Saccharomyces Boulardii, and soil-based probiotic
- The Summer Low FODMAP Reset elimination diet meal plan e-book
- The Wellness Project Book
- Join the SIBO Made Simple Facebook Community Page
- Subscribe to receive a free download of the episode transcript
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WHAT IS THE ELEMENTAL DIET?
PHOEBE: Dr. Ruscio, thank you so much for joining us on the pod today. I’ve been trying to get you for months but your people are good keepers of the kingdom! It’s going to be worth the wait, I know it. I’m really excited to discuss all things elemental diet. We talked about it briefly in Episode 1 of our show, with Dr. Allison Seibecker but we have not given it a deep dive. Why don’t tell people who maybe haven’t listened to that episode what it is because it’s not a diet-diet in the traditional sense.
MICHAEL: Well, thank you, and I hope to deliver on the expectations also. The elemental diet, essentially if you were to picture a meal-replacement shake, many people make a smoothie on the go in the morning, if you were to picture that but designed to be a complete meal replacement in terms of all your micronutrition, and make it hypoallergenic, gut-friendly, and pre-digested. Meaning, even if your gut’s a little bit inflamed or injured, it would be very easy to absorb because all the digestion is already done. Then you would have an elemental diet. The utility of an elemental diet is multifold, but essentially, it can starve bacterial and, theoretically, fungal overgrowths and reduce inflammation. It can, essentially, give the gut a chance to rest and repair, almost like a sprained ankle. If you were running every day on a sprained ankle, it wouldn’t health very well. Same concept with an elemental diet. If your gut is inflamed or injured and you can give it a break with an elemental diet, these meal replacements, then you can really help facilitate healing.
PHOEBE: Who is this best for? Obviously, it’s used for SIBO people, but where in the process do you introduce it? Do you start with it for some people or is it a last resort?
MICHAEL: I think it’s somewhere in between. It’s been depicted as a last resort traditionally because the older formulas tasted terrible. Fortunately, there’s a new crop of elemental diets, one of which we’ve released, and I’m very proud of this formula, which has been quite helpful in the sense that it’s palatable. We have the tool works, but the tool used to taste so bad that no one could do it because the taste was a barrier.
PHOEBE: What tasted so terrible?
MICHAEL: The Vivonex Plus, which was the one that was used in some of the original research, if you were to lick an envelope, that sticky adhesive stuff, that’s pretty much want it tasted like. Postage stamp glue is what it tasted like. It was bad.
PHOEBE: That makes my skin crawl, literally!
MICHAEL: When I heard that, I was thinking people are so finnicky; this probably isn’t that bad. Then I tried some and I said, wow, this is as bad as it’s been portrayed. Thankfully, again, there are these newer crops of elemental diets. The one that I developed is called Elemental Heal. We’re also working on releasing a vegetarian version of that. I’m not sure exactly when that’ll be out but, hopefully, sometime within the next two to six months. Now, with these newer crops, they’re much more able to be done easily, so it’s not this last-ditch resort. I certainly wouldn’t say it’s where you start. If you haven’t cleaned up your diet, if you haven’t tried a probiotic, then there are some very long-hanging fruit for you.
After that, we can make a case for this is, kind of, a second or third line therapy, in some cases, especially if they only use it as a short reset. What some people make the mistake of thinking is because, in very sick individuals, it is sometimes used as the exclusive nutrition for two weeks, that that’s always how it has to be used. That’s actually not the case. You can use it for one day exclusively or two or three or four days and do this mini cleanse reset. Some people, alternatively, they will just, on most days, skip a meal and use an elemental diet as a meal replacement. Many people will do it for breakfast. There is research supporting this – in fact, it’s an interesting story. I was at the SIBO Symposium on a panel, I want to say it was 2016, it may have been 2017, and it was talking about how we were using the elemental diet in this type of application, which is borrowed from the Crohn’s disease literature.
Some of the studies have looked at children with Crohn’s disease. They compared children who had Crohn’s disease who ate a normal health diet, compared with those who would supplement one to two meals per day and use this elemental shake instead. They actually found that the patients who did this for two years had better growth and had less symptoms and flares than the patients who didn’t. Certainly, it’s a tenable recommendation to say, if your gut’s really aggravated, you can use this as a meal replacement on some or on most days and give your gut that little window of rest. Because we have the flexibility and the application, it can be used fairly early on in the therapeutic hierarchy.
PHOEBE: Would this be something that would stand in for the concept of intermittent fasting, if you have someone who’s just underweight and maybe can’t commit to that long a period of time of not eating?
THE ELEMENTAL DIET AND INTERMITTENT FASTING
MICHAEL: Great question. Intermittent fasting is definitely a helpful tool, and I have many of my patients experiment with intermittent fasting. If you’re doing a short fast, then you probably don’t need anything; you can just use water or a little bit of coffee or tea, if you’re doing a fast of 12 hours, 14 hours, 16 hours. When we start getting to 18 hours to a full day or beyond that, that’s when a fair number of people will have a hard time going that long, as you’re, kind of, alluding to. It really helps to give them something that provides calories and nutrition. What the elemental diets will do is they’ll, kind of, keep your gut in a fasted state but it’ll give you some nutrition so you don’t get tired or brain fog or any other negative fasting symptoms.
PHOEBE: You primarily use it for people with IBD and SIBO. Do you use it for coeliac people ever? Who are the top of your list for this?
MICHAEL: Really, for any gut condition, I’ve seen this have applicability. Whether the condition has a diagnosis attached to it or IBS or IBD or it’s just unspecified gas, bloating, constipation, diarrhea, abdominal pain it can be helpful there. It can be helpful for even these niche exotic diagnoses like eosinophilic esophagitis, which is this feeling where something is always stuck in your throat and you’ve got this lump in your throat, which can be because of immune reactivity and inflammation in the throat itself. It can be used for joint pain. One study found an elemental diet equally as effective as prednisone in quelling rheumatoid arthritis. There’s really an array of symptoms that this can be used for. This is not because the elemental diet is a panacea, it’s because imbalances in your gut can manifest in such a wide array of different symptoms.
PHOEBE: Really, anyone on the autoimmune spectrum with a variety of different conditions could maybe benefit.
MICHAEL: This is definitely a consideration, yes.
PHOEBE: Just practically speaking, is your formula/some of the others out there, is it a smoothie, is it liquid? What is it like?
THE BEST ELEMENTAL DIET FORMULAS FOR SIBO
MICHAEL: You essentially are picturing in your head a protein powder canister. You open it up. You put some ice cubes in a blender and you put in a few scoops of this. You can add a fat; that is optional. Some of these have the fat in them, some of them need to have the fat added externally. Ours, we decided to not include the fat, so that people had control of putting it in there or not. Something like a [Udi’s 369] or Megablend, you can add into this. Essentially, all you’re doing is water, some ice cubs, a few scoops of this powder, plus/minus an oil, and you’re good to go. Very, very simple to make.
There are some premade, like Peptamen, but the challenge with some of the “made by Nestle” versions of this, they have corn syrup solids. They have some – sorry, they may not be corn syrup solids specifically, but they have some ingredients that aren’t as clean as I think many people privy to food quality would like. It’s not to say they don’t work; they actually can work. It’s just if you want to have a more organic, cleaner version, that’s where the premade ones typically don’t satisfy that.
PHOEBE: You can DIY your own, right, with a recipe?
MICHAEL: You can. The challenge with that is the taste, you come back to that same taste barrier. It comes down to there aren’t, to my knowledge, any complete amino acid formulas that you can buy over the counter alone that don’t taste putrid. That’s really, I think, the main driver, the amino acid powders. When you’re able to blend them in with some of the carbohydrate sources that are in the premade powders – let me distinguish. If there’s a premade single serving, like you’d grab a premade protein shake, those typically have stuff that you don’t want in them. If you buy a powder, like a protein canister and you make your own with that protein mix, then those tend to be cleaner.
The challenge with trying to make it at home with all the constituent ingredients, meaning you buy your carbohydrate powder, your amino acid powder, your fat powder and you mix them altogether, is they still end up tasting poor. Said simply, the do-it-yourself homemade versions are an option but they really don’t taste very good either.
PHOEBE: Okay, so you may save a couple of shekels but you will suffer –
MICHAEL: You don’t save actually from – I haven’t priced this out myself in a while, but from what my patients told me, the cost really isn’t much different. The one thing, I think, gives favor to the making it yourself is you have complete control over the ratio of proteins, carbs and fats. Some highly, highly sensitive patients like to have all that in their control, but for most people, they don’t really need to get to that level of specificity.
PHOEBE: Obviously, it sounds like your formula’s the best formula because it tastes good. If someone is just searching on their own, besides the corn solids, is there anything else that you should watch out for on a label that would probably, I don’t know, not do damage but undo, potentially, your intention with the elemental diet?
MICHAEL: No, no. The ones I recommend are our formula, which is Elemental Heal, and then also the Physicians’ Elemental by Integrative Therapeutics. Those are really, in my opinion, the best two on the market. It’s not to say that there’s a bunch of other contenders. There’s not really many on the market, so those are really your two viable options. There’s a prescription version, that’s the Vivonex Plus, which tastes terrible. There’s the homemade version, which also doesn’t taste very good. There’s also some of these premade, like EleCare by Abbott, TwoCal HN, or Peptamen, and these are the ones that are more processed food-like.
There’s no specific thing I would look out for on the label because there are people who will do fine on some of these processed food-like elemental diets. It does beg an important issue, which is sometimes we get so wrapped up in the small details, like oh my God, there’s a little bit of aspartame in this premade version, so people don’t do a therapy that can really help them. They miss the forest for the trees, as it were. We try to make, and the two formulas that I recommend are very clean and high quality, but you can also get there with formulas that aren’t quite as perfect. I’m just trying to, I guess, say that we don’t have to be perfect with the formula. Even though there maybe a few things in there that you philosophically don’t like, it still may allow you to heal and get over a hump and really start to feel better.
PHOEBE: Yeah that’s super important to point out. You mentioned just a few days here and there for therapeutic doses of sorts. What about for SIBO people? Are you still recommending the two-week course when you’re trying to bring people’s gas numbers down by a lot?
MICHAEL: This is where clarity definition comes to be very important. If someone is just saying, my SIBO, my SIBO, my SIBO, and that they actually mean is my diarrhea and my abdominal paid, then that’s different from someone who actually has diagnosed SIBO. There are some differences here and it’s helpful to try to be as particular as we can with the language, just so we don’t – I think what’s happening oftentimes is people are saying SIBO even when they don’t have it. They’re just assuming they have SIBO.
PHOEBE: Interesting! You get a lot of self-diagnosis in your practice?
MICHAEL: Right, so we have to be a little bit careful, but really know, it doesn’t make a difference in my opinion. This is one of the biggest challenges, I think, patients face, which is they get stuck in these boxes. Well I have SIBO, so that means I have to do all the stuff for SIBO and they don’t realize that these boxes are just made to help the clinician understand the context in terms of here’s the available treatments. Here’s other conditions we should be concerned about. Here’s therapies that are helpful. Here’s therapies that may not be helpful. The challenge is they don’t get the other context the clinicians get, which is there is SIBO and there’s IBS and there’s candida, and all these things have overlap. There’s not a box that you get put in but there’s just suggested ways of thinking about things.
If someone does or does not have SIBO, it doesn’t make that much of a difference in terms of how you utilize the elemental diet. You could make the case that, well I have SIBO so I’ve got to do the full two weeks. That’s not really the way things play out in the real world. It’s much more patient-centered and patient personalized. If someone has SIBO, documented by a breath test, or they just have the symptoms of SIBO and IBS, gas, bloating, constipation, diarrhea, whatever, they can use this therapy and they can use it anywhere from a one to four-day rest, or as a meal replacement on most days. If they’re really motivated and their symptoms are fairly severe, they could go all the way to doing it for one full week, or even two or even up to three. It’s not really that specific. Meaning, if you’re patient X and you don’t follow the corresponding protocol, you’re going to spontaneously combust! It’s not that specific and I think it’s really empowering when patients understand that.
Let’s say you’re the worst case scenario, where you have SIBO and you have fairly severe symptoms and you’re saying to yourself, well that must mean I have to do this diet for two weeks exclusively. It’s not really the case. It may be very empowering for you to realize that if all you feel you can do is do this for two days exclusively and then use it as a meal replacement for breakfast, then do that. You’ll likely see a nice improvement in how you do. That improvement may be accrued over six weeks rather than getting a lot of improvement in two weeks, but both of those methods will get you to your endpoint.
The good news here is a lot of how you do this can be personalized to what fits with you. If you’re a busy mom and you’re saying, oh my God, I can’t do it for two weeks. Don’t freak out., you can do it in an application that more fits for you. There is a lot of wriggle room and I hope I’m doing a decent job of articulating that.
PHOEBE: You are, and you bring up and important point. That’s something I’ve had to grapple with on my own autoimmune journey, which is that sometimes it’s okay to get to 80%, 80% is pretty good. I think people get very wrapped up in the idea of 100% recovery, whether that’s with the gas fully plummeting or your symptoms being completely absolved not matter what you eat. It’s just not always realistic and can cause a lot of stress, when in reality, you could live a pretty good life for a little while and slowly inch your way up to that 90-plus-%.
Okay, so in terms of potential side effects and whatnot, what are things that people should look out for or any risk factors that come with the elemental diet?
ELEMENTAL DIET SIDE EFFECTS, SYMPTOMS AND TROUBLESHOOTING
MICHAEL: Like any other therapy, there’s always the potential that something may not sit well with your system. This could happen with a probiotic. It could happen with a pearl of oil of oregano. It can happen with an elemental diet. There’s an important distinction that one should be on the lookout for, which is, is this a short-term rebalancing or adjusting reaction or is my body intolerant to this treatment. Time helps one ferret that out. If it’s an adjusting reaction, so to speak, usually what you’ll see is some type of negative symptoms appear and then after three to five days, they start to really resolve and go away. If after a few days, the negative symptoms are persisting, then that’s more indicative of you being intolerant to whatever the treatment is; in this case, the elemental diet. That’s one key thing to be on the lookout for.
There’s also the very important piece of advice, which is you don’t drink these like a protein shake or like a meal. You sip on them. Remember, these are predigested, meaning they’re going to absorb very quickly into your blood stream. If the carbohydrates in here all absorb very quickly like that, they can cause a blood sugar spike and then a drop. Instead of just drinking the whole glass of the elemental meal replacement in, let’s say, three minutes, you would sip on it over the course of 30 minutes, or even an hour. What I would do, I did this for four days, I had one of those hydro flasks, the larger ones that keeps your liquid cool, and I made a shake and I sipped on it over the course of, probably, two hours. I diluted it with water so I could drink a lot and that is really the best way to do it. Think of an IV drip, drip, drip, sip, sip, sip. That’s the way that you want to use these.
Occasionally, people will experience a little bit of a whitening of their tongue, and that’s really inconsequential. It’s just because there’s this predigested carbohydrate in there. Sometimes, that can feed some of the fungus on the tongue and you can see a little whitening on the tongue. If you use a mouthwash, that’ll go away, usually goes away. Whenever you stop using the diet, that goes away on its own. That usually only happens with people who are using the elemental diet exclusively. If you’re only doing it as a meal replacement or you’re doing it only in the short term, that’s usually not a problem, and it’s not really anything I’m concerned about to begin with. It’s just a little bit of a skewing of the oral macrobiotic, due to touching it on its way down.
Sometimes, people think that means that they’re having this overgrowth of candida. I think this is one of the most destructive [canards] that’s circulating on the internet, is that an elemental diet can feed candida.
PHOEBE: That’s one of my questions for you.
ELEMENTAL DIET AND CANDIDA OR FUNGAL OVERGROWTH
MICHAEL: It’s really a silly contention because by definition, elemental diets starve your intestinal tract of nutrients because they absorb in the first couple of feet. Maybe there’s a rare exceptional case where that’s occurred, but if someone is having a negative symptom, it’s almost for certain because they’re intolerant to the solution, not because all of a sudden they have this flaming fungal overgrowth. I think it’s really important that we understand that. It’s sad to me when a patient comes into my office, and they could have done the elemental diet through an article they read on a website or through my book and they didn’t because someone told them it can feed fungus. One lab test they had from three years ago showed high fungal markers. When I reassure them and they do it, they come back a few weeks later and say, oh my God, why did I wait so long; I’m feeling so much better.
PHOEBE: Why do people on the internet say that?
MICHAEL: There’s these pre-digested carbohydrates in there, and there’s this belief that carbohydrates feed fungus, which is, kind of, true but it’s really not that simple. The number of patients who I see who do fine on a moderate carbohydrate intake with documented fungus on their labs is pretty high. I think that it’s incorrect to think that you have to eat according to your diagnosis, in most cases. We want to eat based upon the bio feedback we get from our body. There is such a good example, just really briefly. One patient came in suffering with fatigue and insomnia and she asked me if she’d ever be able to eat fruit again. I said, what do you mean? She goes, “Well, I don’t eat fruit because I was told by my last provider that I have candida on my stool test but, gosh, when I eat fruit, I sleep so much better, I have so much better energy. We have to be careful how much we extrapolate from lab testing.
PHOEBE: Yeah and that’s actually a good lead-in to one of my questions that your book sparked, which is you emphasized often that we should think about eating for our blood sugar over eating for our gut bacteria. I was curious – you kind of got into it a second ago – what some of the risks were in terms of blood sugar with the elemental diet.
Then also as a part two, I’m curious how you reconcile the blood sugar piece with low FODMAP. I don’t know if you do that a lot in your practice, but, I guess, the whole idea in the SIBO community that fiber is the devil when you have SIBO, which is, to my knowledge, the best way to balance your blood sugar.
HOW TO MARRY THE ELEMENTAL DIET WITH THE LOW FODMAP DIET
MICHAEL: Regarding the elemental diet, like we talked about a moment ago, the way to get around blood sugar spikes is by making sure you don’t drink the whole shake in three to five minutes, but rather, sip on it slowly throughout the day, in that IV drip-like application.
Regarding blood sugar and fiber, there’s a lot here that can be confusing, and we can get down into a lot of the weeds. The take home is that if you eat in such a way where you’re listening to your body and eating in that direction, you will fall into the right camp of diet for you. Now, some people do better on a higher carb-type of diet; higher carb, lower protein and lower fat. Other people do great on more of a low carb, almost like ketogenic-like diet, lots of fat, a fair amount of protein and a very low intake of carbohydrate. Then there’s a spectrum of people in between.
Fiber can be irritating, especially high prebiotic, high FODMAP foods, especially in the initial phases, when someone’s gut is agitated and inflamed. This is where something like a low FODMAP, or even just a lower fiber and a lower carb diet because there’s a lot overlap between going low carb, low fiber and low FODMAP. Usually, the lower carb you go, the lower fiber you go. That doesn’t always mean you go low FODMAP but with a little bit of guidance and then looking at something like a paleo low FODMAP handout, you can make sure that you’re not inadvertently going low carb and high FODMAP. That’s just initially.
As people start to heal, they can broaden their intake. The first thing I recommend people do is start to reintroduce the FODMAPs that they have cut out from before. Some people have a very high tolerance after healing their gut, other people have some foods they have to be cautious with. I would simply advise someone to eat as broad as their body will let them. It’s really as simple as that.
PHOEBE: Do you find, regardless of – well, I guess, not regardless of the SIBO being “eradicated” but do you find that people who have done the elemental diet, even just for a few days, have an easier time reintroducing high FODMAP foods because they’ve had that more intense concentrated period of healing?
MICHAEL: Yes but there’s a caveat. This is where I feel so privileged to have a clinic where I see patients and I can really get a sense for the user experience with these things. People tend to see nice improvements in their symptoms and their food tolerance when they use an elemental diet. Because people improve so much during and they lose a little bit of that when they reintroduce foods, sometimes people freak out and they don’t understand that, okay, you went from, let’s say, zero is terrible and 100 is feeling fantastic. You went from zero to, on the elemental diet, 70. You’re saying, yes, I’m finally feeling like myself again. Then you start reintroducing foods and you drop down to 60. Because you dropped, some people will freak out. I’ve learned to explain to people that this is going to be three steps forward, one step back, in some cases, and that’s okay.
It’s important to keep that in mind because people with digestive symptoms have a higher prevalence of anxiety. We want to make sure that we’re explaining these things in such a way that we’re not exacerbating the anxiety. That we understand – it’s almost like you had a knee brace on. Now you’ve take the knee brace off and you’re able to run, but you’ve got to give the leg a little bit of time to gain strength without the knee brace, so there’s going to be an adjustment that has to occur. I’ve learned to forewarn people about that, to offset the potential despair that can follow that small shift when they add the food back in.
PHOEBE: Yeah, you need food sensitivity PT. I know some people who do the longer period of elemental diet will use it as an opportunity on the back end to reintroduce foods elimination diet-style, one at a time. Is that something you recommend?
HOW TO REINTRODUCE FOOD AFTER THE ELEMENTAL DIET
MICHAEL: I recommend it as a general principle. The longer you do the elemental diet, the more gradual and cautious your food reintroduction is. In Healthy Gut, Healthy You, I talk about if people are going to do it in that more traditional two-week to three-week SIBO treatment style, what I recommend people do is a transition to what’s known as a hybrid application of the elemental diet, wherein they don’t go from all elemental to all food. They go from all elemental to 70% elemental, 30% food. Give that a few days, go to 50-50, then the 30-70 and then gradually fully to food. For some people, they feel so good on keeping one, let’s say, shake in the morning as part of their protocol. They just do that for a while and they’re happy with that. A gradual wean off, essentially, is what I recommend if people are doing it for one, two or three weeks.
PHOEBE: Are there other things to keep in mind transitioning back on food, even if you’re staying low FODMAP? Should you focus on broths and soups and cooked soft foods for a few days?
MICHAEL: This is also something that I outline in Healthy Gut, Healthy Youbut exactly like you said. These things are just, kind of, common sense where you wouldn’t want to say, my reintroduction mean is going to be hot wings and pizza. You’d want to focus on a smaller, safer meal. Things that are soft, so no raw vegetables; steamed vegetables, soups are great, broths are great. Smaller meals, softer foods. Safer foods, meaning if you know you have a problem with high FODMAP foods, then reintroduce low FODMAP foods. Yeah, those are some general principles that can be very helpful in that transition.
PHOEBE: You would think it’s common sense but it isn’t for everyone. I know a lot of people who don’t even understand that raw food is harder on the gut than cooked food!
MICHAEL: Fair. I’m living in my gut bubble here, so that’s fair.
PHOEBE: That’s right. Back to the healing effects beyond starving the critters, if you have SIBO. Does it help with leaky gut? Does just keeping food out of that area allow those tight junctions to repair? How else does the healing process work exactly?
MICHAEL: Well, it’d be great if we had studies that actually tested these things, so we could say we had a before and after zonulin, although that’s not a perfect leaky gut marker. If we had some before and after that tried to specifically quantify these things. We don’t really have that detail of analysis in the data, but I can tell you what I think and what’s pretty safe of an inference to draw. Almost for certain you’re seeing a drastic reduction in leaky gut because you can see a drastic reduction in SIBO and a reduction in inflammation. We know that low-FODMAP diets can lower histamine, and this would be the ultimate low-FODMAP diet because there’s almost zero prebiotics. Histamine is a signaling molecule of the immune system, and so that’s wrapped up in the inflammatory and the leaky gut process.
Likely, what happens mechanistically is you’re starving the bad bugs. You’re reducing inflammation. You’re reducing histamine. You’re reducing immune system activation, and that has secondary benefits because we do know that inflammation is poisonous to healthy bacteria and unfavorable bacteria can actually thrive in that proinflammatory environment. This is why in one study – I wouldn’t say all the data here is in agreement, but one study actually found that from using the elemental diet, the microbiota looked healthier afterwards even though there was no fiber to feed the bacteria and this is because if your immune system is kicking out all this inflammation in your gut, that poisons the milieu, and it makes the colony less healthy.
It’s a key [00:31:37] misunderstanding that if you can reduce inflammation and improve immune system balance or homeostasis, that has a favorable effect on your bacteria. Said another way, if the environment is healthy, healthy bacteria will grow, and it doesn’t always mean that just jamming fiber into that environment is going to be the best way to go. Sometimes an intervention that’s lower in fiber but very anti-inflammatory is the best way to see a flourishing of the healthy bugs.
PHOEBE: Interesting. I’ve been thinking, the more research I do on SIBO and conversations I have, I’m just wondering why a more standard elimination diet isn’t a baby step for people. Since obviously low-FODMAP, you can still in some capacity have some of the big allergens like gluten, soy, corn, dairy. I mean, all of them. Do you try and integrate that into your practice for people who have these inflammation issues, autoimmune issues, and haven’t ever tried one before? For me, I just think, common sense to me sounds like that would be a better first step than what a lot of people do, which is just go straight to low-FODMAP, which is more restrictive in many ways and may not necessarily get to a root cause that’s causing a lot of issues for leaky gut and just, yeah, rampant issues in your gut.
MICHAEL: 1,000% agreed. Let’s just make sure for the audience we put a loose hierarchy on the board here. Start with an elimination diet. Definitely step one, where you cut out the common irritating allergenic foods. You try gluten-free, dairy-free, soy-free, or even more simply, really the most rudimentary step is get off anything processed and cook everything whole and fresh yourself. Then rudimentary step two, would be go a step further into your typical elimination type diet. We’re going to cut out common problematic foods, dairy, soy, gluten. Yes, that is 100% where you start. It’s for the people where that doesn’t work, then we can escalate to a low-FODMAP.
I even go a bit more nuanced in Healthy Gut, Healthy You. I talk about if you’ve done an elimination and it has not helped you, you can go right on to the standard low-FODMAP diet, which allows some grains and allows some dairy because there wouldn’t be a need to continue to eliminate those foods if they didn’t lead to any benefit. If they did, then you can do what I call the paleo low-FODMAP diet, which combine some of those rudimentary practices of elimination, cutting out gluten, cutting out dairy plus a low-FODMAP diet. Your point is an incredibly important one, which is yes, don’t start with a second or third level diet if you haven’t done the first level first of just your basic elimination and food quality focus.
PHOEBE: Totally, and I’m glad you brought up the cooking element because I also feel like so many people because low-FODMAP in particular makes it so difficult to eat out, it’s the first time a lot of people are really making the majority of their meals, so of course you’re going to feel better.
MICHAEL: Yeah, that’s a great point.
DIE-OFF ON THE ELEMENTAL DIET
PHOEBE: Okay, one more question about die-off and the elemental diet. How are the symptoms different than taking antimicrobials – also, I guess I haven’t asked you if you ever mix in any medications or supplements with the elemental diet?
MICHAEL: I like to follow the following hierarchy, and I guess, before we go to the hierarchy, let me just speak to die-off. I think die-off happens much less frequently than people think, and more often what happens is people have negative reactions to a treatment, that they have an intolerance reaction to a treatment, and they are quick to attribute that to die-off. In my experience, in the clinic where I really administer therapies in a very controlled meticulous setting, die-off outside of maybe a couple of days of just feeling a little bit yucky that’s somewhat mild, die-off is not very common. What happens more commonly is someone doesn’t tolerate berberine or an herb that we’re using or whatever it is.
That same concept and that same observation applies for elemental. Die-offs would be considered very rare, but more often someone just may not do well with the formula itself or it may have this short-term adjusting reaction where their body is shifting in response like when you go on a low-carb diet. There’s going to be that low-carb flu as your body is adjusting. That seems to be more common and die-offs fairly rare. Regarding other therapeutics, I start people off step one with an elimination diet and a focus on just simple steps for food quality. Then the second is considering some type of derivation including low-FODMAP. If elimination diet helped them, then they would do elimination plus low-FODMAP. This is also known as the paleo low-FODMAP diet. If the elimination did not help them, they would go just a regular low-FODMAP.
From there, probiotics are the next thing that I reach for, and a good well-rounded probiotic protocol can be very, very helpful. Oftentimes, patients don’t need to do any more than that. Next I often will consider herbal antimicrobials, and then after that, elemental dieting. I will typically carry forward the probiotics into the elemental diet. Antimicrobials are more, we use a course then we stop, but probiotics can be used in a longer-term application. If someone has responded favorably to probiotics, I will keep them in the program as they’re going on an elemental diet.
PHOEBE: Do you have any favorite probiotic specifically for SIBO?
THE BEST PROBIOTICS FOR SIBO TREATMENT
MICHAEL: No. The reason I pause is again because sometimes people don’t actually have SIBO. They think they have SIBO and there’s SIBO and then there’s the symptoms of SIBO. I use three probiotics in my practice. Lacto-Bifido Blend, and these are probiotics that I have formulated. Lacto-Bifido Blend, Saccharomyces boulardii, and soil-based probiotic. These cover all your probiotic bases. The unfortunate thing is that because healthcare consumers are interested in probiotics right now, every new probiotic study that’s published, all the supplement companies are clamoring to say, well, here’s our new formula based upon this study and this is the probiotic for constipation, and this is the probiotic for joint pain. What they’re doing is they’re taking these snippets of information and marketing to you for a given symptom. The challenge is, if you don’t have a broader view of the probiotic literature, you missed the fact that many different probiotics have been shown to help constipation or with mood.
Then you start to realize, well, if all these different probiotics can help, maybe we should be looking for different classes of probiotics. There are really three, and then we should personalize or have – said more simply, we should have someone try all three and continue on which ones they feel well on. If you look at the probiotic research, you can really break down any probiotic product into one of three categories. Either a lactobacillus-bifidobacterium blend, that’s our Lacto-Bifido Blend, a Saccharomyces boulardii or a soil-based probiotic. Instead of jumping from different product to different product to different product, you can zoom way out and say, okay, let me try each one of these probiotics one at a time and if one works and helps me, I’ll continue with that. Then we’ll add in the second. Then we’ll add in the third. If I have a negative reaction to any of them, I’ll stop because some people do have negative reactions to probiotics.
It’s a fairly small percentage, but what ends up happening is they try one – let’s say it’s a soil-based probiotic and they have a negative reaction. Then a month or two later, they hear about another soil-based probiotic, not realizing it’s the same type of probiotic. They try that one and have another negative reaction. They are stuck in this merry-go-round of trying the same formula, the same category, just the name is different so that’s alluding them. We can really simplify the landscape, and the ones that I use, those are just three quality formulas in each one of the categories. They’re not the best probiotics. They’re good probiotics but any top shelf probiotic that satisfies those criteria would be viable. Then someone can really personalize the probiotic protocol for their gut.
I will say that for some patients trying all three probiotics at once compared to trying just one, is a difference between chronic symptoms and no symptoms. It’s not a cure-all. It doesn’t happen with everyone, but there had been cases. We even released one probably about a month ago, with a patient in our clinic named Phyllis who, all we had to do, even though she had prior candida and SIBO positive, was get her on all three probiotics at the same time, and then within about six weeks, all of her symptoms were gone. The probiotic landscape can be greatly simplified if you just have a wide view, and you get off of this marketing claim merry-go-round that unfortunately floods the internet. Then you go in the internet trying to research probiotics, and what you’re getting, not realizing its marketing, it’s all information marketing, and then it gets really hard to get a sense for what to do with a probiotic.
PROKINETICS AND THE ELEMENTAL DIET
PHOEBE: Got it. No, that’s really great to know. Before I let you go, last question, prokinetics. I know some probiotics have prokinetic qualities. What’s your thoughts on them and then in conjunction with the elemental diet, is that something that you use off the backend?
MICHAEL: Yeah. I haven’t been using prokinetics, sorry, as much, and so I question how needed prokinetics are for SIBO. I’m open, but I also think it’s important for anyone to be critical of a concept and not just take that concept as proven because there’s been one or two studies supporting that concept. That’s essentially where I think we are with prokinetics. There’s been one or two studies, really in my view only one good study that show that probiotics can extend time in remission. It’s important to mention that that one study that used tegaserod next to low-dose erythromycin, yes, they did show that prokinetics helped extend time SIBO free, but these patients still had relapses. One of those medications caused cardiovascular side effects.
Not only that but we recently had Richard McCallum on our podcast who actually studied. He took a sample from the small intestine and they compared what they found from the direct sample to a SIBO breath test. What they found was the bacteria that were causing the SIBO were actually from the mouth, not from the further down the line that refluxed upward, which is the hypothesis that says, you should use a prokinetic because the prokinetics prevent bacteria from the large intestine from refluxing back up into the small intestine. Because of the paucity of data supporting prokinetics, because of some of the findings that are countering them from McCallum’s work, and because I fear that one of the lead researchers here who I respect and I think has done a good job, Pimentel is seeing the sickest of the sick, and is a motility specialist, and is pioneering this hypothesis, I think what’s happened is, you’ve seen one expert in a certain niche, his opinion has predominated the thinking in SIBO.
What I’ve been doing is instead of giving someone a prokinetic, some of which can cause cardiovascular complications, we’ll say, okay, let’s have you take two pearls of oregano per day, and this can function as a method of reducing your SIBO relapse. I would rather do that than use one of these strong medication prokinetics. The herbal prokinetics have no data yet to support their use so there’s not one study had been done showing that they actually prevent [00:44:29]and SIBO relapse. This is probably the most important point. The longer your intestines are healthier, the less your risk of SIBO returning is.
In my mind, the goal is to find whatever treatments reduce someone’s symptoms and use those until someone can come off of those supports without their symptoms returning. I like that approach better and oftentimes what that looks like is, okay, we’ll take those two pearls of oregano and on most days, I’ll have an Elemental Heal shake and I feel great. That’s their SIBO prevention plan as opposed to something like Resolor, which that’s a prescription medication. There may be side effects associated with that. Now, I’m open and I think we don’t have the data to fully say one of those approaches are better than the other but I lean toward my approach because I feel it to be a little bit simpler and doesn’t require the use of medications that I’m a little bit tenuous about.
PHOEBE: Interesting. Let me know if I’m summing this up correctly. You are more of the mind that motility is less the issue with a lot of these IBS/SIBO cases. We can put SIBO in quotes since some people don’t know and more maybe just general gut damage like leaky gut and just an imbalance of some sort in the good and bad bacteria. Is that right?
MICHAEL: Yes, and motility is likely part of the process but the question is, is treating the motility directly the best method or is treating the intestines with things like elemental diet, probiotics, low-FODMAP, is that a better way of restoring motility? We do know – this is one example, that a low-FODMAP diet can lead to increased serotonin cell density in the lining of the intestines and serotonin regulates motility. I don’t mean to be overly critical of Pimentel’s work because I think he’s done some phenomenal work in discovering some of these underlying mechanisms. I think the problem is, that’s been the only opinion that’s been out there, and so by default, it appears to be the best, but I think there hasn’t been enough challenging or other therapeutic hypotheses put forward.
PHOEBE: Yeah, I mean, it is crazy that is the name of the game in terms of the research. I don’t want to open another can of worms before I let you go, but I’m just curious based on what you just said about your recent guest on your podcast, and I’ll definitely listen to that episode and link to it on the show notes. Are you a believer in breath testing at all?
MICHAEL: Oh, yeah. I think we can make a case for breath testing, but the evidence there are mixed, right? You can make a case for and you can make a case against breath testing. There’s a better scientific case for glucose breath testing even though some of the bigger names namely Pimentel prefer lactulose testing, right? There’s more scientific evidence supporting glucose testing than there is lactulose testing. Now there’s nuance there and if you read a lactulose tester right away then it can likely be done appropriately. I think an important take home for the audience is, there’s invariably a lot of people out there who think they have SIBO who do not.
This is because a lactulose breath test suffers from false positives, and part of the reason why they suffer from false-positives is, if you’re reading the cut-off point of the test incorrectly, you can think someone has SIBO and they don’t. Someone breathes into this tube every 20 minutes, and time point zero, 20 minutes, 40 minutes, 60 minutes, 80 minutes, 100 minutes. If someone has a positive gas finding at 100 minutes with the lactulose test, that oftentimes is a false positive meaning they don’t actually have SIBO. I fear what’s happened is, as we’re learning more about these nuances, the nuances aren’t getting out to people who are not specialists in gut and in SIBO, and just more of your general providers. They’re saying, “Whoop, at 100 minutes, you had a hydrogen of 32. You’ve got SIBO,” and they most likely don’t.
I think it is important that people understand that because if you don’t have SIBO, we don’t want to have you take on that psychological burden. Not to say that SIBO should be a psychological burden but it’s another problem on the internet that people seem to come away with a conclusion about SIBO that’s far worse than it actually is. To your point about SIBO breath testing, I think you can definitely make a time – you can make a case for it, and it can be helpful, but it can also be destructive in the sense that it can make people think that they have SIBO when they don’t because of the false positive. We have to be a little bit bridled with our use of the SIBO breath test.
PHOEBE: Amazing, so much good information not just on the elemental diet but many, many gut-related things. Thank you so much Dr. Michael Ruscio for coming on the show.
MICHAEL: Yeah, it’s been a pleasure. Thanks for having me.
Disclaimer: The information shared in this podcast is not meant to provide medical advice, professional diagnosis, or treatment. The information discussed is for educational purposes only and is not a substitute for medical or professional care.