Why Healthy People Get Broken Guts, And What You Can Do About It.

In this episode of the Ben Greenfield.

Fitness show, your immune system can accidentally attack these interstitial cells of cajol. And that may be exactly what's happening when we see this impaired motility that causes all these problems of bloating and distention and just funky digestion in general. You could have two different people doing the same amount of exercise, and that could be causing disease for one person and wellness for the other. This is where I think the problem occurs with exercise. It has been well documented, and I'm sure your listeners are aware of this, that excessive exerc exercise has been correlated with immunosuppression and increased risk of infection.

He's an expert in human performance and nutrition, voted America's top personal trainer and one of the globe's most influential people in health and fitness. His show provides you with everything you need to optimize physical and mental performance. He is Ben Greenfield.

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Hey, folks, it's Ben Greenfield here. And you've probably seen this scenario before. If you're an athlete or you're an exercise enthusiast or you follow any of those crazy things. The classic photo of, say, a marathoner bent over the road puking their guts out, or a triathlete who's hunched over with abdominal pain on the bike and has to drop out from the race or walk the run. Or maybe it's the bodybuilder wandering around the gym. I used to see this all the time back in the day. And they're constantly ducking into the bathroom with annoying gas or the weekend warrior who wants to roll out of bed and go for a long run, but they can't because they get bloating or they get diarrhea or we even have a lot of health nuts who seem to be constantly constipated no matter what they do, no matter what cleanses they use or herbs they take. And so there's all these issues that seem to be kind of flying under the radar in folks who look pretty good on the outside, athletes and exercise enthusiasts who do still seem to get broken guts. So I have invited show today a guy who studied exercise science who was an athlete in college, and we'll learn more about that in a moment. But he's also a leader in the functional medicine movement, a clinician and a Lecturer and he's particularly well versed in all things gut, especially from a functional medicine standpoint. His name is Dr. Michael Ruscio and Michael has a postgraduate degree from Life Chiropractic College west or Dr. Russo, are you a teacher at Life Chiropractic College west or did you graduate from there?

I graduated from there and then I teach a seminar where we offer continuing education credits which are certified through life.

Okay, so you graduated, now you're giving back a little bit.

Trying to.

Yeah. Okay, gotcha. And then you also went to UMass. You played sports at UMass?

Yeah, I played lacrosse for a year at UMass and then with the pre med requirements and having to take organic chemistry and physics and calculus, I couldn't do all the academics and the athletics, so I dropped out after a year.

So that sounds very similar to my story. I played collegiate tennis and realized after a couple years that I couldn't handle the enormous course load that I had and wound up dropping tennis because I realized I wasn't going to be a pro anyways.

It's painful to do it, but I'm glad I did now.

Yeah, of course around here tennis is acceptable and lacrosse still in the Northwest is considered to be a bit preppy, even more so than tennis. So lacrosse hasn't quite caught on over here still.

Yeah, it might be a bit of a prep. That might be. Cause you can go one of two ways when you're from the northeast. You can be a prep or you can be kind of a meathead. And I fell into the. I had a lot of meathead friends. I may have some meathead tendencies, but thankfully I fell more into the, the prep camp. So I don't have many affliction T shirts or anything like that in my closet.

Nice. Well, hopefully we've got some, some good material here and meatheads listening in. I'm curious though, before we jump in, because it's always interesting to ask this question to a guy who studies the gut and provides medical care for the gut. What did you eat yesterday? Like what was your breakfast, lunch, dinner scenario yesterday?

I was in the clinic, so it's a little bit of a quicker sort of meal day. I drive right by, thankfully Whole Foods on my way into the clinic. And so I grabbed two hard boiled eggs, a half of a breakfast sausage, and I had a handful of raw broccoli with some lightly steamed kale. So that was my breakfast.

There's a lot of people that are going to give you a really hard time now in the comments section about vegetable Oil and whole food, sausages.

Right. And maybe that's a good chance to chime in my overarching kind of philosophy on functional medicine, which is, I try not to be heretical or a fanatic. And I think that's one of the main detriments that people in our space or some of the knowledge in our space can do. It can make people scared to death of food. And I really think we have sort of this pseudo eating disorder sort of thing presenting itself with a lot of. I see this with a lot of my patients where they are scared to death to eat anything off plan. And that really does have some major health implications because it creates a lot of stress and it creates a lot of social impairment, and those have been clinically shown to really be deleterious for your health. I'm a big believer in doing it right 80% of the time. If you have a 20%, that's not perfect, I don't really stress out about it because the negatives you will induce because of the social and stress ramifications of that just aren't worth it from a health perspective.

Completely agree. I'm more prone to cheat on coconut ice cream than sausages, but I completely agree. What about lunch?

Lunch? I actually had a can of tuna fish with a little bit of olive oil and then some steamed asparagus and Swiss chard.

Nice. That actually sounds pretty good. And for dinner?

And for dinner, I had some more of the leftover steamed asparagus and Swiss chard. And I also had. What did I have last night for dinner? I think I had baked chicken that I, you know, seasoned with some curcumin and some olive oil and salt and pepper.

Nice. Nice. And are you doing all your cooking yourself? Do you have a family?

I do not have a family. Nope. Or at least not that I know of right now.

Sounds like something a sailor would say.

It's pretty easy on the food piece for me right now, anyway. Yeah.

Okay, gotcha. And as a doc, are you spending most of your day in between those delicious feedings, working with folks in the clinic? Are you doing primarily research, a combination of both, or how does your day look?

Well, you ask a really important question because I spend two days in the clinic and I spend three days writing, researching, and working on the studies that we're going to be publishing through our clinic. So I have a nice balance of both, and I think that's very, very important, because early in my career, I was frustrated by some of the stuff that I learned because it seemed so impractical. And I think some of that came from the providers, the educators, the doctors, the researchers, what have you, that never had any interface with patients. And so it really skewed their ability to take the science and figure out a way to apply it logically. And so I'm really grateful for the days that I have in the clinic because it helps keep me grounded and it helps me keep my recommendations practical. And also because if you listen to a patient and the patient's story, you can really learn a whole heck of a lot. So to your question, two days in the clinic and then three days working on research studies and also just researching and writing and teaching and all that good stuff.

Gotcha. So you do spend a lot of time with your nose in the books, but also kind of another foot in the camp of just seeing people.

Yeah, it's a nice balance. Yeah.

Okay, got it. So like I kind of alluded to earlier, we've got a lot of athletes, a lot of exercise enthusiasts that listen into the show, and simply as a pure result of movement, they tend to eat more calories than the general population. I mean, I would say the average calorie count of many of, for example, like the males who I talk to, we're talking 3 to 4,000 plus calories a day, along with lots of exercise. So can you describe or do you have any observations about anything different that happens to the gut or to the digestive system as a result of an exercising athlete scenario, or is all the extra food stuff just burnt his calories?

Well, you're really kind of opening a Pandora's box with this question, because we have this whole world, as I'm sure some of your listeners are familiar with, of the gut and more specifically the gut microbiota. The gut microbiota is this world of bacteria that live in your gut and should have what we call symbiotic effects, meaning you work together to, to the mutual benefit of the host and of the bacteria. So there's lots of things going on because it really is. It's a community of bacteria, it's a community of life. And so there are many inputs that will affect this community of bacteria. And so that's why this can be a bit messy, is because it's not just this linear one input to one output, but you have your calories in, you have the type of calories, you have your sleep, you have your stress. And these things have all been shown to also affect the microbiota. We sometimes don't think about things like sleep or stress, being able to affect the microbiota, but they all feed in together and have an effect. So to your question, there's really a number of answers and I'll try to kind of walk us through them. One of the most interesting answers we have to that question as it relates specifically to the microbiota comes from a research paper published in the journal Gut in 2014. And this study wanted to look at what does the microbiota again, the microbiota being the world of bacteria that live in your gut. What is the difference between an elite rugby player compared to just a regular average Joe? And so they looked at a group of males that were rugby players and they selected another group that were similar in weight, in age and in gender. And they did these comprehensive microbiotol assays, trying to see what the differences were. And they found a few very interesting things. They found that the athletes consumed more calories. And of the calories, protein was the one that was the most increased in terms of relative consumption. So the athletes ate more calories, ate more protein. Nothing really surprising there. What was surprising was the fact that the rugby players had increased microbiotol diversity, which we think is healthier. And they may have had an overall microbiotol colony, bacterial colony, that was healthier than the aged sex matched controls. And so what's really interesting about this is that typically we think that only foods that are starchy and carby and fibrous feed the gut bacteria. But this study really hints at a completely different concept. And the thing that I'm starting to notice, and really combing through all of the microbiota literature, is that the environment that you create in your body will either harbor healthy bacteria or unhealthy bacteria. So if you create a healthy environment in your body, exercise, stress reduction, good sleep, you create a healthy internal environment. That healthy internal environment fosters the growth of healthy bacteria. If you create a more sick, if you will, environment, too much stress, not enough sleep, that creates an unhealthy environment and that harbors unhealthy bacteria. And that's what I think we're seeing with this study published in gut, that the rugby players probably had a healthier environment because they were getting good amounts of exercise. And we could extrapolate here, we're speculating a little bit, but they were probably getting halfway decent sleep because if you're competing at a high level, you probably can't have a totally awful lifestyle. And that the diet, even though you might be able to make an argument that a high protein diet is not good for Feeding bacteria. This shows that that lifestyle may be equally as important or if not more important than your diet. And there's a couple mechanistic things I can dig into in a second. But with that said, is there any things you wanted to ask for me to expand upon?

Yeah. So in terms of microbiota, does that actually express itself? Or did the study note, or have you seen that expressed in terms of a change in gut function in athletes? The reason that I ask this, for example, is I know many triathletes, marathoners, crossfitters, et cetera, who probably have exercise, sleep, diet regimens that are potentially even more healthy than these professional rugby players. Probably less beer, since this is the professional Irish rugby team. But ultimately they still tend to have functional issues during exercise. Bloating, gas, or they have constipation or, or they have issues related to food intolerances, or they eat certain things and just get gastric upset, et cetera. So does having a diverse microbiota actually express itself from a functional standpoint or are we stuck with a scenario where we've got some nice looking gut bacteria but still some symptoms?

Gosh, you ask an unbelievably important question. Because one of the things that I see happening now that the microbiota is kind of in vogue, if you will, is people are getting obsessed with the phylotypes that they have or the printout that they get when testing the microbiota. And an important thing for everyone to be aware of. As someone who's just wrapping up writing a very comprehensive e book on this topic, and I see these patients day to day, and we're conducting research on this in my clinic, that the microbiota testing things like Eubiome and American gut, they are great tests and they are incredibly important for research purposes, but we cannot derive any clinical value from them right now. They don't give us any actionable clinical data. So that's an important preface for me to make. Now I want to work my way into answering your question, but there's a little bit of context I want to provide the listeners with so that they understand how this all kind of unravels in the gut, so to speak. We know that when you exercise, this affects something called toll, like receptors in the gut. And these receptors are essentially sensors that are trying to figure out, hey, is that a healthy food or do we need to have an allergic reaction to that food? Hey, is that a healthy bacteria or do we need to attack that? So there's signaling sensors that help the gut in its purveying of the stuff that's moving through the gut. Now, one of the things that we know exercise will do is it will modulate these toll like receptors. And to put it loosely, the exercise may downregulate these toll like receptors. And. And when you downregulate these, your immune system is going to be less aggressive in killing stuff in the gut, so it's not going to kill as much bacteria. And that will likely allow more bacteria to grow in the gut, which is why we see these rugby players having a more diverse microbiota. But what is a clinical tie in with that? Well, I think what the clinical tie in there is is that a little bit of downregulation of these receptors will allow you not to have an overly inflamed autoimmune type gut. Right. Because if your gut is attacking too much bacteria, you run the potential of falling into colitis, celiac ulcerative colitis, or Crohn's disease. For example, in Crohn's disease, we know that your immune system attacks saccharomyces ceviche antibodies. That's one of the markers we can use to test it. So we don't want too much aggression by the immune system. But if we say, well, if a little is good, is more better. And this is where the excessive amount of exercise may become a problem, because if we downregulate these receptors too much and the immune system checks out too much or it gets too immunosuppressed, then we may cause the opportunity for pathogens and infections to start to occur. And so this is where I think the problem occurs with exercise. It has been well documented, and I'm sure your listeners are aware of this, that excessive exercise has been correlated with immunosuppression and increased risk of infection.

Absolutely. I do some work with Wellness FX and see the blood panels of a lot of, like, the crossfitters and triathletes, et cetera, who they send over. And typically, WBC counts are always suppressed. So white blood cells seem to be very down in many of these folks.

Right. And so this begs the important question of what is the appropriate dose of exercise? Because someone could be, you know, you could have two different people doing the same amount of exercise, and that could be causing disease for one person and wellness for the other. And so there's not this one size fits all. We should all exercise this much. But rather, we all have to find what our threshold for overtraining is. And there's different ways that we can determine that. We can just Be practical and we can see how is our sleep, how is our energy during the day, how are we digesting food, do we have gas or bloating? Everyone kind of has little tells, if you will, in terms of if they start overdoing it, where do the wheels fall off? For me, I start not to sleep very well for some of my patients. They start having bloating or fatigue or whatever it is. But you can do this or track this symptomatically. And then there's also some more objective measures you can use, like heart rate variability to help determine if you're over training.

Yeah, that makes a lot of sense. Now with tracking stress, that seems to make sense. But what about removing stress from a caloric standpoint? This is something that I've always wondered with athletes who are day in and day out eating and eating and moving and moving and never relieving stress on the digestive system. I've seen some evidence that a lot of these cultures in the blue zones, for example, they have certain periods of time where they go without eating, almost a digestive cleanse or a way to fast away a lot of the inflammation that might occur from excessive calories. Are you aware of any studies that contrast never fasting during the year with fasting and the effect that might have on gut inflammation or immune reactions in the gut? Do you personally fast or encourage it with your patients? What, what's your opinion on the constant calories coming in and whether or not that should be broken at any point?

That's a great question. And there's definitely a lot of clinical utility around fasting. And I just want to quickly say that we'll definitely, at some point, I want to give people some very specific tests they can do and actionables they can go through for trying to figure out if they have an underlying gut issue and how to kind of resolve that. But coming back to your question about fasting, yes, it's been very well documented. Probably the best documentation we have for fasting type interventions in gut health has to do with something called the elemental or an elemental diet as a treatment. And what an elemental diet is, it's essentially a liquid diet that someone consumes that becomes very rapidly digested within the first few feet of the small intestine. Everything in an elemental diet formula will be digested. And this gives the entire other 20ft or so of the small intestine and all other 6 to 8ft or so of the large intestine a break from digestion.

Is that because the elemental diet is liquid or Is it because it's only comprised of specifically compounds that will only be absorbed in the upper part of the small intestine?

Well, to be absorbed that quickly, it likely has to be liquid because all these things have been broken down.

I mean, could you like blend a steak and mashed potatoes for example?

No, no. Because you have everything is broken down into its most pre digested composite. So for example, protein would be administered as an amino acid blend, for example. So these things are all very highly broken down. So we have great research studies looking at the elemental diet for inflammatory bowel disease for ibs and there's even some literature being published looking at, for example, in rheumatoid arthritis, it was found that using an elemental diet was as effective as prednisone, the anti inflammatory drug in inducing remission of rheumatoid arthritis. So that's where we have really the best scientific evidence. There's also some evidence regarding just doing a, a straight up fast where you don't eat at all. But I find that to be more challenging for people because I rarely hear a patient that can do a strict water fast and do well with that because of the lack of calories, unless they're doing it something short term, like maybe a day here or there, or half a day more of like an intermittent fasting application. And that's certainly something that I think people could benefit from experimenting with is by going into these periods where they do brief intermittent fasting.

So it's just a very simple diet, this elemental diet and I assume all its components would be something that you would purchase or do people make these type of liquids that they consume during this diet themselves?

Well, there's a few versions that are available. Dr. Allison Siebecker is a good friend of mine and she's a naturopath who specializes in treating sibo, or small intestinal bacterial overgrowth. And we've gone back and forth a lot about trying to find the ideal treatment offerings for patients in this regard. So to go kind of from the top down, the prescription version which are pre made and these are known as Vivinex plus or Peptamin and these are elemental or semi elemental diets that you would need a prescription to have. And then once your doctor prescribes that you may be able to have insurance coverage for that. And it's just a pre made shake that comes in a little can or a canister.

I see that made by Nestle.

Right. Once Nestle acquired the company, they really jacked up the price and I think it's like $800 or something ridiculous like that if you don't have insurance coverage for it. So it's in my opinion, pretty much cost prohibitive. What Dr. Seibecker did was she made a homemade version of this. We have the directions available on my website. She has the directions available on her website for this. But essentially you buy things like oils, maltodextrin, amino acid blends, and you mix all this stuff together and you create a homemade elemental diet.

I'm looking at the ingredients right now. They look like about half a dozen different sports nutrition compounds I've seen on the market. Like things people would tend to consume during exercise. Amino acids, medium chain triglycerides, glucose or maltodextrin, honey, et cetera. I'm guessing perhaps there's some athletes out there who probably have some of these very same ingredients in their cupboard already.

Right. So it might make it easier for someone to start on this. And a big reasoning for that is you want fast absorption during exercise or post exercise. And again, remember, with the elemental diet, we want it to be absorbed within the first few feet. So that's where that comes in.

So the argument is not that this is necessarily a healthy diet. I mean, obviously it's a lot of sugars, et cetera, it's not extremely nutrient dense. But the idea is that it relieves stress on the digestive tract for a short term solution for healing.

It relieves stress. And the other thing that it does is it starves bacteria. And this comes back to the application we were talking about before. That has relevance, I think, for your audience for athletes, which is if you're exercising too much and you're causing immunosuppression in the gut, you risk having a bacterial overgrowth in the gut or a fungal overgrowth. And this could be one tool toward helping to reverse that or treat that or what have you.

Now, what about the use of to achieve a similar effect to kind of like relieve stress on the gut or to give the body a little bit of extra help? The use of digestive enzymes. For athletes who are eating a lot.

Of food, I think digestive enzymes can certainly be helpful. And what I typically do in terms of how I use these in the clinic is when someone first comes in and has a number of digestive problems, we will do some testing. We usually find either Candida or Sibo or some other sort of infection or imbalance. And as we're treating that, in our initial stages, we use an enzyme hydrochloric acid blend. And then once we have Someone feeling well and maintaining their improvement for a few months, we have them wean off of that and try to find the minimum tolerable dose needed. In a lot of cases, people don't need anything in the long term. Now, could someone who's an athlete who's on the edge of overtraining try one of these supplements to maybe help give them that little bit of an edge? I think so, because we do know that stress, exercise being a stress, causes a sympathetic shift in your nervous system, which steers you away from digestion. And so this would be a way of externally taking some of the enzymes and acids your body would release should you, or would you have more time being parasympathetic. But you're not because you're maybe over training. So I think there is an application there. And I would just say to people, try a formula. Try one of these digestive support formulas, see how you feel. If it works, great. And if it doesn't, then I'd look elsewhere.

It's an interesting paradox. We are stressing our guts from one end with exercise, and we're stressing our guts from the other end with the calories that we need to exercise.

Right. And I mean, it's all about. There's an old saying, I think it goes, stress is to life as tension is to strings on a violin, meaning if you have too much, you'll break the strings, and if you have not enough, you'll be out of tune. So it's finding that appropriate amount of stress that is going to be keeping us in tune, so to speak.

Yes, I played violin for 13 years. I can appreciate that analogy.

Oh, nice.

Although I always did an internal fist pump when my string broke because it meant I could leave violin lessons for that day anyways, though, so I want to switch direction here for a second and talk about people who have taken a deeper dive, so to speak, I guess, both literally and figuratively. We've got a lot of people in the health sector and perhaps the bulletproof coffee enema post that I did a few months back is, Is partially responsible for this, who are doing things like cleanses, colonic hydrotherapy, enemas, et cetera, and they're doing these to maintain proper bowel function. What is your take on the whole, like, cleansing? I know there are different things, but like cleansing, detox, enema, speaking to one or speaking to all three.

Well, if someone needs an enema in order to be regular, meaning they're constipated, if they don't have an enema, then something is clearly wrong, and they need to see a doctor to figure that out. And that's a fair number of my patients. When they first come in, they will be going to the bathroom only once a week unless they have an enema. And so there's clearly something there that needs to be investigated. So if someone is in that boat, I would really urge them to figure out what's going on, because there may be something serious going on underneath the surface. And you should not ignore that.

In athletes who are chronically constipated, what type of issues do you tend to see?

Well, the most common thing that we'll see after someone improves their diet, right? I mean, if someone's eating a terrible diet, that certainly can be an easy cause and fix for constipation. So once the diet is out of the way, the most common cause of constipation that I see is something known as small intestinal bacterial overgrowth, also known as as sibo. And this is where the bacteria from the colon grow into the small intestine. And depending on the type of bacteria that overgrow, it can cause diarrhea, it can cause constipation, or it can cause an oscillation between the two.

How do the bacteria get there, from the large intestine to the small intestine? Is that normal or something broken or open or disrupted for that to happen, like, anatomically?

Well, it's all one tube, right? So to visualize it simply, if you were to draw a line from the mouth right down to your rectum, you know, the digestive tract is one tube. It's not a straight line, of course, but the order goes from your mouth, your esophagus, then your stomach, then your small intestine, then your large intestine, and then your rectum. Now, the further down the line you go, the closer to the rectum, the higher the level of bacteria in one of those compartments there should be. So the rectum and the large intestine have a lot of bacteria going up the line. The small intestine has far less. And going up the line even further, the stomach has even less. So one of the major underlying mechanisms that causes sibo is an impairment in what's called motility. And essentially, motility is just the intestines trying to contract and keep a downward flow of food through the intestinal tract. And if someone has impaired motility, that won't keep things moving down smoothly, and then the bacteria can start to kind of crawl back up, so to speak. And the analogy that I like to use Is if water, for example, is running, it doesn't really foster bacterial growth, but if it becomes stagnant like in a pond, then it of course does foster bacterial growth. So if motility in the small intestine becomes impaired, we can set the stage for sibo. And then, ironically, SIBO can then cause diarrhea or constipation, depending on the kind of gas that is released by the type of organism that overgrows.

Yeah, it makes sense. And I know that you've got some comprehensive information on SIBO over on your website and many hours worth of podcasting over there, so I don't think we need to dive too, too deeply into that because it would probably be a multi hour podcast. But regarding sibo, one of the things that I know people will ask are regarding testing. I know that the breath test for a while was the best test that you could go out and get if you suspected that you had SIBO, or if you had constipation chronically or gas bloating, etc. Is that still the case? Is a breath test still the way to go when it comes to sibo?

It is. It's really the only test you can use to accurately diagnose sibo, with the exception of taking a sample directly from the small intestine. That is very prohibitive because that would require a gastroenterologist to literally shove a tube either down your throat or down your nose, through your esophagus, through your stomach, and then into your small intestine and take a biopsy of that fluid. So it's not really available for routine clinic.

I'd choose the mouth, a few less inches for the tube to have to go. Right.

So it's not really something that's routinely available or practical, but the breath test is. And that's an important distinction to make because there are other tests that are sometimes recommended online, potentially from a healthcare provider that doesn't have a license to be able to order this test. But really the only reliable test we have to truly diagnose SIBO is the breath test. And I would recommend that someone use a breath test where lactulose is part of the solution that you have to drink for the test, and hydrogen and methane are measured for at least three hours.

Gotcha. We've talked a lot about the microbiota and bacteria when it comes to the digestive tract. However, there are a couple of other things, such as muscles and nerves that are down there and in there. When it comes to nerves, how do nerves interact with the ability to have digestive comfort move things through. Can you have damaged nerves in the gut from eating too many calories over the course of an athletic lifetime, those type of things?

Well, I'm not aware of anything that shows that eating too many calories can damage the nerves, but the nerves do control the motility that we were talking about a moment ago. And interestingly, when your body is in a fasted state, that actually stimulates motility. If someone's ever gone 4 or 5 ish hours without food and they've heard that grumbling, that gurgling in their stomach, that's a motility function known as a migratory motor complex. And essentially, when most of the food is kind of out of the system, so to speak, that's when the stomach and the small intestines run through their housekeeping function called the migratory motor complex. And it just kind of sweeps everything down the line into the small intestine. So you can think of it like when there's not a lot of stuff in the stomach and small intestine, when you're somewhat fasted, that's when the stomach and small intestine say, hey, now's a good chance to take out the broom, sweep stuff down into the colon where it should be. And so there is plausibility to your comment, Ben, that if you're always eating every three hours the way I used to, then you, you may slow down your motility a little bit, and that could potentially provocate a problem like sibo. But will you do damage? There's no evidence to support that you will do damage. Food poisoning can cause damage to these cells. Eating won't cause damage, but eating may impede your opportunities to perform this housekeeping, sweeping function that we talked about.

Gotcha. Okay, so when it comes to motility and ensuring that, say, in someone who has had sibo, or in someone who perhaps has slowed down motility just from excessive stress, exercise, et cetera, are there herbs, supplements, foods, activities, you know, whatever, massage techniques, things like that, things that can increase motility and the movement of things through the gut?

There are, and we're actually putting together a randomized control trial through my office, studying one of the most popular motility agents, natural motility agents, in the prevention of sibo. So there are motility agents. There's one formula known as Iberogast. It's made by a German lab. There's another compound known as Motilpro, which is made by a lab in the States. And then there's isolates like things like ginger, that may Help with motility. And then there's medications also. Tigasarod is one medication, and it's no longer available in the United States. Low dose erythromycin, it's an antibiotic, but used in low doses, it does not have any antibiotic characteristics and only has this, what we call prokinetic or pro movement function. And another medication is known as resolor, which has promotility characteristics. So, yes, there are agents that can help with this. However, it's important that if someone has sibo, they treat the sibo first, because these agents are usually meant to prevent sibo from coming back and not necessarily to treat sibo.

And if you don't treat the sibo first and you've still got all this bacteria in the upper part of your small intestine, and you take something like this, this Motel pro or ginger or iberogast, what happens?

Well, someone actually may see symptomatic improvement, which would be nice. Iberogast, for example, has been used in conditions known as dyspepsia or dysphagia, where people have a hard time swallowing or indigestion. So it can't provide symptomatic relief. But what will likely happen is as soon as you stop taking this agent, you're gonna go right back to where you were before A, and then B. I doubt someone would achieve the level of symptomatic improvement they potentially could. Should they first treat the sibo and then use this agent.

Gotcha. Okay, now how about, you know, we talked a little bit about nerves and motility. How about mechanical or anatomical issues in athletes? For example, people with very, very strong stomachs who have done planking and sit ups, et cetera, who have, for example, the ability to push very hard when they go to the bathroom, or people who have very, very tight stomachs. I'm always curious if having strong abs can backfire on you from a digestive standpoint and whether you've seen anything like.

That, that's a great question. I don't know of having highly developed or even over developed stomach muscles would necessarily cause a problem. But there is something there that we should discuss, which is if people have had abdominal trauma, meaning maybe a hernia surgery or a C section or an ovarectomy, or any kind of abdominal trauma that may cause scarring or damage, or even if a woman has really bad uterine fibroids, for example, which can cause pelvic obstruction, anything in the abdominal pelvic area that creates scar tissue, whether it be surgical or impact trauma or what have you has the potential because the abdomen and pelvis rest up against your intestines has the potential to impede the movement of stuff through the intestines. And there is one physical therapist, or a physical therapist couple known as the Worns. And they've developed something called the Wurn Protocol Wurn. And he'll be coming on my podcast soon to discuss this. They've published a tremendous and impressive amount of literature looking at their therapeutic technique which breaks down abdominal adhesions and scar tissues. And by doing that, they've seen relief of sibo, they've seen relief of ibs, they've seen relief of even things like infertility or other female related disorders that have. For example, let's say a woman has a real hard time getting pregnant, she may have a scarring in one of the fallopian tubes that's not allowing proper cycling or expulsion of the egg. And they've actually been able to go in and break down that scar tissue to open up the fallopian tube to allow proper flow and the same thing in the intestines. And they've done an excellent job of publishing this stuff in scientific journal. So it's all very legitimate.

Interesting. That one's called the Wurn Protocol Worn.

W U R N By the way.

For those of you listening in, I am taking comprehensive notes as Dr. Ruscio is talking and you can find them all@BenGreenfieldFitness.com broken gut that's BenGreenfieldFitness.com BrokenGut now, in terms of other hands on physical types of methods to help with digestion, another thing that I've seen appear several places on the Internet which we can always trust this concept that there is. There's a valve called the ileocecal valve between your large intestine. I believe it's between your large intestine and the end of your small intestine. Correct?

Right.

And that apparently can become closed or open and responsive to manual therapy. Do you have thoughts on that?

I do. So I really like to fact check things. As much as I love the field of natural medicine and functional medicine, I'm also a bit of a skeptic and I'm not much for being a lemming, meaning just following what everyone else is doing and following what my teachers say or following what the industry standard is, I constantly fact check things. Things. And by doing that I found a number of things that we've held as truths in the functional and natural medicine community are not in fact true. This is one that I think falls a little bit more under the side of the argument of not being. I don't want to say it's not true, but let me come full circle with my comment on this, and I think it'll drive the point home. Do we see much in the scientific literature showing that therapies for the ileocecal valve, ileocecal valve manipulations and the like have a positive impact on health? No, there's very, very little scientific documentation to support that concept. There's even some studies showing that people that have had their ileocecal valve region removed are not at an increased risk for sibo, which really supports that. The ileocecal valve is not a major implication in causing SIBO and many of its associated symptoms like gas bloating, abdominal extension, constipation, and diarrhea. However, when we were talking about motility, the main cells that regulate motility are these neuromuscular cells known as the interstitial cells of Cajal.

And the interstitial cells of Cajal, Yes.

Interstitial cells.

It sounds like something out of game of thr.

We can call them the ICCs for short. But these cells are essentially the regulators of motility in the gut. And what we know can happen if someone, for example, has had food poisoning. After food poisoning, when your immune system comes in to attack whatever bacteria or parasite is causing the food poisoning, your immune system can accidentally attack these interstitial cells of cajol. And that may be exactly what's happening when we see this impaired motility that causes all these problems of bloating and distention and just funky digestion in general. Interesting, interesting, interesting. Now, how does this tie in with the ileocecal valve? The highest density of the interstitial cells of cajol is in the ileocecal region. So the region is important, and restoring motility is important. But do we have to do a physical manipulation to restore that motility? Maybe I'm open to it, but thus far, it has not been very thoroughly documented scientifically and clinically. I haven't seen a need for it either myself.

So these cells of Cajol, these ICCs, suppose that they're damaged, or suppose they're reacting with an autoimmune issue like they're. Do they die, or do they simply become reactive to tissue within one's own body?

Well, the exciting thing is we finally actually have a test where we can test antibodies against these cells and against the component of this attack known as vinculin. So we have a test to actually be able to document this. And one of the questions that people who become diagnosed with SIBO have is, you know, can I recover? Is this autoimmune attack that I've had, like you mentioned, is that terminal diagnosis meaning I can never recover, recover? And unfortunately, because a lot of people on message boards are just trying to treat SIBO at home on their own and don't do a good job with it and never fully recover, a lot of people are falsely feared in the thing that you can't recover from sibo. And my clinical experience with SIBO has been very good where we've seen very good recovery with sibo. And I believe part of that is because, yes, these interstitial cells of Cajol can regenerate. They have the ability to regenerate and also rewire, which is also known as plasticity. So they can regenerate. We just have to make sure we dampen inflammation because a pro inflammatory and highly oxidative environment will reduce the rate at which these cells can regenerate themselves.

And so we come full circle to the point where if you've done that type of damage, you would need to go through some kind of a stress reduction protocol or, God forbid, take an off season from your sports performance protocols.

Definitely stress reduction, sleep clearing sibo if it's there, or any other sort of parasite, and then following kind of the standard algorithms that we as doctors are trained to follow and the proper treatment and follow through on some of these things. And that's one of the most common mistakes that I see is that someone does a lab test on the Internet for sibo and then they come back positive and then they go and they look for someone's SIBO protocol on a blog. And just because you have a SIBO protocol doesn't mean you really know how to treat sibo. I mean, if your car broke down, Ben, and we let you into someone's mechanic shop, would you know how to use everything in there? People always want protocols, and I'm happy to try to share those with people to help help them. But it's not as simple as just having a protocol. It's knowing how to comprehensively manage these things back to a successful outcome.

Now, before we talk a little bit about the gold standard for different tests that you would recommend for different issues, one more question about kind of the end of the tube. I guess we started more up towards the top of the tube and now we're towards the end of the tube. What about things that can happen inside as you get down into like the colon or the rectangle, like fissures and hemorrhoids. And I believe they're called strictures or areas where things just can't seem to get through, even if motility is good the rest of the way. Do you see those type of issues in athletes or in exercise enthusiasts, or again, in people who strain, have stress, things like that, and if so, do you have protocols that you like, like for those type of issues?

Well, the most common area where you're going to seeand so I should maybe answer first. I don't have much experience with hemorrhoids. I just don't see a lot of that coming into the clinic. So not a lot of experience there. But with things like strictures, which can form as a byproduct of inflammatory bowel disease, either ulcerative colitis or Crohn's. Yes, definitely inflammatory bowel disease, ulcerative colitis and Crohn's being two of the main sub diagnoses that can definitely be an issue for some people, and especially for some people that have changed their diet, changed their lifestyle, they're like 80% to what they would consider fully improved. And they have these lingering symptoms that come and go. Sometimes these patients have low level inflammatory bowel disease that's never gotten bad enough to flag diagnosis via a gastroenterologist. And so we just have to use some of our therapies for inflammatory bowel disease, our natural therapies. Is my preferential starting point to try to just tone the immune system down a little bit more. So definitely to things like strictures. Yeah, I think there's some good relief for those things in the context of inflammatory bowel disease. And then also speaking about the colon more, this is where a whole other class of problems can happen, which would be infections with things like amoebas or protozoas. So I myself in college, how I got into all this, this work, I had an amoeba infection, amoeba hisolitica, in my colon, and it really, really messed me up. And I went from being a fairly elite athlete just feeling like I could run through a wall, almost invincible at 23, right. And then I was having terrible insomnia, ridiculously bad brain fog. I would eat anything and just feel like an idiot for three hours spells of fatigue. And I do. A lot of my patients do. I went on the Internet and I thought I had hypothyroid, I thought I had low testosterone, I thought I had all these issues. And I tried these natural treatments and didn't really get anywhere until I did some stool testing and I figured out I had an amoeba. And it was only treating that amoeba and clearing that amoeba that really allowed me to have all those other symptoms clear up. And those are things in the colon. So definitely we've been talking about the small intestine, but the colonial rolling can be very important also.

Gotcha. That makes a lot of sense. That's interesting. I've personally come back from multiple races in international locations, specifically triathlons, where you swim in just horrible water. And about every two years I wind up with an amoeba or a parasite. I have a local doc, he's a functional medicine doc, he's a Chinese herbal formulator and, and basically he's had to treat me many a time for issues that I come back from triathlons with. So typically it's about twice a year now that I get one of these gut panels to ensure that there's nothing there. And it's almost without fail, after international travel, Mexico, Thailand, Asia, et cetera, that I come back with things. Little critters, new pets. It's interesting. It's interesting. So far, knock on wood, been successful at knocking them out every time. But. But it typically involves drinking very untasty herbal formulations.

Right, but at least you're aware of that because there are so many people out there that have been carrying around one of these issues for years and years and years and they've been treating all the symptoms. Right. The symptom might be fatigue, the symptom might be brain fog. And people sometimes chase down things like, oh, maybe it's my testosterone, maybe it's my brain, maybe it's my. And in some cases it is. But I certainly think the best place to start in a lot of cases is looking at the gut, because the gut, a problem in the gut can manifest as so many other symptoms that before you chase down those other symptoms, you should look to see if the root cause is with a gut based issue.

Yeah, yeah, makes sense. And as far as testing goes, let's say that you could, let's say you have gut issues and you could kind of like go through the gold standard protocol for gut testing. I know, I just mentioned a stool test, like a three day stool panel. I'm curious if you have other tests that you like to run. If you go in a specific order based on symptoms and what your gold standard testing protocol would be if you wanted to really truly dig down into issues that people experience with the gut.

It's a Great question. And I. And I've got an answer. But there's sort of two ends of the spectrum that I play to here. One end is trying to be comprehensive, but the other end is also trying to be cost effective. And the cost effective piece is actually a highly legitimate piece for functional medicine. One of the things that challenges the functional medicine movement is its cost prohibitive nature. And I think that functional medicine is so cost prohibitive because many doctors in the functional medicine community, and I include myself in that, and I include myself in this criticism as something I'm actively trying to improve every day, is we are not selective in our testing. And sometimes we think we have to test every marker under the sun in order to be a quote, unquote, good doctor.

Well, and it's not covered by insurance in many cases, right?

And so when you compound that with the fact that some of these things are not covered by insurance, this is where you hear some. When someone goes to their functional medicine doctor, the initial lab bill is 3, 4, 5,000 dollars. And I'm not saying there's not a time and a place for that, but I think for most people and for a good clinician, you should be able to peg the underlying problem with much less lab testing. And I like the old saying that he who is the best can do the most with the least. So if you have two doctors and one can find the problem for $700, and the other one, it takes $3,000, well, they both found the problem, but who's giving a better quality of care, Right? So with that in mind, there's a ton of testing that we can do. But I try to pinpoint the testing at what makes the most sense for the patient. So what testing do I actually do if we're going to do? If someone comes in with chronic issues, especially chronic gut issues, there's a few things I like to test initially. I always like to do a breath test for small intestinal bacterial overgrowth. And that test is actually not very expensive. The lab we use is $180, and it also has an insurance billing option, so that's definitely one. And then I like to do that in tandem with two stool tests. And I usually try to do one of those stool tests through the patient's insurance. Most insurances are contracted with either LabCorp or Quest. And there's this misnomer floating around in the functional medicine community that the conventional labs like LabCorp and Quest, that are these huge national labs with a huge repertoire of resources at their disposal, are somehow bad at testing for parasites and infections. And unfortunately, I think that comes from the fact that much of functional medicine education is put on by lab testing companies. Right. And so you see a bias in the education that is reflected in the care of the doctors. I have been using LabCorp and Quest, and I've seen LabCorp and Quest actually outperform some of the most popular functional medicine labs where patients may spend well over $500 for a stool test. And we've been able to get that for free, essentially, through their insurance through LabCorp and Quest. So that would be the one stool test I would do. Of the two stool tests, if someone.

Has insurance coverage, and that one is the.

Well, it's through LabCorp request. And there's not. You have to have all the codes. And this is probably part of the reason why a lot of doctors don't use it also is you have to. It's taken me well over a year to get all these codes and refine them. And it's not always Easy working with LabCorp requests because they have thousands and thousands of markers, and it's not always easy figuring out what they actually have. And they don't have. Their website does a pretty bad job of displaying this. You have to call them a lot of times and speak with a consultant and figure it out and get the code and yada yada. So it's been a lot of work, but it's really paid its dividends because. Because we can get really comprehensive testing for essentially free if the patient has insurance coverage. And this is something I do teach, a workshop for doctors in a clinical training course. So if there are doctors out there that wanted to get the deep dive on all these marker specifics, then that's available. But that's LabCorp and Quest, and it's just getting the appropriate coding and ordering the appropriate panel.

And a physician does that for you?

No, we do that through our office. So as a dc, I'm licensed as a practical patient.

Well, yeah, that's what I meant for the listener, if someone was.

Oh, for the listener.

If someone was wanting to get that test, they could approach a functional medicine doc or someone like you and discover which panel they could order through a Quest or a LabCorp if they wanted to save them money on a panel like that.

Exactly. Most doctors, of course, any MD or DO will be able to order this. Any DC, and then most naturopaths or most NDs should be able to order this, depending on the license rights in their states. The only important qualifier there is just because you go to LabCorp and poop in a cup does not mean it's been a comprehensive sampling of the poop in said cup. Right, and that's where you have to tell the people at the labs with all the codes. Hey, we want Yersinia run. We want toxoplasmosis, we want open parasite times three. We want a stool culture for Candida, we want Candida antibodies, we want H. Pylori stilantogen, we want H. Pylori breath tests. So you have to really tell them what to do. So just because you go to LabCorp doesn't. Does not mean it's been a good test. But that's where you have to have confidence in the doctor that you work with that they're doing a good job.

Yeah, that makes sense. So we've got the SIBO test, we've got the gut test. What about any imaging?

One thing, Ben, before I move on. Sorry. So I like to do two stool tests in tandem. So I'll usually do kind of the comprehensive panel through LabCorp if I can. And the LabCorp panel usually consists of urine, breath, blood and stool. Now, I usually do that in tandem with another stool test. And I typically will use either biohealth labs, diagnostics labs, or doctor's data for the second stool test. And if someone doesn't have insurance and can't use LabCorp request, I'll just use two of those other labs I mentioned where I'll do a bio health in tandem with a diagnostics panel or a diagnostics in tandem with a biohealth panel.

Okay, makes sense. And if someone were to go to your website and what we'll link to that too, over@BenGreenfieldFitness.com Broken Gut. They can contact you if they have. Do you work with people remotely, for example?

I do. I think about 40% of my practice is probably remote because unfortunately, people sometimes have a hard time finding a doc in their area that excelsior at this stuff. So, yeah, we are able to accommodate people via phone or Skype.

Gotcha.

Cool.

What about these tests where they look at how fast things are moving through your digestive system? These transit time tests, do you ever order those or do you find any value in those type of tests?

Well, these are mainly an issue the transit times. It's also known as antroduodenal manometry, which is essentially looking at how well things move through the intestinal tract. There's only a few centers that provide this testing, and there's also a barium test which can give you imaging of the small intestine, large intestine, and the stomach, of course. So these imaging in these motility studies, they have their place. Typically, if we're looking at, for example, the SIBO treatment algorithm, these have their place if someone's been diagnosed with sibo, treated for SIBO and can't clear SIBO or chronically relapse. And so they're not really a frontline test, they're more of a. We've run through our initial diagnostic and treatment protocol and we're now, you know, hitting a road where we have a patient that's a chronic non responder. So that's one of the next things to look at, would be a anatomical problem, a structural problem, and also that's when a potential referral for some of this worn therapy to break down on adhesions would also be an issue. So those are more your end phase therapies rather than your frontline therapies.

Gotcha. Okay, that makes sense. So you do these stool tests, you've got the sibo breath test, you save any of the fancy lab imaging for if nothing else is working, any other last test that you like to use?

Well, there's also a urine test that can be used for dysbiosis, which can be helpful. And sometimes we can miss some types of SIBO on breath testing. This is known as hydrogen sulfide sibo, and there's not really a sanctioned test for this yet. There's not really a research validated test for this yet. So us as clinicians are using the best thing we can use. So we have urine organic acid testing, and there's also a urine sulfide, which may also be helpful. So this would, again, it wouldn't be a frontline test, but it would be for someone that's sort of, you're scratching their head at the response and maybe they come back negative for sibo, but they have all the SIBO symptoms. This would then be a consideration. And then of course, there are other tests, depending on the patient's presentation, that we may want to run that are non gut related. But we may want to look and screen for anemias or high or low iron levels, or hypothyroid or inflammatory markers associated with inflammatory bowel disease, for example. So there are other things that we can definitely look at. But I try to really consolidate this to the most cause focused test first, because let's say someone comes in with somewhat low testosterone and a really bad gut infection. Well, if I find the gut infection and treat the gut infection, the testosterone will probably take care of itself. So that's why I recommend that we start sort of start trying to peg the cause, and then we can always do more lab testing later.

So much starts with the gut, huh?

Right.

As you kind of test it with your own personal experience where you used all these different therapies before finally turning to this amoeba that you had. Right.

Exactly.

Well, Dr. Ruscio, you're a wealth of knowledge on this stuff. And again, if you're listening in, go to BenGreenfieldFitness.com Broken Gut and I have a list of notes a mile long for you to go through over there if you want to delve into everything from the worn protocol to the interstitial cells of Cajal. But Dr. Ruscio, you've also been very generous with your time. So thanks for coming on the show and sharing all this with us.

Yeah, it's my pleasure. And for your listeners, we'll put up a landing page where we'll try to I'll have some of the people on my web team try to put together some of the podcasts and articles that are most relevant to what we've spoken about. And if people want to visit there, they can just go to Dr. Ruscio. Beng sO-R-R-U-S-C-I-O.com Beng and we'll try to organize some of this stuff for you in one place.

Ben G. Ben with a G. Not to be confused with a dog, Ben G. Which I use. JI I believe it's been a while since I've seen that show. All right, well, cool. So, DrRuscho.com Ben G. Or for my notes, you can go to BenGreenfulFitness.com Broken Gut either way, you're going to get knocked out with a ton of info, but that's what you asked for, folks. So anyways, thanks for listening in. Dr. Ruscio. Thank you for coming on the show, man.

Thanks for having me. My pleasure.

All right, folks, this is Ben Greenfield and Dr. Michael Ruscio signing out from the Ben Greenfield Fitness Show. Have a healthy week.

You've been listening to the Ben Greenfield Fitness Podcast. Go to Ben greenfield fitness podcast.com for even more cutting edge fitness and performance advice.

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