Dr. Michael Ruscio on Probiotics and Gut Health

Content By: Ari Whitten & Dr. Michael Ruscio

In this episode, I am speaking with Dr. Michael Ruscio – who is a Doctor of Chiropractic, clinical researcher, expert on the gut, and author of the bestseller, “Healthy Gut, Healthy You.” – about probiotics and their role in gut health.

Table of Contents

In this episode, Dr. Ruscio and I discuss:

  • The connection between gut health and overall health
  • Germs are they really harmful to our health?
  • The role of probiotics and prebiotics in health
  • The mechanisms of probiotics
  • How to heal your gut to heal fatigue

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Ari Whitten: Hey, this is Ari. Welcome back to the Energy Blueprint Podcast. With me today for the third time is my friend, Dr. Michael Ruscio, who is a clinical researcher and author working fervently to reform and improve the field to functional and integrated medicine. With his clinical and research teams, he scours existing studies to inform his ongoing clinical research, patient care and guidance for health seekers and fellow clinicians around the world. His primary focus is gut health and its impact on other facets of health, including energy, sleep, mood, and thyroid function.

His research has been published in peer-reviewed medical journals and he speaks at integrated medical conferences across the world. While actively seeing patients in his clinic, he also runs an influential blog podcast as well as newsletter for functional medicine practitioners. This is a podcast where we talk a ton about really important aspects of gut health and probiotics in particular. There’s some topics that are controversial and we have really wonderful exchanges around these.

I personally really enjoyed this conversation and this interview of Dr. Michael Ruscio. He gives a lot of value and I think you’re going to get a lot of value from this podcast. Particularly if you’re a high-level health science geek who’s very interested in gut health, I think you’re going to find this fascinating. Enjoy the episode. Welcome back to the show, Dr. Ruscio.

Dr. Michael Ruscio: Thanks for having me back. Always good to be here.

Ari: I think this is at least number two, also, I think number three.

Dr. Ruscio: Maybe three.

How gut health connects to your overall health

Ari: Cool man. Let’s talk about big picture how gut health connects to the health of the rest of the body. How it connects to autoimmune disease, how it connects to inflammation, immune function, how it connects to fatigue, brain function. There’s so many different accesses, the gut immune access, the gut lung access, the gut brain access, the gut mitochondria access. I’m sure each one of those you could talk for an hour about but give us the overview of how good guts go bad.

Dr. Ruscio: This is a great question. As you know, it’s something I learned painfully in my early 20s where I had terrible sleep, almost crippling. If someone listening to this or watching this has had fairly market insomnia, it’s almost like being tortured. I had that along with fatigue in the day, obviously, because if you’re not sleeping well at night you’re going to only be able to get a couple of days, and then it just wears on your energy and my mental clarity of course and my mood.

For me, I learned, wow, the brain is connected to the gut. As you noted, there are so many systems that are connected. Skin conditions, various types of rashes or acne or pimples, thyroid conditions, immune conditions in general, joint pain, mitochondria, nutrient absorption, there’s just so many areas that tie to the gut. Cardiovascular disease, more research is appearing on this. There’s really a wealth.

As you said, there are so many directions that we go, especially if we’re going to get into the academic minutia. Thankfully, I think why we get along so well is as cool as the academic minutia is, I think we try to center our focus around, okay, what can someone do to improve this thing and therefore have a positive impact on their health?

This is where the gut is such a cool lever that we can pull on in terms of seeing various gut interventions actually improving things like cholesterol, like for myself, brain fog, and sleep or a skin condition or joint pain, or what have you. To try to answer your question with a couple of concise responses, the largest density of immune cells in the entire body is in the small intestine.

If we understand the relationship between the immune system and inflammation, we also understand that not only autoimmunity because of the immune connection there but also inflammation tie back to the health or lack of health in the small intestine. That’s the one. Then one or two others to tack on behind that would be absorption of calories but perhaps, more importantly, is absorption of your nutrients. If you’re not absorbing nutrients well even if you’re eating a healthy diet, you could be pseudo-malnourished because you’re not getting that much out of your diet.

This isn’t highly speculative. Sure, if someone has very bad, let’s say inflammatory bowel disease with 13 diarrheas per day, pretty obvious that there’s going to be a degree of malabsorption. There are even studies at the other end of the spectrum that have shown something like a probiotic can improve absorption of various micronutrients. The inflammation, autoimmune, and nutrient absorption pieces might be three of the most upstream ways in which gut health affects all these things that we see downstream.

Ari: I took a gut course recently with a world-renowned gut researcher and I learned a ton actually. One of the interesting things that he talked about in all these different lectures and all these different gut conditions, ulcerative colitis, diverticulitis, IBS, and on and on and on, a dozen different conditions. One of the things you see consistently over and over again is– Yesterday I was reading one on ulcerative colitis has increased 11-fold since the 1990s.

You see that same trend, almost every gut disease has increased 2, 3, 5, 10-fold in the last few decades. What do you see as the biggest contributing factors to why there is a need for so many gut specialists like yourself to emerge and why there’s so many people talking about gut health right now? What has caused so many people to have gut issues now?

Dr. Ruscio: It’s likely multifactorial, antibiotic use probably one. Although I think it’s important to clarify, the antibiotics have the most deleterious effect the earlier they’re administered in life. This would be children, especially infants. When you’re an adult, I think it’s important to clarify that while sure some antibiotic-associated side effects are documented, they don’t have the same negative impact. We don’t want to use them willy-nilly sure, but just as a quick aside, I think it is important almost like a PSA. Adults shouldn’t be highly, highly trepidatious regarding any antibiotic because the adult microbiota is somewhat resistant.

If you’re trusting in your doctor and you think they’re making the recommendation with a good level of circumspection then sure as an adult. For children, the early use of antibiotics is one, the lack of exposure two, the environment and what I call naturally occurring or good dirt, hunter-gatherer dirt. Literally being outside in the dirt, touching animals, not in a weird way, [laughs] and just doing things that would expose you to all these microbes that tune your immune system. That’s been very well documented.

Maybe one of the most elegant studies looked at mothers and children and they mapped out on one access, the amount of autoimmune conditions they had and on the other access, the amount of farm animals they had contact with. There was a totally inverse relationship where the more contact with animals, the lower the incidence of inflammatory and autoimmune conditions. That’s another big one. It’s harder to rectify perhaps and go live in a farm. It’s not like you can just easily do that but the antibiotics, the environment to kind of large, and along with that would be our diet.

This is where things get a little bit murky in terms of yes, the processed food, obviously definitely a bad thing. Do you have to go to a super high fiber diet? Maybe not. Do you need to not be on the Standard American Diet? Definitely. From there, if you go in any direction where you’re eating less processed food, whether it’s something more like a Mediterranean or a paleo or a low carb, or even a vegetarian relative to baseline, that’s going to be healthier for your gut.

Ari: What was the last dietary pattern you mentioned?

Dr. Ruscio: Vegetarian. I’m not a huge proponent of a vegetarian diet but I think you can certainly make a case, any diet relative to no diet. If it’s centered around standard processed foods it’s going to be a huge win. I try to get too caught up into the debates about the diets and have this meta-view on them.

Ari: I’ll make sure to ask you a lot of questions about your diet theories and diet debates and which dietary camps you hate.

Dr. Ruscio: Then lifestyle. We know that sleep and stress will perturb the microbiota. There’s some really cool studies looking at college students pre-exam, whereas they’re coming to the pre-exam stress period and there’s a skewing of the microbiota and a dwindling of healthy population.

Once we start weaving all these things together kids who also may not have been adequately breastfed, let’s say, plus antibiotic use, plus lack of exposure to the environment and the natural germs and bacteria that are supposed to partially colonize and partially help tune the immune system. Which by the way that immune system tuning by the second or third year of age, sets the tone of the immune system for your entire life to a greater or lesser extent, plus lack of sleep, plus processed foods in the diet, plus minimal amount of exercise.

All these things start accruing. We have not only gut problems, but as I’m sure you’ve talked about a whole cascade of the problems that are associated with the western diet lifestyle.

The hygiene hypothesis

Ari: Let’s go back to the farm animal thing that you mentioned. Obviously, this relates to the hygiene hypothesis. Can you explain the hygiene hypothesis? Let’s say probably a lot of people listening to this have never heard of it, or maybe have heard of it, but don’t really know what it means, and how the gut is involved in mediating that immune education?

Dr. Ruscio: This is a great question and I love the way you phrase the immune education. You can think of or one can think of the immune system and the gut, as systems that require stress in order to work properly, very similar to bones. If we’re in a no stress, or no gravity environment, our bones would not work and we take that for granted. The same thing happens in our gut, the immune system, it requires, I guess, you could say hormesis or healthy stress in order to function.

It’s easy to get caught up in this, “Oh, my God, germs are bad, bacteria are bad,” and want to get away from everything. That’s the baby with the bathwater philosophy in the sense that, sure, being exposed to things like animals and dirt, and germs, does pose some risk but along with that risk, there’s a lot of benefit. This almost breaks down to a current day like COVID the way people think about the environment where some people want to just hide and preclude and other people want to try to be healthy.

This is like the germ versus terrain theory. I’m not a big proponent of extremes but you do see extreme. You see some people who throw caution to the wind completely. That might be a little bit too far. You see some people who are trouble masking and slathering themselves and antibacterial soaps and washes. The essence of that I think is important to keep in mind, which is, these exposures are important.

This is why you’ll maybe see some pediatricians who say, “If you drop the pacifier on the ground, you don’t necessarily have to worry about washing it off.” Some of that exposure is good for your kid. Now, I guess it does depend on where it falls so a little bit of logic applies. If you’re in a bathroom, or somewhere where it’s a highly trafficked dirty area, like modern dirt maybe you rinse off the pacifier.

Ari: If it falls in a kitty litter box, maybe rinse, sterilizing bleach that thing.

Dr. Ruscio: Exactly. In response to your question, we have this need for training. If the immune system doesn’t have an opportunity to learn, “This thing in the body, is this a good thing or a bad thing?” I use the analogy oftentimes, of target practice and this really maps on nicely to immunity and especially autoimmunity. Autoimmunity is when the immune system can’t distinguish between is this friend or foe? Part of that’s because it doesn’t have adequate target practice.

This is where the exposure to things are important and this is why you see back to the farm animal study, the more exposure to animals, the better the target practice, the better the aim, the less we have this bystander effect, where you’re accidentally shooting the things that you shouldn’t. Because we have this very large density of immune cells in the gut, that’s really one of the main ways through which the immune system samples the outside world.

You do get some sampling from your skin and your lung, like all these different mucosal membranes. Because you’re putting stuff in your body, and some of that stuff needs to be absorbed, and some of it needs to be kept out this is arguably the most sensitive area for purveying what do we want to have in the system, what do we want to attack and keep out of this system. That sets the tone for the rest of your life.

There’s these really interesting receptors in the gut. You probably learned about this in the course. There’s things like toll-like receptors or pattern recognition receptors. That’s just looking for the surface of these microbes or food particles, and learning truly like, what does the pattern of a piece of chicken look like as compared to a virus? That’s what helps the immune system say, “We’re going to not touch that. We’re going to shoot that.”

When it breaks down, this is when you have someone who is reacting to all these foods, let’s say, like, “I can’t eat anything, and I’m on [unintelligible 00:15:28] foods.” It’s like, “Part of this is the immune system has gone haywire.” We can help you expand your diet and have a calmer immune system if we get these things right. Your question, a lot of this does trace back to things that happened earlier in life or the lack of the ability of the immune system to develop and be really well-trained.

Ari: I think it’s interesting to contrast. I’ve been to many third-world countries where, for example, like in the backwaters in Kerala, India, where you see people literally bathing and kids swimming, and mothers doing the laundry in waters with sewage, pumping out into that river, pretty nearby. Maybe funeral pyres and corpses and ashes and all kinds of animals and creatures right in there, and feces of humans and other creatures and they’re literally bathing in it, and swallowing bits of it, and getting it in their nasal passageways, and ears.

Then you contrast that to the way that a lot of modern Westerners, and particularly probably North Americans, are when it comes to germs, we’re living in these totally unnatural artificial environments with fake wood on our floors and everything sterilized and clean every day or every few days. The difference in exposure to these germs, both the magnitude, like how many germs as well as the diversity it’s got to be a thousand orders of magnitude difference as far as what you’re getting exposed to. [laughs]

Dr. Ruscio: It’s very well said. There is a, I think an important point there and this is something I did review in Healthy Gut, Healthy You because I was curious about this. You do see, we looked at data from Bangladesh, where they had a much greater exposure to microbes, and they had more diverse microbiotas, but the incidence of diarrheal illness was also much higher. This is one of the observations that helped me make the distinguishment between what I call old dirt versus new dirt.

It’s not an exact science to finding that but just applying a little bit of logic to it if it’s something that you would have encountered as a free-living hunter-gatherer, we can turn that loosely, older. If it’s something that is more of a modern advent, we can phrase that new dirt. What you’re describing, those things are natural to some extent, but it’s probably just the volume and the concentration that makes them unnatural. There’s a little bit of gray in the exposure.

Ari: It’s not like a hunter-gatherer tribe, maybe. It isn’t bathing in the runoff of a city and the sewage-

Dr. Ruscio: Exactly.

Ari: -to some extent [inaudible 00:18:35].

Dr. Ruscio: There’s probably some animal feces and maybe a hunter-gatherer peeing up the river from you. The concentrations are probably orders of magnitude less in the hunter-gatherer society.

The role of probiotics in gut health

Ari: Absolutely. How do probiotics fit into this picture and map on to this territory that you’ve built out so far?

Dr. Ruscio: This is one of the most, I think, frustrating areas that I’ve been watching as someone who prides myself on really staying abreast of what’s being published in the probiotic literature. I do think it’s really important maybe just to start with one distinction here. I’m trying to choose my words carefully because I put myself in the shoes of the healthcare consumer as often as I can.

What I could see being very challenging, is there’s all these experts up here talking about various things. They all seem to pay lip service to science or the science says. As someone who really knows the science in a couple of areas, certainly not every area, but the areas where I do know the science really well, you’ll look at others who are making comments and you just see how sloppy and I think lazy some of the arguments are.

In fact, I recently did a YouTube video on antibiotics and there was a BBC reporter who wrote an article about why you should avoid probiotics if you’re taking antibiotics. It’s just, if I’m being honest, infuriating looking at how there was this one study, one study that found taking a probiotic after taking antibiotics delayed the time until which the microbiota returned to normal.

Now, on its face, that may sound like a bad thing. If you keep in mind that the microbiota measurements are still evolving and we’re still trying to figure out, and you probably learn this in the course, I’m sure the professor or the teacher probably expressed some frustration at some of these direct to consumer microbiome tests. They haven’t validated that what they’re saying actually means anything.

This is something I think consumers really struggle, “What do you mean? I bought this test, and these are green, but those are red. Those are bad and these are good.” It’s like, “Yes, but the thing is, who is determining what’s bad or good?” Because if they’re like uBiome that got shut down by the FDA for using in part dog poop, to determine what the normative ranges were.

Ari: Oh my God.

Dr. Ruscio: Then when you’re saying something’s good or bad, you’re doing that in part literally based upon dog feces. How that maps on your human, obviously, is a huge inferential stretch. This study found that the microbiota may be delayed in returning to normal, if taking antibiotics, and got all this press. The BBC reporter made sure that this was the primary person they reviewed as part of their investigative journalism. Yet, they ignore meta-analysis, which are summaries of clinical trials showing better clearance of whatever the infection that’s being treated when co-administering probiotics alongside antibiotics, and less antibiotic associated side effects, like diarrhea and abdominal pain.

What the BBC did in this case was, they said, “It’s more important to optimize for this one study based upon a somewhat speculative measure of the microbiota for turning to normal more quickly, that’s more important than meta-analysis of clinical trials, saying that you’ll have less diarrhea and less side effects.” I just want to maybe start there with the framing that if people get contradictory opinions on this, yes, you will but it’s incredibly important the type of science you look at.

If you get the highly publicized one study that was different and made good news, that’s different than actually looking at what matters in terms of clinical outcome translation. You go this path, “John, congratulations, your microbiota looks better.” “Doc, I’m crapping my brains out.” [laughter] As compared to, “The microbiota hasn’t returned to normal, per se but how do you feel John?” “I feel great. I have no side effects.” That’s the delineation in terms of what day do you choose could to determine what path you end up on?

Ari: Yes, and this overlaps with something we’ve talked about in some of our previous conversations. One of the things that I’ve always commented on that I really love about you and the way that you think and approach the scientific evidence that to be blunt. There’s a lot of people, including many of our colleagues, who just quite frankly, don’t understand hierarchy of scientific evidence, and who are all too willing to latch on to one or two particular studies and ignore 10 others that say the opposite. Then present those one or two to support their particular bias.

That can sometimes be well meaning and they just don’t understand the hierarchy of scientific evidence, and that it’s not okay to do that. You have to look at the overall body of evidence and things like, as you said, systematic reviews and meta-analysis. Sometimes it does have ulterior motive, somebody has a particular dietary dogma that they’re trying to promote and make money off of, and they are deliberately misrepresenting the body of evidence and cherry-picking one or two studies and framing that as if that’s representative of the evidence as a whole.

Anyway, one thing I really love about you is just the commitment to the hierarchy of evidence and representing that evidence accurately.

Dr. Ruscio: Thank you. With that in mind, when you do look at the evidence in this way, it becomes apparent that we can greatly simplify the approach to probiotics. Now, going back maybe seven years ago, I’ll do about an hour of reading per night, I get sent every time there is abstract published on a wide array of papers, I get sent the abstract, and I filter through those. Read the ones that make sense, throw out the ones that don’t.

Now it’s me plus two other researchers because the body has grown, I think the work has grown and so I get to review a brief now that’s pre-filtered. There are many, many relevant studies being published on probiotics every week. I’m always reading through these. Here’s what the evolution of the probiotic science looks like on the macro level.

Going back sevenish years, you’d see the first study in a rigorous randomized control trial set up documented that probiotics can help with, let’s say constipation. That’s just one of many different things that have been studied, but we’ll just use the model of constipation. Wow, okay, great. I was very excited about this. I think most of us in the natural health community, were saying, “Awesome. Here is a natural agent. Instead of having to go on a prescription laxative, like Amitiza or Linzess, we can now look at this one study.

The company that made that probiotic wanted to broadcast that. That’s totally fine and good. You invested in a study that had a positive result, you’re totally justified in wanting to showcase that. Three or six months later, another study was published with a different probiotic, also showing a benefit for constipation. Now you come years and years later, there have even been comparative trials that took one group of people all with constipation, one group got the one probiotic, another group got a different probiotic, and they both showed a similar benefit.

The same thing has been shown with depression, with anxiety, with SIBO because there’s just so much literature now. However, there are still those who are making the claim that you need this specific formula for X condition, or reductionists even further would be saying you need this specific strain. With probiotics, species designation, and then strain, species a little bit broader, let’s say lactobacillus acidophilus. Then there may be three or four different strain designations of lactobacillus acidophilus.

It’s almost like saying, and this is a really crude analogy, but you have dogs, and then you have different breeds of dogs. The way I try to respond to this is, “Okay, if different formulas have all shown benefit, those different formulas have different species, and they have different strains.” There’s no need to get down to this very, very [unintelligible 00:28:04] specific level of granular detail, and say, “You need this specific strain.”

I’ll tie it back to how these matters in second and this is getting a little bit deep. When you look at the strains, and this is something that we’ve recently done, and we’re hoping to publish this as a narrative review, by the end of the year. When you look at the different strains, you can trace them back to different pharmaceutical houses. I’m not saying this means there’s like the monopoly man behind us, “Oh,” trying to make money.

It’s a logical outcome, which is you invest in doing research on a strain, and then you want to broadcast and showcase how helpful that strain is. If there’s three different companies who have patented and made three different strains and have all shown similar benefit, then when we’re arguing back and forth over this strain, versus that strain, this formula versus that formula, this is just a derivative of the influence that marketing pressures and industry influence has had on the body of science, not necessarily that you have to be this specific with your selection of probiotics.

When you realize that you can step out of this, “I’ve got depression, so I need this formula but I also have constipation so I need that formula.” You can just go crazy. Whereas there’s a really simple heuristic we can use to help people navigate how to find the right probiotic for their system. We can unpack that in a moment but let me I guess pause there for a second before we jump into that.

Ari: Yes, it’s interesting. I will say the gut course I just took with this professor, his name’s Dr. Hawrelak, actually, emphasize the opposite.

Dr. Ruscio: He has the opposite opinion.

Ari: Yes, he emphasized that there is a ton of strain specificity and he spent like an hour presenting study after study showing that even within a given species of probiotic, there were massive differences in outcomes for specific conditions. Now I’m sure– I just interviewed him and we talked about this topic. I haven’t released the podcast yet.

He did acknowledge and I think this is where there’s overlap between your views that, I think he gave the example of let’s say all Bifidobacteria species might all produce a particular short-chain fatty acid, propionate let’s say. It doesn’t really matter what particular strain you’re getting.

If the benefits for that particular function that you’re looking at are coming from the production of that specific short-chain fatty acid and all Bifidobacteria in general, or of this particular species, they all produce significant amounts of that you’re going to see benefits, but there are also more specific conditions. He would argue that, where even within a specific species of bacteria, a particular strain either showed a benefit or didn’t.

Dr. Ruscio: I’m familiar with the argument. Gosh, where to begin in addressing this? I have asked to have a debate and it’s not something that’s been received in terms of wanting to have this discussion and trying to be as tactful as I can. The burden of proof I think is on those who want to make the use of probiotics more complicated.

If I can produce evidence that shows positive outcomes, and I’m not talking about getting down into the granular detail, because this is how you can obfuscate in my opinion truth, details can be the enemy of clarity. If I throw enough details at you, I can confuse you into submission. This is usually the arguments that are deployed by those that are trying to use that tactic.

I would argue, if I can take a group of free-living people with IBS or depression and hit the outcome with no specificity regarding the strains, then you have to show me that you can get better outcomes with the specificity of strains. I think this is most easily able to be seen when looking at meta-analysis. With a meta-analysis, you will have different formulas used including different species and definitely different strains.

If a meta-analysis of 18 clinical trials, let’s say found that probiotics can resolve SIBO and they’re using different species and different strains in a lot of those studies yet the arrogant finding was still positive. That tells us that it doesn’t really matter in terms of you can pick one or two or three or four formulas of the one through four options. Those all seem to confer benefit.

I appreciate Hawrelak’s work. I think it’s become less relevant, especially over the past five years when we were at an earlier point in time that seven-year ago, [unintelligible 00:33:40] put out there when there was only a handful of studies showing certain outcomes, constipation, depression. That’s where I think the probiotic advisor information really made the most sense.

My argument has been that now that we see, again these head-to-head comparison trials, looking at different formulas, showing the same benefits, it becomes very hard to justify that approach. Again, unless you zoom down into the mechanism and that tends to obfuscate, you can paint a very attractive case when saying, “This probiotic is an antihistamine, and these people have depression therefore we should be using this probiotic.”

I can turn and find new clinical trials that I’ve shown an antihistamine effect in those with conjunctive [unintelligible 00:34:30] or atopic dermatitis. We can do this like point-counterpoint all day, but I guess the decision the consumer is confronted with is, do you want to have to do a course to determine what probiotic you need or think about your probiotics that taking three different drugs?

This drug for depression, this drug for blood pressure. Or the different paradigm is how can we use probiotics as effectively as possible to heal the gut and therefore intervene upstream like we were discussing earlier, where if you have good absorption and a healthy immune system, the downstream benefit is going to be multifold, cognition, sleep, mood, joint, skin. That’s where we’ve targeted our intervention.

As someone who does research in the clinic and we have a clinical team and our research team, I feel very justified in the approach that we use, because it’s something that is helping patients. It’s not something that’s highly complicated in terms of it’s a simple protocol.

That I think maybe the most important thing, which is with a higher degree of understanding, we should see clinical care become more simplified. Usually, the more elaborate something is there’s a lower or poor degree of understanding, but with a higher degree of [unintelligible 00:35:56] understanding, you get out of the incomprehensible level of details and you get to a simple protocol. That’s what I’m arguing for is this simplified protocol doesn’t have to be so specific.

Ari: As you were talking, I was formulating something that we can take out of the realm of gut health and probiotics that I think is analogous to this. That I also think that probably neither you nor he would object to. My background since I was a kid and this might be true for you as well, was more in fitness in bodybuilding and athletic performance.

I think an appropriate analogy for what you’re describing could be exercise in the sense that we could go find systematic reviews and meta-analysis on exercise, a category of exercise. That might include everything from riding a stationary bike for an hour or doing long duration steady-state endurance, cardio activity, to weight training, to high-intensity interval training, to sprint interval training.

Totally different types of activity. Maybe one is a five-minute workout, that’s all-out intensity. Another is a two-hour, low-intensity walking or light jog. We could find research looking at brain health and the incidence of neurodegenerative disease or cardiovascular disease. We could say across all these different types of exercise, we see reductions in the incidence of neurodegenerative disease, cardiovascular disease, stroke, cancer, diabetes, da, da, da.

Then based on that analysis, we could then say, “Oh, it doesn’t matter what type of exercise you’re doing. Just do exercise, because they all have similar reductions in those outcomes,” which is true on that level. Yet it is also the case that if we looked at other specific outcomes, let’s say the amount of muscle building that takes place or strength game that takes place or the translation into performance enhancement in the context of playing soccer or basketball or something like that, we might see huge difference.

In fact, we would see huge differences between different types of exercise, as far as those specific outcomes, in terms of the high-intensity interval training type activity might translate way better into athletic performance enhancement in those kinds of high-intensity sports. If somebody’s goal is building muscle, then obviously weightlifting is going to be vastly superior to endurance activity. Anyway, that’s my attempt to reconcile maybe both of the way that you guys are thinking about this topic.

Dr. Ruscio: I appreciate the analogy. I think Hawrelak and I, we just have very different worldviews. I think he’s wrong in his hypothesis and we’re going to publish a paper, like I said within a year, but his argument does break down.

I also like your point and I appreciate your point. However, one of the things I noticed in exercise, I did a lot of training with the CHEK Institute earlier in my career and they went through these very elaborate assessments only to have very similar protocols that were used for all of the participants with some nuance. I take your point fully.

There is some nuance, but the nuance, in my opinion, and I think this is the most tied in with what the evidence supports that the evidence is not cherry-picked is the nuance is not within the probiotic per se. We use three different types of probiotics. We personalize those to the individual, but then from there if they’re not healing appropriately we move on to other therapeutics. This I think, to try to just cut to the bottom line, we want to be able to use probiotics within six to eight weeks to determine are they helping get their full benefit out of them, and then move on to the next therapy. If you’re doing it for too long, I would argue you’ve gotten way past a level of detail that helps you perform any better as a clinician.

Similar thing, I would argue with exercise, right? If someone still has hip pain after two months on a protocol, you can keep modifying a protocol or you can say, “Well, maybe this type of support isn’t helping the individual. Maybe we thought their hip flexors were too weak, but maybe they’re too tight or maybe this is a compensation due to the ribcage not expanding, and therefore the pelvic floor being hyper-contracted so now we have to modify our approach.” This is where I think the clinical experience really ties into this as a practicing clinician.

I’m not sure if Harlech is seeing patients or not but we should be seeing a level of improvement with probiotics within a couple of weeks. There’s one or two modifications you can make and then from there, you have to move on to the next thing. I take your point, and I think personalization is important but there is a point at which the personalization gets so fastidious that it doesn’t offer any additional benefit clinically and I would argue, you end up spinning your wheels.

Ari: Yes, well, look, my personal philosophy and approach to health is very much a generalist philosophy. That I’m a big critic, as you know, of what I think is a hyper-focus on individualization and personalization that is often built on tests that aren’t even accurate or clinically valid. I think I’m really an advocate of the basics, the fact that 80-plus % of the chronic disease burden are diseases of lifestyle and most people are nowhere close to an optimal diet and lifestyle. I’m a huge advocate of that, whereas I think, purely from a marketing perspective, there’s so many functional medicine doctors.

You’re definitely not in this category but there’s so many functional medical doctors who have promoted this narrative that there’s nothing universal about health and that everything needs to be hyper-individualized to the person. Anyway, I’m a big critic of that and I think there’s so much that is universal and I would go so far as to say most people can fix almost all of their health problems based purely on optimizing their nutrition lifestyle using universal principles rather than individualized strategies.

Dr. Ruscio: Yes, I think that’s well said. I think another way we could state that would be we need macro medicine, not micro medicine. Here would be an example. Someone comes in, their gut is not healthy and they’re having a number of symptoms that are a derivative of that. Well, there’s a couple of different ways you can go with diet, right? I’m going to argue the macro. I think the Harlech is kind of the micro. The macro would be, “Okay, there is maybe two or three different diets that would work for you. We can go high carb, we can go low carb, we can modulate fiber and prebiotics,” but beyond that, you can get into such a uber level of detail where someone could be trying diets for a year, and we see this in the clinic.

They’ve done low salicylate, then low oxalate, then low histamine, then low lectin and they come in and it’s like, “Diet’s not the problem.” You get a A+ triple gold star, right? You’ve done every diet in the world, and you’ve gotten a 10% yield. Maybe you didn’t identify early enough that you’ve done as much as you can in the diet camp and now it’s time for another therapy. So we go over the probiotics and we have them use a Lactobacillus Bifidobacterium blend combination, plus Saccharomyces Boulardii plus a soil-based, and we see what kind of response that gets us.

If it’s working, great, maybe we’ll go to a higher dose but that may only get you in some cases, let’s say a 30% level of improvement. Now what we could do is say, “Well, we need a different soil-based formula because we need a different strain with a different mechanism of action,” and you do this for four months and just like with diet, you probably get very little additional benefit, whereas you could say, “Okay, we’ve gotten 10% out of diet in two months where we didn’t do the year diet ridiculousness. We got another 20% or 30% of the probiotics after six weeks. Okay, now we’re at 30 or 40% total improvement. Now let’s do a gut reset with elemental diets or let’s do a [unintelligible 00:44:48] microbial therapy.”

You work through the therapies again on the macro level and you’re thinking about this decision tree with the patient. You’re going from one to the other to the other and it’s this cascading array of decisions that you run through. This way, you’re getting patient’s improvement as quickly as you can, and you’re not floundering too long in any therapy because it does sound, admittedly, does sound appealing and alluring when someone can give you this narrative of, “Well, you need this because specifically, your system is not producing enough this or that.”

People love that idea of highly personalized medicine. The problem is, you end up being the guinea pig because if it’s so personalized, it’s never been done before, or it’s only been done in a very speculative manner, then you are the guinea pig and your clinician doesn’t really have a lot of data to go upon, whereas on a macro level, we can construct for a person a roadmap and say, “We’re going to have a high demand upon every therapy. That therapy is either going to help, or it’s not going to help and if it’s not helping, we’re moving down the path to the next item.”

This way, we will navigate you to the endpoint of feeling well as quickly as possible and we’re not going to spin our wheels in the micro-level of theory, or this highly, highly personalized approach that sounds really awesome, but doesn’t tend to deliver.

The best probiotics for gut health

Ari: Yes, well said. I like that. I love everything you said there. Let’s talk specifics on probiotics and let’s get practical now. As much as I would love to just continue to back and forth for another hour, I’m sure people listening want us to get with, “Okay, tell me what I should do.” Let’s say people are struggling with chronic fatigue, they’re struggling with maybe gut issues. They notice a lot of gas and bloating and abdominal discomfort and they’ve got brain fog, they’ve got sleep issues, depression, anxiety, those kinds of things and they’re just listening to this thinking, “What the heck. Just tell me what to do. What probiotics should I take?”

Dr. Ruscio: Yes, and this is what’s nice about the simplified approach. We don’t have to go to this uber level of detail. When you do zoom out and look at the probiotic research, you see the vast majority of probiotic research uses one of three types of probiotics, either your traditional blend of Lactobacillus and Bifidobacterium. This is your VSL 3 or your Visbiome. This is your traditional type and different studies will use different formulas. Some will have 5 species, some will have 8, some will have 15 but there’s this clear general trend of a formula that’s predominated by various Lactobacillus and Bifidobacterium species.

This is your one type, we call it a category one, Lactobacillus Bifidobacterium blend. The other is Saccharomyces Boulardii. This is actually the healthy fungus. Florastor is one of the bigger kind of off-the-shelf probiotics you’ll see and there’s been a number of studies done with Florastor, a lot of research actually with helping to reduce either traveler’s diarrhea, or antibiotic-associated side effects. It’s another type and then the third, the soil-based. This is the Bacillus. There’s various Bacillus strains you’ll see with the soil, or spore-forming probiotics, as they’re also called. Bacillus licheniformis, Bacillus clausii, Bacillus subtilis.

Some of the studies use one species, some use two, some use three, some use four, but they all show a similar benefit. When we look at this on the macro level, it doesn’t make a huge difference what specific formula you use because we know different formulas have been used, and they’ve mostly shown benefit. What we want to do is try to use the best, the broadest probiotic support that we can because remember, our goal isn’t to use the probiotics to suppress a certain pathway, it’s to help heal your gut as far upstream as possible. If we heal the gut, all these second-order or downstream effects should follow.

Here’s how you apply these. If you’re someone who’s very sensitive, and you’ve exhibited a history of being reactive, I would start these formulas one at a time because there is a possibility that one of these three will not sit well with you. Start one at a time, give yourself three or five days, and if it’s tolerated, great, move on to the next one. If it’s not tolerated, you want to identify, is this an adjustment reaction? These usually roll on and roll off inside of a week. All right, two days in, you have some turbulence, you might feel a little backed up, you might feel a little bit headachy or flu-like but that should come on and abate within a week.

That’s important because you don’t want to jump ship too early. You don’t want to be a day two and say, “Oh, I feel a little bit turbulent,” and stop because that might be actually a good thing. However, you don’t want to be a month into a negative reaction and say, “I’m peeling this onion. Eventually, I’m going to get through the other side.” Usually, that other side should be achieved at about a week. If you’re sensitive, start these one at a time, give yourself up to a week to see if it’s an adjustment reaction. If the reaction goes away by a week, continue, if the reaction persists at a week, stop and attempt to work on all three, or if you don’t tolerate one, put that one aside and then use the other two.

Now, if you’re not sensitive historically, then start on all three at once. What this essentially does is this is like a super probiotic in the sense that you’re now using all three categories together. We see this in so much of the antibiotic research. For H.pylori, there’s triple or quadruple therapy, meaning at least two antibiotics. For SIBO, oftentimes two antibiotics are used. This is because having a diverse array of whatever therapy you’re using tends to have a better effect. Part of this might be due to the pattern recognition receptors and the toll-like receptors tuning the immune system.

We also know that probiotics are anti-inflammatory, they’re anti dysbiotic, and they’re anti-Sibo. Just like anything else, if you have, let’s say 6 species, or you could have 20 species, you probably will have a better effect with the broader stimulus. This is almost akin to replicating an environment that’s very rich in bacteria. There is also a trend that a multi-species formula in probiotics tends to work better than let’s say a single or a double species formula. We’re just taking that same concept and we’re broadening it out to use this super probiotic, again, borrowing from so many other observations in medicine that this broader stimulus tends to work better than more of a narrow stimulus.

Then you ride the wave. You want to see where you plateau. There was recently a study that found the length of time on a probiotic did make a difference in terms of the peak outcome someone hit. Now it’s not to say three years, but you want to think of this in my opinion, in month intervals. Go on for a month, do a look back, “How do I feel?” Continue for another month, do a look back, “How do I feel?” At some point, you will plateau. Once you’ve plateaued, then I would stay there for a month or two, just to make sure your new plateau is consistent because things tend to change or you’ve probably had one week is better than another, and especially if you’re looking at one day versus another day, there’s a lot of variabilities there.

But if you go, again, more macro and you do a month, look back, you’ll be able to determine, “Okay. I have less food reactivity than they’ve had in a long time. That’s been persistent. I’m also sleeping better. My skin is also more clear. It’s been getting better and better and better. Now it seems to have plateaued. Now I feel stable.” Once you’ve hit that stable point, I like to aim for at least two months, then work down to find the minimal effective dose. For some people, they come off of a probiotic, they never look back. For other people, they notice, “I’m not as good as I was, but– “

I’ll use myself as an example. If I’m not on probiotics and I eat out and I have a glass of wine, I’ll feel a little bit, won’t be anything crazy, but you’ll have a looser bowel. You’ll have a little bit of bloating, whereas when I’m on a probiotic, I don’t exhibit any of that. You want to look for those, in some cases, more subtle tells and work to find the minimal effective dose that works for you. This can allow one within a few months to really go through a probiotic protocol, extract as much benefit out of it as possible, and not get too caught up in floundering with this whole array of different formulas because again, the challenge with all the different formulas is people tend to exhibit multiple symptoms.

If you’re saying that you’re going to use a probiotic for one specific symptom or one specific mechanism, find me a person only has one symptom. Most people have multiple symptoms. This is because problems in the gut, like we talked about earlier, can lead to a number of downstream symptoms. I think another reason why we don’t want to get into micromanaging the probiotics, but rather let’s give the gut this really comprehensive support of the three different formulas, go through that clinical application in the outline and that works really well for a lot of people.

The mechanisms of probiotics and prebiotics

Ari: Nice, great explanation. Can you talk briefly on the three mechanisms? I know there’s many, but mechanisms behind the Bbifido and Lacto, generally what those are doing in the gut and to health more broadly versus the Bacillus, the spore-based, and the Saccharomyces Boulardii. Then also, I remember, spacing on who I had this conversation with, but after a podcast that you and I did previously and you were talking quite a bit about Saccharomyces Boulardii. I mentioned it to one person, maybe it was Grace Liu, I forget who it was, but they poo-pooed Saccharomyces Boulardii and said, “Oh, that doesn’t do anything.”

Anyway, I don’t know if that is representative of some broader controversy about that particular probiotic. I know that I personally have seen quite a lot of positive research around it, but I’m just curious if you would speak to maybe why some people are negative about it.

Dr. Ruscio: Well, again, I think it depends on your frame of analysis, right? To be totally transparent, I don’t spend much time looking at the mechanism because I don’t care. What I care about is you have diarrhea, you have depression, you have brain fog, you have joint pain, you have insomnia, let’s make sure we can fix those things. There is so much literature being published. It is challenging just to keep pace with the clinical trials. That’s why I think I may have a different approach because those probiotic research briefs, and by the way, we do a podcast per month, just on probiotic research updates if people ever wanted to tune in.

Ari: Nice.

Dr. Ruscio: I’m looking at this through the frame of you have symptoms. We’re going to essentially do a clinical trial. If you were a patient in the clinic, we are doing the clinical trial. You come in with a number of symptoms, we’re trying to treat those symptoms. This is one of the things we use as a guiding principle at the clinic. We treat people not labs. Over the years, I’ve gotten less interested in the mechanisms because the thinking there keeps changing, right? It’s trying to pin the tail on the wrong end of the donkey. It used to be, “We need more prebiotics and short-chain fatty acids,” something that Grace Liu was a huge proponent of.

I was over there saying, “Have you seen in the IBS and IBD literature that a higher intake of prebiotics tends to flare those people, increase inflammation and make them feel worse?” But I was looking at the clinical trials and I think she was looking more so at the mechanism of healthy bacteria in the gut produce things like short-chain fatty acids, these feed, the enterocytes, these help to close the Actimycin tight bridging in the lining of the gut, therefore less leaky gut. Sounds cool, except, you’re not looking at this in a Petri dish or a mechanism. You’re looking at this in a human being who has a problem.

What happens when we give that human being, let’s say with IBS, a high dose of prebiotics? Turns out when it feeds those bacteria, and it produces more short-term fatty acids that pisses off the immune system. There’s an inflammatory response and leaky gut gets worse. The underlying mechanism has become much less interesting to me because this is how I think one gets led into treating people like lab values and not treating people for, “We want to make you as healthy as possible and reduce your symptoms.”

Ari: What you said about prebiotics is interesting. I’m curious how much you would generalize that because one of the things that I saw a lot of research on in this gut course I’ve been taking the last few months is the specificity of specific probiotics and that even in the context of SIBO–

Dr. Ruscio: Probiotics or prebiotics?

Ari: Oh, prebiotics. In the sense that people who might react like let’s say in the context of SIBO, people who might react to certain kinds of fiber, where there is a tendency among a lot of clinicians to think, “Oh, well, let’s get rid of fiber, move towards the elemental diet, low fiber diets.” There’s actually quite a lot of positive research around the intake of specific prebiotics as being highly beneficial in that context, as well as IBS. Do you have any, thoughts on the specificity of prebiotics?

Dr. Ruscio: It’s a great question. I use that as that example of prebiotics being problematic as a good example of why we have to be careful about making a speculation from mechanism and broadening that out to clinical intervention. I also discuss this in Healthy Gut, Healthy You. There is evidence showing that a higher fiber diet can produce benefits. There is evidence showing that prebiotics supplementation can help those with IBS and with IBD, but the incidence of adverse events is higher than it is with a probiotic intervention. When I look at this again on the mental level, both of these tools can work. There are some people for whom they do better on a higher fiber, higher prebiotic, which is why I mentioned the vegetarian diet earlier.

For some people, that works well. It’s a smaller subset. Yes, these things have a time and a place. The clinical benefit is better for probiotics than it is for prebiotics, and the incidence of adverse events is lower, but it’s not to paint with the absolutes brush and say, “Never.” We at the clinic, tend to start with a lower FODMAP probiotic starting point because that seems to produce more consistent results with a lower incidence of adverse events. There was some excitement around certain prebiotics like Bimuno was one that was purported to have a lower incidence of side effects. I wasn’t really impressed after using Bimuno in the clinic for a few months. I wasn’t really impressed with the outcomes there.

It didn’t seem to move the needle enough clinically to be any better than the other tools that we were using. I hear that case and I see that argument. Also with fiber, certainly soluble versus insoluble fiber. There was another fiber made that I’m blanking on the name. It was purported to be better for patients with SIBO. I used it for a little while, but it didn’t seem to have a clinical signal that was more beneficial when comparing it to the other therapies. Open on those things and there are definitely some for whom these things work to a notable degree. I think the cohort there that does the best are those that are more prone toward constipation.

That cohort with fiber and prebiotic intake, I think you can make the strongest argument. Again, with the tinkering that I’ve done with various prebiotics and fibers, yes, there’s some benefit, but for us, on the macro level, looking at all these therapies, the fiber and prebiotics are more of a mid-level intervention. They’re not a great starting point because remember, I’m thinking about all this and not in terms of the one thing or the other thing, but how do we put this into a clinical model that’s built around the person’s data and looking at this in terms of how often does a therapy produce benefit as compared to how often does it cause some harm or adverse event?

With the fiber and prebiotic interventions can be helpful, but if you can get some traction in the gut first by, let’s say, using a low-FODMAP diet or using probiotics, that tends to make some of the disease activity a little bit more quiescent, and then you have a higher likelihood of benefit and a lower likelihood of adverse events if you then use something like a prebiotic or a fiber. For us, it tends to be more of a mid-level intervention but something that I do think has a time and a place.

Ari: I have just a couple more questions for you. What do you think of the possibility of benefits with certain low-fiber interventions initially? Let’s say a low-FODMAP or maybe — I know an elemental diet’s meant to be done short-term, so maybe we’ll leave that one out.

Dr. Ruscio: Sure.

Ari: A lot of people are adopting carnivore diets now and noticing, “Oh, all my GI distress, my abdominal pain, my bloating, it’s all gone. I have discovered the best diet ever. This is the way I should eat forever. This is the optimal human diet,” and then a lot of those people I’ve seen experiment, experience problems down the line, and then they become hypersensitive to plant foods when they try to reintroduce them. What do you think of the potential harms of low-fiber type diets done long-term?

Dr. Ruscio: Fully agree, and this is one of the things that, as much as I’ve found myself arguing against prebiotics and fiber because there was such a tailwind of microbiota enthusiasm for just feeding the gut bugs. It’s not to say there’s not a middle ground. Carnivore, I find myself on the other side of trying to pull us back more to center, and that, sure, carnivore as maybe a upfront elimination diet shorter-term, okay. Beyond that, no, I don’t think it’s a diet that’s justifiable long-term. My suspicion is, these people are essentially eating around problems that they have and they need to heal their gut so that they have improved food tolerance.

This is a subset of patients that we see at the clinic who went carnivore. It worked well for them, but now their hair is falling out. They’re not sleeping well. They’re tired all the time, what have you. It’s probably because they’ve tried to overly leverage the diet tool. I learned this myself. I was doing all the stuff. I was paleo, paleo-autoimmune, all organic. I thought that maybe it was stress or I was burning sage and meditating before I ate. I was doing all the stuff and I was still having reactivity, and then I learned, “Oh, I had this active issue in the gut,” and until I started using some of the tools to heal my gut, diet will only get me so far.

Carnivore, I see very similar in terms of yes, it will reduce symptoms. I’m also appreciative of how the carnivore movement has helped people understand that meat and animal foods aren’t bad like they’ve been vilified. I think there’s some good there, but in terms of a long-term diet, no. Also, in terms of what do those people need to consider, other tools that can help them heal their gut so that they can get to a broader diet. That’s one of the most important things I would like to see a patient get to is mid-phase we’re really broadening out their diet and minimizing the number of supplements that they use and they can determine what diet they want to go to.

If they want to skew a little bit more into animal-based direction, fine. If they want to skew a little bit more on a plant, fine, but we’ll at least try to get you to a point where you have the gastrointestinal resiliency so as to be able to thrive on whatever diet it is that you want to be on.

Colonizing probiotics

Ari: Okay. Last question for you and then I want to wrap up. Thank you for going over time with me. I appreciate it.

Dr. Ruscio: Yes, it’s always fun.

Ari: It’s fascinating. Colonization. What are your thoughts on the colonization of different species of probiotic? This is something that I think the general public often thinks, “Oh, I take a probiotic and it just goes in, and it starts seeding everything and those bacteria start multiplying. Six weeks later, my gut is filled with all those bugs.”

Dr. Ruscio: Sure. This is something that I’ve certainly shifted my opinion on over the past, maybe three years or so. Most probiotics don’t colonize you, but some do. The exact breakdown, I don’t know if this has been determined or if it has been determined, I haven’t seen it. It is generally a misnomer to think that whatever you take in terms of a probiotic, it will colonize you, but there is some evidence showing a degree of colonization with some probiotics. The other thing here that is still unclear is the impact on the small intestine because a lot of this research is predominated by stool samples, which tell you about what’s going on in the colon, but that large density of immune cells that we talked about, that’s mainly in the small intestine.

The small intestine is where 90% of caloric absorption occurs, where most nutrients are absorbed. It’s the most thin, sensitive, permeable membrane, so it’s also most prone to leaky gut. This is where the impact of probiotics is really in its nascency because it’s so hard to assess what’s going on in the small intestine. You can’t get a poop sample. You can do a breath test, but it’s limited in what it tells you. Really, to a fair degree right now, we’re limited in terms of what we can learn about the small intestine through biopsy, which means you have to have a nose or nasogastric tube put down or through the throat and a sample taken from the small intestine directly.

It’s a very invasive sampling procedure and because of that, it’s much harder to know. I suspect that there is a degree of colonization that occurs in the small intestine, but more importantly, these probiotics tend to have a transient benefit. They secrete antimicrobial peptides, which is probably why they help with fungus, with SIBO, with parasites. They trigger some of these receptors that helped to attune the immune system, which is why they help with leaky gut and with reducing inflammation, so more of a transient benefit. Now, that transient benefit may perpetuate long-term if there was an imbalance and the probiotics rectify the imbalance.

Then once you stop taking the probiotics and the imbalance is now rectified, you can maintain that improvement going forward, but for some people, they do better on a lower dose, long term, and that’s probably, because most of the benefit, not necessarily all, but most seems to be transient in nature.

Heal your gut to heal fatigue

Ari: Good stuff. Okay. The last thing is, if you were going to tell that scenario that I presented earlier, somebody’s got all these different symptoms, chronic fatigue and brain fog and depression, anxiety, gut issues. If you were going to leave them with three bits of advice, what would those three things be? Then where would you like to direct people as far as any resources that you have to offer?

Dr. Ruscio: Well, I think it’s important to think through your healthcare, again, on the macro level. It’s really easy to get pulled into a test, making all these promises, and tying a pathway or a mechanism back to your symptoms, and thinking, “Oh, I just need this one test,” or this one new, whether it’s Butyrate, or whatever the new thing is. There’s always something very alluring about a promise of this thing. You could take all those little things, and consider them as part of this larger roadmap that is your healthcare picture, and that’s the way you should be thinking through these things.

Why this is important is, it prevents you from floundering and spinning your wheels with any one thing for too long. A good clinician, or a good healthcare process, they’ll constantly be moving you forward, right? You should have this expectation that within two to six weeks, I’m either improving, and we’re continuing, or I’m not improving, and we’re modifying. I think that’s really important just to keep in mind, because [chuckles] if you spend six months on a diet, and you’re trying to go through three diets, that’s a year and a half, right? If you spend six weeks, and you’re going through three diets, that’s three months.

Compound that by diets, and then a number of different therapies, you can get in and out into your goal in a handful of months, or it can take you a handful of years, not to mention the expense that goes along with this. Have a high demand for your healthcare provider or the approach. I don’t mean demanding, [chuckles] coming there frustrated, but–

Ari: You better get me results right now. [chuckles]

Dr. Ruscio: In a tactful, and supportive way, you should be looking for this high demand upon having improvements, or at least feeling like, “Okay, we ran the experiment, it didn’t work, and now we’re modifying to the next thing,” and not a feeling like you’re just floundering and spinning your wheels. I think that would be one of the more important things. Also within that, be careful not to get too zoomed in on any one thing. SIBO would be a good example. Every time I see something from a Facebook group on SIBO, I just want to pull my hair out, because people make everything that’s happening in their healthcare picture centered around SIBO.

Again, you want to have this macro view on things, because who knows, this person could have SIBO, and they could have undiagnosed sleep apnea. They could flounder with the SIBO for five years, and then a clinician says, “Oh, you may have sleep apnea.’ They do a test, and then they get treatment for the sleep apnea, which by the way, there are some noninvasive, very simple therapies for sleep apnea that can work phenomenally well, just as a quick aside, but the point I’m making is again, be careful, this reoccurring theme, not to get too zoomed into the micro.

I guess that would be a couple of remarks, and then in terms of resources, my book Healthy Gut, Healthy You was my attempt to give everyone as much as I could put into a personalized guide, so that’s one option. Then the clinic is also there in case people need help, and yes, we’re always more than happy to help people through their healthcare journey, which I get, it can be challenging. I was there, I floundered for a while, and it’s great now to be able to help people get to improvement as quickly as possible, and take them through this macro medicine, where we build out a plan for you based upon the best evidence in the macro level, not a mechanism, not speculation.

As I mentioned earlier, this high standard where we’re going to build out a plan for an individual, and we’re going to move them through the plan. We’re expecting, we want to see you improve, and if we’re not, we’re going to pivot, we’re going to modify so that we get you momentum, and perpetuate that momentum as quickly as we can.

Ari: Beautiful. My friend, it is always a pleasure to connect with you, and have these conversations. I always really, really enjoy it and get a lot of value from it. I know our listeners got a ton of value from this, so thank you so much for coming on the show again, and I look forward to the next one. I’m sure since you’re always staying abreast of the latest research that’s coming out on probiotics, we’ll do another one in six months or so. I’m sure you got more new stuff to share.

Dr. Ruscio: Let’s do it, I think between now and then we should have two papers published, which I’m really excited about a gut thyroid case series, and then another paper in the journal Nutrients. I think we’ll hopefully have some cool science to geek out on.

Ari: Awesome man. Well, it was a pleasure, and I look forward to the next one. Thank you so much for sharing your wisdom with my audience.

Dr. Ruscio: Same here. Thank you.

Show Notes

How gut health connects to your overall health (01:47)
The hygiene hypothesis (10:50)
The role of probiotics in gut health (18:52)
The best probiotics for gut health (46:16)
The mechanisms of probiotics and prebiotics (54:53)
Colonizing probiotics (1:07:43)
Heal your gut to heal fatigue (1:10:20)



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