Dr. Ruscio’s 4 Tier Intervention Hierarchy for GERD

There are many medical websites and blogs out there these days. As someone who is suffering from LPR, or any kind of GERD, you’ve probably come across many of them. The challenge is that it’s very difficult to distinguish between genuine authorities, charlatans and everything in between.

One online authority who I’ve really come to respect recently is Dr. Ruscio. His podcast, blog post, videos and everything else seem very well thought out, balanced and clear. He takes an evidence-based approach, and he’s not hung up on either the natural/functional approach or the conventional medicine dogma. He seems happy to take the best of both, which is refreshing.

Dr. Ruscio recently released a podcast, in a collaboration with Dr. Ben Weitz, all about Gastroesphageal Reflux. This wasn’t specifically about laryngopharyngeal reflux, but I felt it really had a lot of very interesting ideas that would help LPR sufferers think about their treatments, as much as it would help those suffering from more mainstream types of GERD.

I would encourage you to watch or listen to the podcast in full, but I’ve tried to summarise some of the most interesting points and ideas in this blog post, as much for my own benefit as for any potential readers.

Dr. Ruscio uses 4-tier intervention hierarchy for GERD

One of the things I particularly appreciate about Dr. Ruscio is his structured thinking. In this instance, he describes a 4-tier hierarchy that he uses to approach treatment of patients with GERD.

Dr. Ruscio 4-tier Intervention Hierarchy GERD

My visualisation of the hierarchy Dr. Ruscio describes in the podcast

What’s great about the approach described is not only that it’s tiered and very clear; Dr. Ruscio also explicity talks about avoiding getting hung up with mechanisms. There’s a lot of overlap between symptoms and mechanisms of various related ailments, so he rather focuses on treatment options with his patients. Very practical!


Starting with diet, Dr. Ruscio explains that he likes to start with some sort of elimination diet. He feels that many instances of GERD have some sort of food allergy, intolerance or sensitivity at their root. The simple way to address this is to go through an elimination diet process. He recommends this over testing, particularly when cost is a factor.

In terms of type of dietary approach, he suggests using either a paleo or auto-immune paleo protocol, though he does say that more traditional elimination diets can also work. The point of this exercise is to eliminate the most likely potential culprits, such as:

  • Gluten
  • Dairy
  • Caffeine
  • Spicy foods
  • Alcohol
  • Nightshades

The last one is potentially more difficult to address with a traditional elimination diet, but there are plenty of guidelines available on how to implement a low FODMAP diet out there, including Dr. Ruscio’s own guide.

Dr. Ruscio seems to think starting with a simpler elimination diet is based, and then if that is unsuccesful, trying a low FODMAP diet and even a low histamine diet, to try to narrow down the potential causes of GERD.


If elimination diets don’t expose any culprits in terms of food sensitivity, Dr. Ruscio then looks to the possibility of dysbiosis. He mentions two types that may be involved.

H Pylori

The link between H Pylori and ulcers has been known for some time, and H Pylori overgrowth can apparently also cause GERD. Dr. Ruscio recommends testing for H Pylori in more than one way to get a more certain diagnosis.

SIBO (Small Intestine Bacterial Overgrowth)

Echoing the ideas of many other functional medicine practitioners and GERD authorities, Dr. Ruscio also believes that SIBO can be one of the underlying causes of GERD. This is where the low FODMAP diet mentioned above can be particularly useful, as a low FODMAP diet limits the amount of fermentable carbohydrates in your diet. When you have SIBO, fermentable carbohydrates promote the release of gas by pathogens, which can force open the lower oesophageal sphincter.


The third tier in terms of intervention is addressing abnormal levels of acid. As discussed in the podcast, many functional medicine practitioners blame GERD on low stomach acid rather than high. Dr. Ruscio suggests that either one of them can be a problem.

Unsurprisingly, Dr. Ruscio’s recommendation here is to bring acid levels to normal levels. If acid is low, one should supplement with Betaine HCL. If acid is high, acid lowering medications may be appropriate.

On an interesting side note, Dr. Ruscio does take a moment to question the pervasive belief that GERD is driven by low stomach acid more often than not. He calls Dr. Jonathan Wright’s research into the area into some question, suggesting that the references he made to studies to support this hypothesis “don’t hold up”.

Natural interventions

The final tier in Dr. Ruscio’s intervention hierarchy is natural therapies for gastric healing. Here, he mentions quite a few potentially helpful substances:

  • Slippery elm
  • Melatonin
  • B Vitamins
  • Betaine
  • Prokinetics

He also mentions some specific products

  • Protexid
  • GI Guard
  • Motilpro
  • Iberogast

Other interesting food for thought from Dr. Ruscio

For any new sufferers of LPR or GERD, Dr. Ruscio’s 4-tier approach seems to make a lot of sense. There were also a few other ideas that jumped out, in listening to the podcast.

Maybe low stomach acid isn’t the problem

Already mentioned above, this is a particularly striking question to think about. Dr. Ruscio suggests that people may be too quick to attribute GERD to low stomach acid. He suggests that plenty of people actually are having issues because of the more conventionally accepted diagnosis of high stomach acid.

He mentions that if you’re young, have family members with a tendency towards GERD, having gnawing stomach pain or react badly to stomach acid supplements, your issue may be high rather than low stomach acid.

Motility is an important factor

Dr. Ruscio also mentions that reduced motility may play an important role in GERD. This is why he says that prokinetic compounds can help. This also is connected to the overlap between GERD, IBS & SIBO – an interesting topic that we will dive into in the future!

Don’t be afraid of short-term PPIs

I was quite surprised to hear Dr. Ruscio say that we shouldn’t be afraid of a short course of PPIs to help heal GERD-related conditions. He seemed to suggest that 4-8 weeks could be particularly useful for people suffering from ulcers. He goes on to explain that long term use may well be dangerous, but it seems that he thinks that PPIs have been unnecessarily demonised, and a short course may be beneficial for some people.

Keep an eye on Dr. Ruscio

I really believe that Dr. Ruscio is a great authority on the subject of all things digestive, particularly after listening to this podcast episode. His approach seems measured, well thought out and free from bias. I will certainly be keeping an eye on his podcast and blog going forward!

Listen to or watch the original podcast episode with Dr. Ruscio

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