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A case study that appeared in the June 2019 issue of the Future of Functional Medicine Review Clinical Newsletter showcases the strong link between the thyroid and the gut. It’s critical that clinicians recognize this link to treat thyroid issues effectively, and review data on the true likelihood of various scenarios. In this podcast, hear clinical pearls from the case study. And learn how you can get access to a thyroid treatment algorithm and many more insights that have led other clinicians to outstanding patient results.
Dr. R’s Fast Facts Summary
Thyroid Case Study: June 2019 Future of Functional Medicine Review
Evidence shows that only ~ 10% of hypothyroid medicated population needs combo therapy
Switch from T4 (Synthroid) to combo T4/T3 (Armour) made patient feel worse
Treating for gut health, intestinal dysbiosis healed patient
Able to return to Synthroid successfully
July 2019 Presentation from FFMR
Treating H. pylori in Hashimoto’s study yielded better outcomes for thyroid autoimmunity than absorbable thyroid hormone gel tabs
Many symptoms attributed to hypothyroidism can improve with probiotics, low FODMAP diet
Optimizing gut health should be first step in thyroid algorithm
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Episode Intro … 00:00:40 Clinical Pearls of Gut & Thyroid Health … 00:02:24 Access an Effective Thyroid Algorithm … 00:05:54 Hashimoto’s Treatment Outcomes … 00:10:39 The Profound Gut-Thyroid Connection … 00:17:25 Enhance Your Functional Medicine Practice … 00:19:42
Dr. Michael Ruscio, DC: Hi, everyone. I wanted to talk about thyroid health and the gut-thyroid connection. This is something we’ve been talking more and more about, but I wanted to share some pearls that have come directly from our Future of Functional Medicine ReviewClinical Newsletter.
Now, if you haven’t heard of this yet—hopefully you have, but if you haven’t—this is a monthly paid access newsletter that I write to help clinicians do a better job in applying functional medicine to their patients, specifically in the realm of both gut and thyroid. We’ll cover some pearls and some insights taken from this newsletter in just a moment that center around gut and thyroid.
I wanted to make you aware of the fact that I’m running a special during the month of September to help make joining this newsletter easy for you. As you will see here momentarily, the results of other practitioners who have read this newsletter and applied it have been phenomenal.
To make it easy for you to sign up, if you join any time during the month of September, you will receive your first month of all access (including the nearly three years of back issues) for only $1. It’s a full month of access for a dollar. I do this so you can get in there, read around, make sure it’s something that you would find beneficial. This way, it really lowers the barrier to entry and gives you a chance to see all the benefit that waits for you on the other side.
Now, if you go to drruscio.com/review—and that link is also in the description of your podcast players—you can plug in. Again, $1 for your full month of all access.
Clinical Pearls of Gut & Thyroid Health
So let’s talk about the two pearls, if you will.
One, it’s nearly impossible to obtain optimum outcomes in thyroid patients if you overlook a problem in the gut. We’ll share a practitioner success story from our readership. And also, a bit more of the academic nuts and bolts behind the gut-thyroid connection and its legitimacy.
But what’s so inspiring about this case is it’s not mine. It’s Dr. Joe’s. What’s even more impressive about this is you can really see the impact that the information we articulate in the newsletter had on Joe as his practice evolved. As he started getting a sense that, “Boy, the run-of-the-mill treating the thyroid labs approach isn’t really working. What else can I do?”
Joe hit a home run with this case. And there are a few things we should touch on. Again, if you click through, you can read Dr. Joe’s full case study with all the details, the lab findings, how he treated the patient, how the patient responded to the treatment, how he modified the treatment.
One of the things you’ll see is a switch from Synthroid to Armour, and this person actually felt worse. You will see this when you give someone combination therapy. Instead of giving them a standard T4, you give them T4 plus T3, as in Armour. You will see some of the patients have negative reactions who don’t need it. And surprise, surprise, the evidence actually substantiates that only perhaps 10% of the hypothyroid, medicated population actually needs something like Armour.
So it’s a big miss to jump there. But what’s beautiful about this case study from Joe, early in his career, he’s still figuring some of this stuff out. You see how the patient gets what she thinks is a better, more personalized form of thyroid medication, and her symptoms flare. This starts this whole—what I would call—thyroid medication optimization chasing endeavor. It’s back to the Synthroid, then to Armour, then to Nature Throid, and she had reactions to the T3. This was even evidenced by high T3 on her labs.
A really powerful case, illustrating that, no, it’s not valid to say that any patient on thyroid medication who’s not feeling well, who’s still exhibiting symptoms, needs to be put on a combination of T4 and T3 instead because that’s the source of their symptoms. That does happen, but it’s actually the minority of cases. This is what I’ve organized into my thyroid algorithm, which you also get access to with a newsletter subscription.
Access an Effective Thyroid Algorithm
Ultimately, this patient found she did best when—surprise, surprise—eventually Dr. Joe worked his way around to testing for and treating intestinal dysbiosis and being on simple, standard Synthroid. That tells us genetically she could convert okay, but the symptoms that she was plagued with were from her gut.
Trying to optimize a thyroid medication dose was a red herring, distracting from the fact that her symptoms were coming from intestinal dysbiosis.
Again, this is exactly what is codified into the thyroid algorithm, that all practitioners have access to with a subscription. Essentially, one of the main strokes of the algorithm is, before trying to personalize thyroid medication dose, you should rule out and address any problems in the gut. That can definitely cause the symptoms that you might be attributing to a problem in the thyroid, but they’re actually coming from a problem in the gut.
Now, this ties in beautifully with the issue from July. In July’s issue, I share a presentation from a practitioner conference earlier in the year called “The Gut-Thyroid Connection: Profound But Underappreciated.” In this presentation, we detail the best current available evidence connecting autoimmune thyroid to SIBO and to H. pylori.
Now, there’s some nuance here. But essentially, there are about two studies associating small intestinal bacterial overgrowth and thyroid autoimmunity. And there are a number of studies associating H. pylori to thyroid autoimmunity. It’s important to understand this, because thyroid autoimmunity is one of the causative factors that underlies hypothyroidism.
But… and this is what I think is more clinically relevant, and often gets left out, because there’s this whole shock, awe, and fear campaign oftentimes around thyroid autoimmunity: “They are thyroid autoimmune. Oh my goodness.” What’s left out of this conversation is that many patients who have thyroid autoimmunity never—in fact, the minority of patients who have thyroid autoimmunity ever—actually become hypothyroid. That’s left out of the conversation.
Likely it is because fear is a better motivator, it’s more marketable. Things that I think are just abhorrently wrong with the profession, scaring people into thinking that autoimmunity is a bigger deal than it is. It is an important issue. Yes, we want to act. Yes, you want to take steps to improve the health of the individual and their autoimmunity. No, we don’t want to inculcate everyone to think that if you have thyroid autoimmunity, you have a high probability of becoming hypothyroid.
Hashimoto’s Treatment Outcomes
In fact, in a previous issue of the newsletter, we discussed a prospective followup study in Tehran where they found between 9% and 19% of participants who had Hashimoto’s (who were tracked prospectively) actually became hypothyroid. You could say maybe 10-20% of people actually become hypothyroid. Now, we don’t want you to become that 10-20%, agreed. Let’s do all we can. But let’s not misrepresent the facts and make people think that they have a majority probability of becoming hypothyroid if they have Hashimoto’s and scare them into compliance.
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Coming back to the other point that I said was more clinically relevant, how do we get patients to feel better in the here and now? This is where there are some very interesting data, mainly looking at H. pylori. Again, this is all reviewed in the newsletter writeup, all the details, all the references.
What’s really nice about the way I try to lay out the newsletter (if I do say so myself) is that I take quite a bit of time to try to lay it out in such a way that you can get all the important bullets by skimming. There are no long sentences. There are no long paragraphs. I try to give you bullet point summaries with sub-bullet elaborations, and then sub-sub-bullet references. It makes it very easy to extract out what you need, and there’s not all this fluff that you have to parse through.
Most of the data in the July issue’s presentation are on H. pylori, but they show that you can reduce thyroid medication dose—and obviously TSH level, because that’s what’s going to dictate the dose—after treating H. pylori. There is some exciting preliminary evidence showing you may need less medication when, or after, you have eradicated an H. pylori infection. Oftentimes, this correlates with improved subjective presentation, so symptoms improve. Some data support an improvement in thyroid autoimmunity, although not all. I think what’s most striking about some of the data I share in this presentation is that when using a highly absorbable gel tab form of thyroid hormone or clearing H. pylori, clearing H. pylori actually leads to better outcomes.
What this tells us is, “Oh, we can use Tirosint, the highly absorbable form of thyroid medication.” It’s like an Advil gel tab. Instead of a hard tablet that may be hard for someone to absorb, it’s thyroid hormone in a gel tab that’s much easier to absorb. But the most highly absorbable form of thyroid medication, compared to clearing H. pylori… better outcomes in those who clear H. pylori. This tells us the profound impact of the gut.
Now, what else is really important here is to look at how many of the symptoms attributed to hypothyroidism, depression, and (most namely) fatigue can improve after using things like probiotics and a low FODMAP diet. So when you put all this information together, you see a pretty powerful case being constructed.
One, we don’t want to prematurely try to fine-tune someone’s thyroid hormone medication, either the dose or the form. Two, we actually may be able to get the patient on less medication if we optimize gut absorption of the medication. Remember that thyroid medication is absorbed in the small intestine, so small intestinal and upper GI tract health is very, very important. Then, three, the symptoms the person is struggling with or complaining about may actually be caused by a problem in the gut. And we have the outcome data showing that by using things like low FODMAP diets and probiotics, we can see improvements in things like fatigue and depression.
There’s a very strong case to be made that it’s a fool’s errand to rush into doing an assessment for all of the thyroid hormone metabolites, then trying to custom-tune their dose, adjust their T3, adjust their T4, try to really dial this in. There is a time and a place for that, and this is something we’ve discussed in other issues of the newsletter. But that is, again, a minority of the population. At best, you’re looking at maybe 10% of the population. So this is something that I think eludes many clinicians and why my thyroid patient subset of my clinic has grown so much. I do think there’s an overemphasis on the importance of T3 in the functional medicine world, and an underappreciation for how important the gut is.
Now, this isn’t to say that we want to exclude the use of Cytomel or some kind of T3 addition into the medication preparation. But if we do that before we optimize someone’s gut health, we vastly increase the probability that we will be missing the underlying cause of their symptoms. Thus, we have these patients who try a litany of different thyroid treatments, changing their medication dose, changing the medication form, and then perhaps even other natural treatments like ashwagandha or selenium to help with conversion, and they never really get anywhere because they’ve missed the gut.
The Profound Gut-Thyroid Connection
As a practitioner, if you can put this together and help get your patients to this more quickly, you will get results where others haven’t. Dr. Mather’s case is a beautiful example of that, that we opened the episode with. This patient had been to a few doctors prior, still unable to get the results. Thankfully, Dr. Mather was a part of our newsletter cohort, and he had been exposed to the thinking that the gut might be the driver of the symptoms. He took that action.
Again, what’s beautiful about this case study is, you see months of tinkering with the thyroid medication with no result, and then literally one month in to starting GI therapies, this patient has a marked jump in improvement. I believe it was at the two-month mark, the patient said, “I’m good,” and didn’t feel like she needed to follow up. That’s how remarkable her improvements were. Gut-thyroid, a profound connection, one that isn’t understood as well as it should be, but that’s something I’m trying to rectify with the Future of Functional Medicine ReviewClinical Newsletter.
Now remember, everything that we talked about and more, of course, is detailed in the newsletter. Again, I want to make you aware of this if you are new to our audience. And remember, to make joining as easy as possible and to really help bring you into our group that’s trying to offer a better form of functional medicine that’s cost-effective, evidence-based but not evidence-limited, and that understands the importance of the gut in a reasonable fashion, you can plug in for your first month of all access for only $1.
Again, if you go to drruscio.com/review, you can read a bit more and plug in. I really hope you will do so, because I feel so passionately about helping patients get to this help. It’s a travesty for a patient who gets circulated along the thyroid merry-go-round. The more of us that understand the importance of the gut and the gut-thyroid connection, the more patients will more quickly get to the help that they need.
Enhance Your Functional Medicine Practice
The Future of Functional Medicine Review, check it out. There’s a lot of great content in there, and it’s really been an aggregation of the things that I found to be the most clinically applicable, and then case studies of my own and others of our readership, that have really been insightful. They illustrate that if you put the information into practice, you will obtain very favorable patient outcomes.
I care about answering your questions and sharing my knowledge with you. Leave a comment or connect with me on social media asking any health question you may have and I just might incorporate it into our next listener questions podcast episode just for you!
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