Today we will cover listener questions, which include …
- Functional medicine training – recommendations
- Candida krusei – how to treat?
- Low TSH with low T3 and low T4 – what does it mean?
- Blastocystis hominis – To treat or not to treat?
- Subclinical hypothyroid – when to act
- Healthy ranges of TPO and Thyroglobulin ranges
- Laxatives and the SIBO breath test – can you take them before the test?
Dr. Michael Ruscio, DC: Hey, everyone. Welcome to Doctor Ruscio Radio. This is Doctor Ruscio. Today, I’m here with Erin Ryan from our team, and we’re going to be doing a different format for our listener questions. Backstory, there are more questions now than I can really keep up with the way I was doing them previously. What I would do previously is, for a question, I’d play it or listen to it ahead of the podcast and take some time to think about a thorough answer and kind of give you different contingencies and really attempt to provide the most thorough answer that I could.
But with the increasing volume of questions that we’re receiving, I can’t do that. And I was watching the list of questions grow and grow and grow and concluded that I needed to change the way I was answering them so that I could keep pace. So what we’re going to do now is more rapid-fire where I haven’t seen or heard any of these questions, and you can almost think of it like you attended a lecture and there was a post-lecture Q and A and this is the result. So I want to be careful and qualify that, while I’ll do my best to provide as much detail as possible, I can’t say I’m that good where I can off the top of my head give you every potential contingency and every relevant data point salient to that question.
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Dr. R’s Fast Facts Summary
Suggestions for Functional Medicine Training
How to tackle Candida krusei?
- A strain-specific approach could be a mistake. You want to treat the patient not the labs
- Prescription – fluconazole
- Herbal compounds like, oregano, caprylic acid, and berberine also has some antifungal characteristics
- Potentially the Elemental Diet
What does low TSH paired with low T3 and low T4 mean?
- If the brain doesn’t have the ability to secrete enough TSH, then you’ll see low TSH paired with low T4 and low T3
- Due to hypothalamus or pituitary involvement
- Repeat the test to qualify that you are actually low. Some practitioners may say you’re low when you might actually be at the low end of normal.
- If ranges are low and continue to be, check in with endocrinologist
Blastocystis hominis – to treat or not to treat?
A young male is subclinical hypothyroid – when should treatment be considered?
- Subclinical hypothyroidism is when you have high TSH paired with normal T4
- TSH above 10 paired with a normal T4 is a level at which one should consider treating subclinical hypothyroid
- 4 Practical Tips for Hashimoto’s Thyroiditis & Hypothyroid Symptoms
- Consider a different test – Liquid Chromatography with Mass Spectrometry (or Dialysis/LCMS) available at LabCorp and Quest
TPO and Thyroglobulin antibody ranges – when to act
- TPO below 300, no need to act
- Thyroglobulin antibodies below ten times the normal range, no need to act
- Can a paleo diet help? Yes, there is evidence that a paleo diet can reduce antibodies by 40-44%
Can you take laxatives before a SIBO breath?
- There is no formally agreed upon answer to this question
- One option to consider is to not use laxatives before the testing, 4 days leading up to the test, unless you get really backed up and heavily rely on laxatives in which case it would be ok to take them and consider that in the test results
- The most important thing you can do in this process is worry less about what the labs say and use your symptoms to dictate treatment
DrMR: So I figured it would be better to give you a few of the more relevant pieces of information to answer a question and be able to get through more questions, rather than getting through fewer questions and really attempting to rigorously answer all the aspect of the question. So that’s what we’re going to attempt to do today, and I’m hopeful that this will still be equally as helpful and we’ll get a little more volume but a little less depth. Hopefully, they will equal out and give you kind of a broader examination of some different questions.
And I guess, Erin, if you’re ready, we can jump in. Actually, Erin, do you want to just introduce yourself and tell people a little bit about your background before we jump in so people know who they’re listening to?
Erin Ryan: Yeah, sure. My name is Erin Ryan, and I came to work with Doctor Ruscio by way of my own health exploration. So my background is in marketing, and after a long stint of gut health issues, I finally seemed to turn a corner when I found functional medicine and integrative health. So long story short, I guess, I decided to shift my passion from marketing in the direction of functional medicine and integrative health. So the rest is history.
DrMR: It’s always great when we have people on our team who get it, for lack of a better term. And then so that’s what’s great about having Erin on board. And she’s definitely helped the podcast and the platform in a number of ways, and I figured she’d be a good person to read some of these questions ’cause I’m sure many of these things are things that you’ve thought about or maybe even grappled with yourself. Yeah. All right. So why don’t we jump in and see where we end up?
Functional Medicine Training
ER: All right. Here we go. So our first question is from Michael. Michael is looking at functional medicine courses and seminars, and he’s also looking at different universities. So he’s wondering if you can recommend one of these over the other. He’s currently looking at IFM, a program called Applying Functional Medicine in Clinical Practice, and he’s also looking at Functional Medicine University. Any thoughts?
DrMR: Yes. So I’ve answered this question now a couple times, but I did one episode that I really gave a pretty thorough answer to this question. I believe it was entitled “How to Become a Good Functional Medicine Practitioner.” And one of the things I discuss is how to interface into the educational process. It was more targeted at do you want to become an MD, PhD at one end or a health coach at the other in terms of length of schooling.
And it’s not to say one is right or one is wrong. It just has to do with who you are as a person and what your goals and objectives are. Also, Robert Abbott who’s been on the podcast before has put together a free resource for what he has found as someone who just completed his medical residency and has been studying functional medicine, what a good student, I guess, onboarding packet would be for both free and paid courses. And I thought Robert did a pretty good job with that.
So there’s pros and cons here like there are with many things. I think Dr. Dan Kalish has a pretty good course for onboarding, meaning it’s very clinically relevant and it’s not unnecessarily complicated and it’s fairly devoid of academics. So I think Kalish has a pretty good course there to start one off with. And while I haven’t gone through anything at the Kresser Institute, I’ve heard good things about Kresser’s course and I’m assuming that’s going to be a bit more cognitively rigorous than Kalish’s. I think Kresser gets a little bit deeper but also, as far as everything I know about Chris, he stays closer to clinical relevance than he does wander into what I would sometimes label clinically frivolous details, which I think you get in some other courses.
So there are other courses, and if I’m being fully honest and a bit too candid to potentially contribute to my own demise here through hate mail from certain groups, I found the IFM’s work to be very academic. That may have changed, and I’m certainly open to there being exceptions. But I’ve also interacted with a number of clinicians who just found that, after leaving there, they were really inundated with all this great theory and conjecture academically but not really a great model to take away for what to do in the clinic. And I believe that was also corroborated by Joe Mather who’s also a medical doctor who was recently on the podcast.
And so … and that’s maybe a good chance to mention the own resource that we have, which is The Future of Functional Medicine Review Clinical Newsletter. And what’s nice about this is, while it’s not a formal training course, you will read a case study every month that I feel to be extremely clinically applicable and you will also have the summary of anywhere from three maybe to 10 research studies that are also clinically relevant and wherein I point to and focus on the most clinically relevant tidbits that one would pull out of the study.
So those are a few things to think about, a few ways to kind of get you started. And one other thing I would just mention would be, as you’re learning, if you find disparities in different educators that you’re following, that’s actually a good thing ’cause you need to be challenged and you need to be confronted with disparate recommendations. Why? Because it forces you to think. One of the things that I think is not positive in terms of our current academic system, and I think this permeates pretty much the entire academic system whether it be a progressive fringe of functional medicine to a very kind of conventional academics at a university, is people are getting too accustomed to just being told what to do and told what to think and people are not thinking.
And this definitely happens in functional medicine, where people find the most popular seminar guru or course teacher and follow what they do blindly, inheriting all of their biases. And unfortunately, sometimes what you see is people who make a living off education and aren’t living also as clinicians. And so what you end up getting is a very clinically irrelevant but appealing sort of narrative in some of these courses. And if you’re not thinking and questioning that, you’re never going to figure out what pearls to take away and how to cut all the other fat out of the model. And you’ll just be using the model kind of verbatim, and that could be really dangerous.
So I think the ultimate thing to carry no matter where you go is to make sure that you’re thinking critically through these concepts. And if you find something that disagrees with what you’ve heard previously, don’t dismiss it like all the people that dismiss me as being a gluten heretic because I recommend some people can eat gluten. It’s only because I’ve been in the real clinical world, seen that there’s some nuance, thought through it, and then came out the other side with a more balanced, informed approach. So those are a few options for you in terms of where to learn more.
ER: Yeah, that’s a great point by the way. My mom just so happens to be a risk manager at the top of a very large hospital system, and the biggest issue they’re facing is the lack of critical thinking of incoming nurses and even practitioners. And she doesn’t want to ever retire because she said it’s just scary. She doesn’t understand why so many people are coming in with … they’re coming in with book knowledge, but it’s like it didn’t click during their clinicals. So it’s interesting you mention that ’cause it’s very true pretty much on all sides of the coin.
DrMR: Yeah, it’s important to think. And I should also mention that that’s one thing I try to embed into the case reviews of the case studies in the newsletter is my rationale and how I’m thinking through this process of helping a patient. And so I would definitely, if nothing else, make sure you subscribe to the clinical newsletter so that you can have that as part of … It wouldn’t be the only educational tool I’d recommend obviously, but I would definitely make that one thing to supplement your reading.
ER: Yeah. And even as a consumer at first before I came to work with you, I had signed up for that newsletter and I was able to distill the points out of it because I was interested in the different topics. And it wasn’t so clinical that I couldn’t understand it as a consumer, so I highly recommend that too.
Treating Candida Krusei
Great. So let’s move on to Emma’s question. Emma is a SIBO patient that would like to know what you typically prescribe for Candida krusei. She says,
“I’ve taken rifaximin and vancomycin, which have worked wonders on other symptoms. But the candida is still there.”
DrMR: Okay. So there’s a number of ways that you can treat candida. I think it’s a mistake to think overly strain specific. And I would caution people that we don’t want to think about treating the gut in terms of one thing. So in this case, pretty specific SIBO and Candida krusei. Now, that’s probably something that came up on a lab somewhere, so I’m assuming that’s why she offers that.
But remember that there are many things that we can’t test for that we know exist. And so if you put on blinders and only treat what you found on labs, what you end up doing is you end up treating labs and not treating the patient. Or in this case, to think about it a little bit less broadly and a bit more discerningly, we want to not just treat the labs but we also want to treat your gut.
And so the way I think is best to consider treatment of this biosis in the gut is exactly under that guise of this biosis, to use that term generally speaking, is a theme of imbalance and potentially overgrowth or undergrowth of the life in your gut. This includes a thousand and some odd species of bacteria, a few hundred species of fungus, how they interrelate to each other, how they interplay with the immune system, also some viruses and some protozoa.
And so we want to be careful not to think about this incredibly complex ecosystem in the context of one or two or three things, SIBO, candida, blasto, H. pylori, what have you. There are some things that we can take away from that, but we want to make sure not to make our treatments centered around only looking at these couple things.
So in answer to the question, there are many things that can be used to treat candida. You can use prescriptions like fluconazole, or you can use many different herbal compounds, oregano, caprylic acid, I believe berberine also has some antifungal characteristics. I like using, unless the patient’s very, very sensitive, broad-spectrum antimicrobials, and this is where we have our Biota-Clear protocol, Biota-Clear 1B and Biota-Clear 2A and Biota-Clear 2B. And I go into detail in the book in terms of how to use antimicrobials to nudge your entire gut ecosystem back into balance, and I make a very pointed piece of advice to not treat just one thing. I say, “Don’t think small. Think big.”
And so sometimes, I would say many times, the difference between success and failure is not “did you find the right agent for the right imbalance” but was your overall approach of treating the gut one that was conducive to re-establishing equilibrium in the gut or eubiosis. And this is where sometimes you have to, instead of just treating and then retesting, you have to treat, see how someone’s responding, and then adjust the treatment in a certain way until you get to the level of symptomatic response, meaning no symptoms, that you’re looking for. ‘Cause again, in my opinion, we typically see a restoration of balance or eubiosis in the gut when we’ve gotten these antimicrobial stimuli just right. It’s not about just trying to treat this one thing.
And that’s relevant clinically because what that means is, rather than just trying to find the right agent for the right imbalance, what you want to do is give the gut microbiome a nudge with an antimicrobial, see how you’re responding. And then if you’re not where we’d like you to be after the initial nudge, we can change the nudge so to speak. And this is where you may want to graduate then to the addition of anti-biofilm agents, as I also talk about in the book. And this would be your Biota-Clear protocol, 1A and 1B followed by 2A, 2B, potentially combined with the anti-biofilm agent that I recommend in the book which is Biota-Dissolve.
And further yet still, someone may need to try an elemental diet. Now, immediately people will say, “Well, doesn’t the higher sugar content of the elemental diet feed fungus?” I think, again, that’s too reductionistic because there are some patients who will have both SIBO and candida and they will do fantastically well on an elemental diet. Why? Because the net effect when you perhaps slightly feed candida with the sugars or the glucose or dextrose or maltodextrin in an elemental diet, while they may feed candida, the overall benefit on the gut may be a net positive. And that’s very important to understand.
Also, it’s important to understand that elemental diets are absorbed within the first couple feet of the small intestine, so at least theoretically, you’re not feeding candida throughout the vast majority of the small intestine. Do people sometimes see a little bit of a white coating on the tongue? Yes. Does that go away a couple days after ending the elemental diet? Yes.
So I think the criticism that elemental diets can feed fungus I think is a combination of two erroneous conclusions. One, if someone has GI upset after using the elemental diet, they attribute it to fungus. Probably not correct, probably just an intolerance reaction to something in the formula. And then two, people sometimes see a white thrush on the tongue, and that’s temporary and that’s usually confined to the oral microbiota, at least as best as I’m able to understand.
Now, someone could also pair an elemental diet with something like … we offer many agents that can help with Candida krusei, but it’s not about just trying to fix that one strain or species of fungus but how to restore a healthy gut globally. And if you go through some of what I just mentioned and use the book protocol specifically to really guide you through that in a detailed way, I think you’d be able to get to the outcome you’re looking for.
Low TSH With Low T3 and Low T4
ER: All right. So let’s try an audio question from Aly.
Ally: Hi, Doctor Ruscio. This is Aly. I just want to get your thoughts on what it could be mean if several blood tests come back with low TSH and low thyroid hormones, both T3 and T4. Thanks for your help.
DrMR: Okay. So low TSH paired with low T3 and low T4. This is, in my opinion, a little bit more of a clinical paradox because obviously TSH and T3 and T4 should share an inverse relationship. Now, what could be happening is there could be a problem at the level of the pituitary. And these conditions are much more rare but they can happen, where if someone has some type of … let’s say as one example, they may have a prolactinoma and perhaps that prolactinoma in the brain is interfering with TSH secretion. So now what’s happening is the brain aspect of the feedback loop isn’t working. Well, what normally should happen is, if the thyroid gland is not producing enough hormone, TSH goes up until you get T4 and T3 where you want them to be.
And just to sort of refresh the audience, TSH is the brain telling the thyroid gland to make hormone. And then, of course, the hormones are your T4 and your T3. So if the thyroid gland is not putting out enough T4 and T3, then T4 and T3 go low. So the thyroid hormones go low, and when that happens the brain goes, “Ah, we need more thyroid hormone so we’re going to send down more of this TSH signal.” So TSH goes up, and then that eventually gets the T4 and T3 levels back to normal and you’re back at balance.
So typically, if T4 and T3 are low, you can see TSH high. And as that progresses and that disparity between TSH and T4 and T3 becomes wider and wider, you become hypothyroid. But that’s assuming that the brain, the pituitary and the hypothalamus, are working correctly. But if the brain doesn’t have the ability to secrete enough TSH, then what you’ll see is low TSH paired with low T4 and low T3. So I shouldn’t say it’s really a clinical paradox, but it’s much more rare clinically. And I think most clinicians will see that at first and sort of scratch their heads and say, “Oh yeah, this probably the much more rarely presenting hypothalamus or pituitary involvement.”
I would make sure to repeat the test, and you have to qualify that you’re truly low. And this is an area I would be very cautious of some of the progressive functional medicine field, where you might actually be normal. And I’ve seen this actually, in the normal ranges of both TSH, T4, and T3, but a provider who’s just over-zealously interpreting your labs may say, “Well, you’re at the lower end of the range for TSH, and you’re at the lower end of the range for T4 and T3, but they don’t tell them. They don’t really make it clear that they’re actually in the normal ranges, they’re just at the lower end of the normal ranges. So, they make the patient think that there’s actually a flagged low TSH and a flagged low T4 and T3. So, that would actually be the first thing that I would do is I would look at your labs, and if you’re in the normative ranges, I wouldn’t worry about it. I mean, the conventional medicine normative ranges.
There’s some nuance there that I won’t really go into, but I guess in a really short story here, sometimes the functional medicine ranges that are more narrow, those are a better goal if someone’s on thyroid hormone. So, the narrower ranges sometimes used by functional medicine may, and I’m speculating here a bit, but they may be better for when someone’s being given thyroid hormone like WP Thyroid or Levothyroxine. So, the ranges are a bit tighter when you’re giving someone a hormone, but when you’re looking at an unadjusted system, meaning you’re not giving the system any hormone, then the ranges aren’t quite so confining.
The first thing I would do is make sure this is actually legitimately low TSH with low T4 and T3, because if you’re working with a functional medicine provider who’s probably well-intentioned but may still be operating under this far too liberal assignment of diagnosis, then this may actually not be a problem at all. If you do have truly low TSH and T4 and T3, I would retest to make sure that just wasn’t some sort of an anomaly. If this is a consistent pattern, then I would check in with an endocrinologist so they can do a workup to see if there may be something going on at the brain level that could be interfering.
ER: Okay. So, let’s do another audio from Becca.
Becca: Hi, Doctor Ruscio. Thank you for your podcast. I have been diagnosed with Blastocystis hominis. I’m not really symptomatic according to the doctor, but I think I am because of other symptoms. I’m wondering, should I try to heal my gut before getting rid of it? How do I get rid of it in a natural way? I’m currently trying diatomaceous earth. Thank you.
DrMR: Okay, so Blastocystis hominis, there is a gray area here and I think this is potentially what you’re trying to navigate through, which is do you treat blasto or do you not? There is some controversy, and that controversy is likely a result of the fact that there are different findings regarding if the Blastocystis hominis can present or show up in people with symptoms or not. It seems that blasto isn’t always a problem. So, we’re having a hard time. When I say we, I think the research community, is having a hard time saying blasto should be considered a pathogen or a commensal. Pathogen meaning bad, commensal meaning part of the normal flora.
Last I checked, the Mayo Clinic’s position was the one I found to be the most prudent, which was to consider treating Blastocystis hominis in a symptomatic patient. Now, how we define symptoms is a bit up for interpretation, because your classical blasto symptoms would be diarrhea, loose stools, bloating, probably your most classical symptoms, perhaps abdominal pain. That is kind of your textbook in the box symptoms, but you know that problems in the gut can also manifest as joint pain, skin breakouts, brain fog, fatigue, insomnia. So, it becomes a little bit harder to adjudicate what a non-symptomatic versus symptomatic person is.
I think it’s a little bit safer to say, although a bit more progressive but I think this is a tenable statement, that if someone has any symptoms not limited to digestive symptoms and they test positive for blasto, then treating the blasto would, I think, be a reasonable idea, especially if we’re going to treat this with natural agents.
So, how do you treat it, and should you heal your gut first? Well, healing your gut and treating blasto is really wrapped into the same thing. So, I would definitely not think about these things as two different ventures. They’re the same venture. In fact, if blasto is a problem for you, that may be one of the main things that’s thwarting the ability for your gut to heal to begin with.
Now, I have found the Biota-Clear 1a, 1b, 2a, 2b protocol that I recommend in the book works very well when also paired with the Saccharomyces boulardii probiotic that we released through functional medicine formulations and combine that with Artemisinin. Now, that’s a pretty strong protocol, and I’ve had very good results with blasto with that. I’ve also found that not everyone with blast even needs to go that far. I think just the Biota-Clear 1a, 1b followed by 2a, 2b along with it at the same time Saccharomyces boulardii will be enough to see results and to resolve this issue.
If you wanted to be really robust, we also recommend an Artemisinin. You will see it in our store. There are different types of Artemisinin, and I think this one is probably the better type for more sensitive patients. That should do volumes to help improve the blasto situation. If treating the blasto doesn’t resolve all your symptoms, make sure to think a little more laterally or broadly, because the symptoms then may be driven by something else, meaning you could have, for lack of a more robust example, you could be eating foods that don’t agree with you and the blasto could be a red herring.
So, it’s important not to just focus on the one thing from your labs exclusively. Treat that, but make sure that if you clear the blasto and you still have symptoms, you don’t continue treating the blasto and going on this blasto witch hunt. Then you can start looking at some other things. Essentially, the Biota-Clear protocol from my book paired with Saccharomyces Boulardii and then plus or minus Artemisinin, and that will work very well for blasto.
ER: Great. When we refer to something as 1a, 1b, that’s not something they’ll find elsewhere on the market, right? That’s our nomenclature for items in our store from the book protocol, correct?
DrMR: Yep. The book Protocol, you essentially have a pairing of antimicrobials. Just for simplicity sake, I labeled the formulas as Biota-Clear 1a and Biota-Clear 1b as our first-month protocol. Then for the second month, we use Biota-Clear 2a and Biota-Clear 2b for the second-month protocol. Yeah, you’ll find those in our store, not anywhere else because these are formulas that I specifically put together for the book. We now use them in the book and in my clinic.
ER: Great, because the internet can be a crazy place. I wouldn’t want someone to type in 1a, 1b. We don’t know what you’re going to get. Anything to add onto her trying out of diatomaceous earth?
DrMR: Oh, thank you. I’m open on diatomaceous earth. I am a bit tenuous to conclude if that could clear blasto. I suppose it could and I wouldn’t have any problem with trying it, but if that didn’t work then what I laid out is what I have found to be highly effective.
ER: Okay. We’ve got a written question from Hamaad. Hamaad says,
“I recently had a thyroid profile test done. My TSH was 5.8 and T4 was normal. My TPO antibody test read 315 IU ML. This suggests subclinical hypothyroidism. I have no symptoms and no family history of thyroid disease. I’ve enlisted in the Air Force, but I’m being referred to a specialist due to these test results. Do you have any opinions or recommended resources on this matter?”
DrMR: All right, good question. You’re correct that that classifies you as subclinical hypothyroid. What’s his age? Did I miss his age, or did he-
ER: No. No, but I’m guessing … Well, I guess you can’t really guess on that, but if he’s enlisting in the Air Force, he may be still pretty young.
DrMR: About 20s. Yeah, probably 20s, maybe even younger. A TSH of that level in someone in their 20s, it’s something to have a second look at, but it’s probably not going to be problematic. Ultimately, you’re going to want to check in with your GP or with your endo and have someone really vet this. The higher the TSH goes when subclinical hypothyroid dictates how much of a problem may be present. For the audience, subclinical hypothyroid is when you have high TSH paired with normal T4.
If you had a TSH of eight or nine, then that becomes more of something to consider looking at. The general agreement is that a TSH above ten paired with a normal T4 is a level at which one should consider treating subclinical hypothyroid. When the TSH is below ten, it’s less of a concern. There’s also an age-associated gradient, so it’s normal to see a creeping up of TSH the older someone becomes. If you had a TSH of 11 and you were 75, most probably would not recommend treating that. That’s been corroborated by some of the research studies showing really a lack of benefit when treating most older patients with elevated TSH and normal T4.
In your case, that’s not a very high elevation, not something I would be overly concerned about. It wouldn’t be a bad idea to follow-up on it. Now, how does a TPO play into that? The TPO of 313, that is not a bad level of TPO. The body of data here I think is still evolving, but the best read I can take away at current is that if you have a TPO of above 500, you’re at a moderate risk of progressing to overt hypothyroidism. If you’re below about 300, you really have a minimal risk. Does that mean it will never happen? No, but it means you have a minimal risk.
If you’re above 1,000, I think there’s a higher risk. This stratification has been shown in just a handful of long-term follow-up studies that have been done tracking normal patients with elevated TPO antibodies and tracking how many of them actually progressed to hypothyroidism in the future. So, there’s some good news there, which is different than I think much of the thyroid community’s party line, which acts aggressively on almost any value of elevated TPO antibodies. I think that is a mistake.
I would have a follow-up on this. What you may find is your next test goes back to normal, or you may find there’s a slow steady creep upward. You could consider some interventions to lower your TPO antibodies. Erin, if you could help me out, there is a link to a post that I’ve provided where I talked about selenium, CoQ10, and magnesium in a protocol that one can use for their TPO antibodies. You could see if you could lower that down a bit. That may help. It’s also, again, possible that this could have just been a coincidental flux. I’m not sure if you went through basic training pre or post to this, but if you’re under a lot of stress, that could have skewed your TSH.
The other thing that you may want to consider is repeating this test with, and when I say this test, this would pertain to the T4 and/or T3 with a different testing methodology known as the liquid chromatography with mass spectrometry, or it’s sometimes abbreviated Dialysis/LCMS, liquid chromatography, mass spectrometry. Essentially, this will help sniff out some cases that have high TSH and normal T4, and they will actually be found to be low T4 when running this testing methodology because this testing methodology filters out confounding binding proteins in the blood that can make someone look to be normal T4 but are actually low T4.
So, that would be salient and that would be clinically relevant because that would be able to tell you if you’re actually hypothyroid but you haven’t been found to be hypothyroid because your lab work may have not been sensitive enough. There have been a number of papers that have discussed this. I have discussed this on the podcast in the past, and I’ve written up these papers in detail in our Functional Medicine Clinical Newsletter. So, there are more resources for you there.
Now, if you wanted to be sneaky and try to not look like you were hypothyroid if you really were, then maybe you don’t want to do that test. I’m not sure if that would bar you from entry. I also would not recommend that, because you don’t want to put yourself in a precarious situation where you’re not feeling well and then you’re in a battle situation and potentially your life could be in jeopardy. So, I wouldn’t recommend that, but that’s something you could exercise depending on how important this is to you.
Again, I will wrap this up with a disclaimer that you should definitely pursue further testing. You don’t want to put yourself in a situation where your health could be in jeopardy while you’re also in a potentially life-threatening situation. So, I would definitely go through the standard evaluations. Keep some of those points that I mentioned in mine. If you wanted to try to get the most accurate read, then you may want to use the Dialysis/LCMS testing methodology, which is available through LabCorp and Quest. So, it’s not this crazy progressive stuff that you have to go to some special lab in Mexico for. This is readily available through the big box labs. Whatever clinician you’re working with should have ready access to this, even if they haven’t heard of it before. It is something that’s available through the big box labs.
ER: Yeah. I think we had a recent episode about that, and there were a couple of studies to coincide with that. So, even if they wanted to print some studies out and bring that in with you, that might be a good resource.
DrMR: Yeah, that’d be great, because sometimes people say, “My doctor isn’t open-minded,” and I understand that, but I have said this many times in the podcast, I spend 30% of my time talking people out of tests and treatments they think that they need. Now, people appreciate it when I do it because I think they have trust that I’ve done my homework. Your doctor may be trying to do the same thing, and perhaps he doesn’t have the same amount of tact or ability to communicate that.
So, I think it’s a good idea to try to give your doctor the benefit of the doubt. If you can bring to them a scientific resource, that’s really helpful because sometimes as a doctor, you don’t know if your patients are reading stuff from the kooky nether-realms of the internet or if they’re pulling something from an endocrinology journal. So, if you can bring with you some references that are scientific in nature, then that can, I think, really help your doctor kind of meet you halfway.
ER: Yeah. He’ll also be really impressed if you can say the name of that test.
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TPO and Thyroglobulin Ranges
ER: Next we have a question from Maddie. She says,
“My thyroid antibodies are currently in 100s, which is the highest they’ve ever been. One is in the 300s and the other is in the 500 range. I have undergone a massive amount of stress lately with law school, moving across the country, and giving birth. Could that be the issue? I’m wondering if a paleo diet could help reduce antibodies enough to where I wouldn’t need to take medication. If I were to consider medication, what would you recommend?”
DrMR: Okay. I’m assuming the tests that she’s having are TPO antibodies and thyroglobulin antibodies. The data for TPO is a bit more established in terms of what’s normal, what’s abnormal. The thyroglobulin, there’s more of a dearth of studies here, so it’s harder to say. With TPO, we already talked about. I think if you’re below a 300, that’s not a bad spot to be in. With the thyroglobulin antibodies, if you’re ten times the normal range, that seems to be when someone should act. So, if you’re below ten times the normal, so the upper cutoff of the normal range, then that seems to be a better value. Again, there’s less data there, so that may come to be disproven in the future.
Can stress affect your TPO antibodies? Yes. The data that we have showing this connection really centers around prolactin. So, it’s a bit inferential, meaning it’s not direct. We give someone a stress questionnaire, right? It asks you ten questions and they’re all indices of stress. I don’t know of a study looking at stress levels as they pertain to thyroid antibodies, but there are data looking at prolactin levels in showing that elevated prolactin, even if it’s not hugely elevated, does seem to correlate with increased thyroid autoimmunity.
Now, what is prolactin? Prolactin is essentially a neurotransmitter, and when you are stressed, that essentially can inhibit prolactin. There does at least inferentially seems to be a connection, but remember that if you are in the acceptable range, and I would look most specifically at your TPO antibodies, and if your TPOs are in the low 300s, then I wouldn’t be overly concerned. It’s very important to draw a line separating Hashimoto’s from hypothyroidism. It seems that the online community leads people to believe that almost everyone with Hashimoto’s will become hypothyroid. That is not true. It is actually the vast minority. I want to say one study found, and I may be slightly off my numbers here, but between nine to 16, 1/6 percent of those with Hashimoto’s actually became hypothyroid.
So, it’s very important not to take the fact that most hypothyroidism is a result of Hashimoto’s to conflate that with most people with Hashimoto’s become hypothyroid. Does that make sense? The number one cause of hypothyroid is Hashimoto’s, but most people with Hashimoto’s don’t become hypothyroid, at least according to what the evidence says. So, you want to contextualize that with if you have a fairly low-risk level of TPO antibodies, let’s say you’re 315, then your probability of becoming hypothyroid is actually quite low.
Now, does that mean you should do nothing? No. We still want you to take the actions that one would take for well-being, which would be mitigating your stress as best you can and also trying to implement anti-stress strategies like laughter, love, intimacy, time in nature, meditation, exercise as long as you’re not overly exercising and therefore stressing yourself even further yet still. Then you can stack on top of those lifestyle factors a paleo diet. There was one study that we reviewed in the newsletter showing a 40-44% reduction in antibodies when people essentially followed a paleo diet. So yes, the paleo diet can be helpful.
Medication, which one should you use? Again, hopefully, you will not need medication and you have a majority probability that you will not need medication. But again, don’t take this advice as advice to not follow up with your doctor. You definitely want to follow up just so that if you do become hyperthyroid, you don’t miss that. So I’m not giving you a license to blow off your recommended follow up. What I’m trying to do is recalibrate your expectations and prognosis regarding Hashimoto’s relative to the overzealous wing that exists, unfortunately, online currently.
Now for medications, you will be confronted with the T4 alone versus T4, T3 combination medication recommendations. So that would be a Levothyroxine or Synthroid compared to a Nature-Throid or an Armour or a Westhroid or what have you. This is very heretical relative to what most of the field believe, but I think this is what is best supported by the actual evidence. I’ve fairly copiously detailed this in the clinical newsletter. Your best bet is likely to start with a T4 medication and then consider if you’re not feeling well after being on the T4 medication increasing your dose of the T4 medication. Then, and only then, consider either switching to a T4 plus T3 or if there’s a lot of digestive symptomatology involved or present at the same time, consider using a liquid T4 like Tirosint. The reason for this is when people jump right to T4 plus T3, there’s a relatively high chance of negative adverse events, mainly cardiovascular reactions like racing heart, tachycardia, potentially insomnia, feeling hot. That happens when you give someone T3 who is already an adequate converter.
Now I can already hear people taking issue with that. We have to be careful not say because there’s a small subset of people … and I don’t know the exact percentage this here off the top of my head, but I believe it’s anywhere between 10% to maybe 30% of people, maybe more depending on the study group that you look at. But the minority of people may have a hard time converting T4 into T3, and they may need the addition of T3. Yes, but because those people exist, does that mean we want to conflate that and say everyone should now be on T4 plus T3? No, that’s like saying because an alcoholic feels better when they don’t drink, no one can ever have a drink. It’s going too extreme with the conflation of the recommendation.
I also lay out an algorithm for addressing that in the clinical newsletter, but it’s essentially, if you have to go on medication, start with T4, allow for a dose adjustment or two over some time. If that doesn’t work, consider going on what would be considered a relatively higher dose of T4. So that’s to get your TSH even a little bit lower, maybe even around like 1. If that doesn’t work, then consider either going to a T4 plus T3 combination. Or if you have a lot of digestive symptoms and you might be mal-absorbing, go with a liquid gel tab that’s easier to absorb in the gut, as Tirosint.
I think that hits all the questions there. There’s a lot to this thyroid piece, this thyroid puzzle, but a lot of these things aren’t actually that complicated. We can make them more complicated if we wanted to, and it might be a complicated answer to come out with a simple solution, and I think we need much more of this in the field.
This, I think, holds true in almost every facet of life. Things have this tendency toward entropy, toward becoming more complicated. So unless you are acting with the objective of making things simplified, things will become complicated. So if you’re looking for … as Jeff Moss would say, sometimes in the field there’s complexity for the sake of complexity. “Look at how smart I am. I’m going to spew off all this academic conjecture and use a bunch of big words and confusing terms. Therefore, I’m really smart. Therefore, listen to me.” I think that is a huge mistake. What we want to be doing is trying to take this complexity, understand it, and as Einstein said, “If you can explain something simply, you truly understand it.” So once we get to mastery, we can make the conclusions and the actions much more simplified.
So even though there’s a lot there, hopefully, you picked out that kind of baseline series of simple steps to go through and you can navigate through this fairly precisely. This will be the next book that I write. Unquestionably, it will be on thyroid, but don’t ask me when.
ER: Taking a book break for a while. Okay, I think that about wraps up the time we have for this episode. Unless you want to tackle one more, but I think we’re at capacity here.
DrMR: While we’re in the zone, let’s tackle one more. I was hoping that this format would allow us to answer more questions. It hasn’t, so maybe I need to start being more concise with my answers. Let’s do one more, and we’ll keep the objective in mind of trying to get to at least ten questions. Was that four or five?
ER: No, we’re at eight. This will be number 8.
DrMR: Time flies when you’re on the other side of the mic. Okay. That’s progress. Alright, yeah, let’s do one more.
Laxatives and SIBO Breath Tests
ER: Okay, let’s do an audio question from Amber. Here we go.
Amber: Hi, Dr. Ruscio. I was wondering if you could clear up some confusion about taking laxatives like magnesium before taking a SIBO breath test. I have some constipation and rely heavily on magnesium for a bowel movement. Some testing instructions say to stop laxatives a week before taking the test, others say four days, and another one says to stop only one day before the test. I even found a testing site from New Zealand that suggests drinking laxative tea the night before a SIBO breath test if you are prone to constipation.
I’m wondering why there are so many different instructions on this and what the effects are on a breath test if you’re taking laxatives for bowel movements. Thank you so much, and I’m excited to read your book. I just got it in the mail. Have a good day.
ER: Yay. We’re excited for you to read the book, too.
DrMR: So the answer here is simple. I’m going to lead with a simple answer, but knowing that sometimes people have a hard time acting on a simple answer unless you give them the complicated rationale, I will then follow with the complicated rationale.
If you are working with a well-trained practitioner or going through the protocol in the book. Which if I may boast a little bit, we have done interviews with a few people who have seen functional medicine doctors, not really gotten much help, and then gone through the book protocol, and actually seen a complete resolution. So I’m not lying when I say that the protocol in that book can really get you some fantastic results, even where a functional medicine provider may not. That’s not a knock at the functional medicine provider. This is my area of specialty, so I wouldn’t expect maybe a generalist to be able to get the same results as a specialist. So you know, I just want to be careful not to denigrate anybody, but I do want to point out that even though it’s a book, you can sometimes get better results than even working with a living, breathing professional.
Now the answer to the question is it really doesn’t matter. It doesn’t matter as long as you’re working the context of working with the knowledgeable provider or going through the protocol in Healthy Gut, Healthy You, because the end-all, be-all of your gut health is not contingent upon the SIBO breath test results.
Now, why are there different recommendations? Well, because magnesium is a laxative, and laxatives accelerate how quickly food moves through your intestines. Remember that the glucose or the lactulose that you drink as part of the SIBO breath test, that’s traveling through your intestines at an assumed pace. It’s assumed that by the time you get to 100 minutes, 90-100 minutes, you’ve now gotten into the large intestine. So when you see elevations of gas after 90-100 minutes, that’s considered normal. So even if you have high gas levels after 90-100 minutes, high is something relatively … there’s a limit. But if you see a spike, abnormally high gas levels after 90-100 minutes, that’s not considered SIBO, because you should be, at that point in time, looking at what’s happening in the large intestine.
But if you take a laxative, now all of a sudden what’s happening is that lactulose that’s creating gas, or glucose, is getting now into the large intestines by 70 minutes. So you’re seeing a spiking gas at 70 minutes, and your practitioner is thinking, “Ooh, this is happening in the small intestine.” They may not be aware that you’ve taken a laxative and that’s moved things through your intestinal tract more quickly. Now what they’re actually seeing is a fast arrival at the large intestine. What you’re seeing at that 60-minute mark, or that 70-minute mark, is now a spike of gas that’s coming out of the large intestine. So this is why there’s debate on this.
Now the counter argument that’s made to that is well, if someone has slow transit, then taking the laxative may take them from slow to normal, so that wouldn’t be a problem during the testing. I think there’s something to that. So how exactly to grapple with that and what exactly to do, there is not a clear-cut answer. Now I lean more in the direction of keeping whatever we’re doing constant while testing so we see what our treatment testing levels are. Meaning if you need to have some magnesium to be normal, I’m assuming …
Let me give you an example. If I was going to watch your squat form, but you always had to wear a knee brace because of a bad injury… Sorry guys, if you hate these physical analogies let me know, but I think it makes it easier for people to connect with. If you had a bad knee injury and you need this knee brace to function correctly, and I was going to assess your squat form, and you were always squatting with a knee brace, but then for the test, I said, “Well, you can’t wear your knee brace during the test.” Then you squat and your form gets all wanky, well I mean, that’s not really diagnostic, because if you’re needing to wear that brace during exercise, and then we’re having you not wear the brace during the squat test, it’s giving me a false read. So that’s the way that I kind of lean, but there’s no formally agreed upon answer to this question.
Now, why doesn’t it matter? Because if you’re trying to resolve your constipation, you can treat SIBO up unto a point where you feel like you’ve cleared the SIBO, and you should get a fairly good read. When you start treating SIBO, does it help your constipation or not? I’m not a believer … I shouldn’t say, “believer.” I think that’s a bad term. You believe in like the Easter bunny, or you have science to tell you what a certain answer is.
The data right now I think best suggests that we don’t have to use serial repeat SIBO testing to guide our care. Can you use some follow up testing after a round of treatment? Yes. Is it necessary? No. This is evidenced by the protocol in the book, which we have received an overwhelming amount of positive feedback from people who have gone through it. There is no testing involved in the book, also evidenced by the fact that I am not routinely retesting SIBO in the clinic. There’s a meta-analysis that concluded perhaps the best way to utilize SIBO breath testing is to test initially to see if that is an issue.
Then from there, treat empirically, meaning use your symptoms to dictate treatment. So if you’re using the retesting in this way, then well, you’re not really doing much retesting. So we’re treating you until we find what combination of factors work for your gut. Now might that be magnesium? Yes. If you have normal or semi-normal bowels and really no other GI symptoms when using magnesium, great, then you’re done, and I don’t care what your SIBO breath test says. If you’re still having symptoms after using magnesium, then we may treat you with probiotics or we may use probiotics and then maybe consider antimicrobials – this is already outlined in the book – until we get you to a point where you’re no longer having symptoms.
Then whether you’re SIBO positive or negative, it kind of becomes obsolete, because the goal is for you not to have symptoms. The goal is not for you to have a clear SIBO breath test. While yes, there is some data showing that people who have no SIBO have fewer symptoms than people who have SIBO, it’s not 100% prediction. There are people who have SIBO who are perfectly healthy. There are people who have SIBO treat their gut, still have SIBO, but have no symptoms. So because of this, you want to be careful not to just blindly follow test results. They can help us understand what’s going on underneath the surface, but I would not keep testing SIBO and treating it until you get to zero. You want to look at your symptoms and that should be what really steers the process of how you intervene and what you do.
So when you understand those components of it, the particulars of use magnesium, don’t use magnesium for one day, four days, one week, or even beyond it during the test, I think becomes a little bit more obsolete. What I typically have people do is not use laxatives before their testing, usually by about four days, unless they get really backed up. When they do, and then I have them simply stay on it, because I want to see when they’re wearing that knee brace, so to speak, how their form looks. So hopefully that helps you navigate this somewhat tumultuous landscape of SIBO and SIBO testing.
ER: Yeah. I’ve been there. I’ve been there and just been so inundated with all the particulars, and you want to do every single thing right, because you’re just feeling so terrible, and you want to feel better as soon as humanly possible. So it’s sometimes hard to get your head out of that and see the bigger picture, which it doesn’t matter. It all depends on how you’re feeling and not what the test says. I feel that. That hits close to home.
DrMR: You make a great point, and I get it. If you’re thinking that the lab test is going to deliver you to feeling well, then that really makes the lab test attractive. This is really what I think, it all emanates from this, it’s the assumption that getting your labs normal will guarantee that you’re going to feel better. Unfortunately, that often doesn’t happen. What we want to do is we want to use someone’s response to guide us and to help us learn your system and learn what works for your system, because if you stop listening to your body and you just look at the lab tests … and this happens way more than I wish. People spend months and months just looking at their labs and they’re not listening to their bodies. So they spend months spinning their wheels and not learning only to then find their way into our office or to the book, and then they finally start learning to listen to their bodies. That’s when they really start making some true progress.
ER: Yeah, definitely. I think that’s a good note to end on for sure.
Episode Wrap Up
DrMR: Yeah. Well, thank you guys for bearing with Erin and I as we kind of get this rolling. Erin, I thought this was a nicer format than me just reading all these, so thank you for helping. We got through nine, right?
ER: We got through eight. This was question number eight. So that’s pretty darn good.
DrMR: Yeah, so we’re getting there. My goal, guys, is to try to get a pace going here that will match the influx of questions. So let us know if you have any questions or feedback on that. We will talk to you guys next time.
ER: Yeah. Just a tip, we say that if you enter your questions at about like 1-3 sentences, that’s even better. Then we can get through it even more quickly. We still want to know how you’re doing, but it helps us to get through more questions.
DrMR: And I should also mention as we’re wrapping up, if you’re submitting an audio question, if you leave us like a three and a half minute audio question, it’s really hard for us to answer those, guys. So if you can take a moment to try to consolidate your question down to like 30 seconds, it just makes it much easier for us to get it on the air.
DrMR: Cool. Alright, thanks guys. Talk to you next time.
ER: Alright. Bye.
What do you think? I would like to hear your thoughts or experience with this.
Dr. Ruscio is your leading functional and integrative doctor specializing in gut related disorders such as SIBO, leaky gut, Celiac, IBS and in thyroid disorders such as hypothyroid and hyperthyroid. For more information on how to become a patient, please contact our office. Serving the San Francisco bay area and distance patients via phone and Skype.