Listener Questions: Tests for Autoimmunity, How to Become a Functional Medicine Practitioner, Thyroid Antibodies & Eating Worse but Feeling Better

Today I will answer more listener questions, including:

  • Tests for Autoimmunity
  • How to Become a Functional Medicine Practitioner
  • Thyroid Antibodies
  • Eating Worse But Feeling Better

Dr. R’s Fast Facts

Autoimmune Testing

Question (part 1): “When you begin treatment for a patient, should exhaustive tests be run upfront or is there a better way to do that?”

  • No, it does not benefit the patient’s health or financial wellbeing to run a bunch of tests upfront.
  • Get someone healthy (feeling better) using foundation treatment/testing that is indicated and autoimmunity should improve as a result.

Question (part 2): “How do you suss out which tests to run, when, and in what order (especially with autoimmune disease patients)?”

Which Autoimmune Markers to Consider:

There are many to consider but these are the three I have found with the most utility:

  • Autoimmune Thyroid – TPO
    • TPO antibodies do correlate with risk of hypothyroidism and there is evidence showing that the antibody levels correlate with one’s wellbeing. We don’t know if lowering the antibodies will improve someone’s outcome
    • You don’t have to keep testing once labs are in the low hundreds
  • Non Celiac Gluten Sensitivity
    • Use blood tests that can show antibodies against gluten (Anti-gliadin antibodies – specifically the IgG fractions)
    • Recent study showed these markers had the highest correlation with gluten sensitivity
  • IBD and Microscopic Colitis
    • Use markers that are used to help identify Inflammatory Bowel Disease and can aid in diagnosing microscopic colitis (ASCA, P-ANCA, etc.)
  • Neurological Antibody Tests
    • Open here, but haven’t done a thorough review on evidence to support
    • There are many things Ab testing won’t show, for example – histamine and food intolerances which could be the cause of neurological symptoms

How to Become a Functional Medicine Practitioner?

Question: “I am a naturopathic practitioner and I take a Functional Medicine approach to my practice. How do I become, or what does it take to become a Functional Medicine Practitioner?”

  • Currently there are no specific credentials that deem someone a functional medicine provider
    • This will become more regulated in the near future
  • Best thing to do – look at your options, choose what interests you, and what level of credentials might be right for you
    • Minimal credential – Health Coach, Guru, Nutritional Cert.
      • Easier, faster to obtain
      • More freedom and less responsibility/liability
    • Moderate credential – Conventional Nutritionist
      • Lower potential for income, less revered
      • Must have business skills, cannot perform research or use insurance
    • Heavier credential – Naturopathic Doctor, Doctor of Chiropractic
      • Higher potential for income, more revered
      • Business skills are not a necessity, can perform research and use insurance
    • Heaviest credential – Medical Doctor, Doctor of Osteopathic Medicine, Physician Assistant, Nurse Practitioner
      • Long schooling period, much more cost, less freedom and more responsibility/liability
      • You’ll always have a job, but you’ll have less control in some cases
    • Best way to start your discovery is with:
      • Free/cheaper resources and see what appeals to you
      • Then move to short courses and seminars
      • Then full clinical training courses

Crohn’s Disease and Eczema

Question: “I have Crohn’s and eczema and I have tried many different diets but have had no real success. In fact, sometimes I notice I seem to do better when I eat off the plan, why is that? If it is a gut issue, will I start to feel better once my gut is healthier?”

  • This is not uncommon and yes, your intolerance should be far less once your gut is healthier.
  • I look at this kind of question from a 3 tiered approach:

Level 1

  • Dietary recommendations: Paleo, Autoimmune Paleo Diet, low FODMAP, and low FODMAP + SCD. Consider probiotics and enzymes (proceed with caution – probiotics and enzymes do not always help people feel better). My book will walk you through this – includes recommendation of trial Low FODMAP + SCD diet.

Level 2

  • Sort out any dysbiosis – my book will walk you through this. Includes various interventions like herbal antimicrobials or for tougher cases, an elemental diet.
  • Fiber is not always good. If fiber makes symptoms worse, focus on less fiber in the diet and less fermentable sources of fiber.

Level 3

  • Consider other dietary protocols like low histamine, low sulfur, low oxalate diets.
  • Other immunomodulatory treatments like – low dose Naltrexone, over the counter antihistamines, helminths, or fecal matter transplant.

Hashimoto’s – Question from Open Skye Fitness FaceBook group

Question: “I know with Hashimoto’s you’re supposed to follow a specific AIP, but what if you had your thyroid taken out? Does that make any difference?”

Leaky Gut and SIBO

Question: “What diet do you recommend for someone with Leaky Gut and SIBO with constipation?”

  • Paleo is a great place to start, also consider AIP
    • Low FODMAP may help, but can cause constipation in some
  • Experiment with overall carb intake and grains, some people have better regularity on these
    • Fiber can help constipation
  • Treat SIBO, it may be an underlying cause
  • Peppermint might also help, in addition to Magnesium or Vitamin C

Thyroid Antibodies

Question: “My thyroid antibodies were 29, so slightly below the normal range. My doctor said they really shouldn’t be above zero. I am having them re-tested but I’m worried about what could be going on. Is there a reason why you would have antibodies present? Is it normal?”

  • TPO antibodies in the low hundreds – OK. Over 500 more risky. Over 1,000 is greatest risk.
  • Antibodies help to clean up dead cells (housekeeping) some are normal. Be careful with thyroid alarmist.
Listener Questions: Tests for Autoimmunity, How to Become a Functional Medicine Practitioner, Thyroid Antibodies & Eating Worse but Feeling Better - RUSCIO10
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Episode Intro …00:00:39
Autoimmunity Question … 00:01:20
Antibody Testing … 00:08:26
How to Become a Functional Medicine Practitioner … 00:20:08
Crohn’s Disease and Eczema Better When Eat Off Plan … 00:33:57
Hashimoto’s … 00:43:00
Leaky Gut and SIBO … 00:46:00
Thyroid Antibodies … 00:48:53
(click gray Topics bar above to expand and see full outline/time stamp)
Episode Wrap-up … 00:53:00

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Listener Questions: Tests for Autoimmunity, How to Become a Functional Medicine Practitioner, Thyroid Antibodies & Eating Worse but Feeling Better

Episode Intro

Dr. Michael Ruscio: Hey, everyone. Welcome to Dr. Ruscio Radio. This is Dr. Ruscio. Let’s jump into another episode of listener questions. And admittedly, I feel a little bit in a weird place right now because I took some notes, but if you take too many notes that can prevent you from answering a question extemporaneously. So I feel like I’m in between these two endpoints of just answering the question but also having notes that may prevent me from being as free-flowing as I’d like to be.

But there are a few important questions that are kind of bare. So the first two are pretty long-winded in the answer, so I guess let’s jump in and hopefully this will sound halfway decent. So I’ll play the first question.

Autoimmunity Question

“Hi, Dr. Ruscio. This is Dr. Sarah DiFrancesco calling in from Portland, OR. I’m really enjoying your podcast, and I especially appreciate your discussion about advanced testing and whether or not these exhaustive tests should be run all up front, spending thousands of dollars, or if there’s a better way to do that. In my training as a naturopathic doctor, I was taught to do it a different way and be basing my treatment on the diagnostic criteria, on the symptoms, on the patterns that I see. And to be honest, I’m a little frustrated with this sort of functional medicine party line of ‘you have to do all of this advanced testing up front,’ and, in fact, that may not be the best thing for the patient, as you’ve discussed. Where I find this is a little bit more tricky is with autoimmune patients and knowing that there are so many different root causes that could contribute to autoimmunity. So I’d love to hear your thoughts on how do you sort of suss out, especially in an autoimmune patient, which tests to run and when and sort of in what order, because I do find that to be a bit tricky. Anyway, thanks for everything that you do. Loving your podcast and hope you’re well. Bye-bye.”

All right. So there is question number one. So, Sarah, there’s a lot to say here. And let me lead by saying that one of the things on my list—and I know I maybe have been saying this for a while—is to undergo a comprehensive review of the literature here to provide everyone with a good, reasonable update. I have not done that yet, so I will give you the answer to the best of my knowledge to date.

So I like the kind of traditional naturopath angle on this, as you described, which is using symptoms and patterns to be one of the prominent ways of gauging this. As you know and the audience knows, I’m not a huge advocate of lots of testing. And I want to correct any thinking that I’m anti-testing. I’m not anti-testing. I’m anti-overtesting.

And unfortunately, I think functional medicine’s been partially hijacked by supplement companies and lab companies. And if I’m being quite frank, by people that like teaching stuff but aren’t really practicing clinicians anymore. That can be problematic because you can lose your grip with reality.

And it’s not to say that supplement companies and lab companies are doing this with malintent. But they need to be regulated because there will be a natural creep toward more supplements and more testing, unless there are forces to counteract that.

And unfortunately, I think there’s also been a confirmation bias from health enthusiasts who flock to this type of medicine: CAM medicine, natural medicine, functional medicine, what have you. And they’re looking for more and this pushes practitioners to do more. So we’re all partially responsible. And I also used to be like this myself, so I get it. I think it comes from a good place, but it leads to a bad place.

So a few things. The underlying core of someone’s health or someone’s core health should provide optimum results for autoimmunity at large because it’s not to say that autoimmunity is this mysterious entity that is disconnected from everything else in the body. If you’re treating someone at their core and going through whatever interventions you can to make them as healthy as possible, that should correlate to the best outcomes for autoimmunity.

So said more simply, if you’re being told to do something because the labs tell you that you should but you’re not feeling better, then the labs probably are not very useful. Or alternatively, if you focus on doing things that make you feel healthy, that will likely correlate to an improvement in autoimmunity.

So again, focus on getting someone healthy, and that should lead to a pretty good outcome. Also remember that there are modifiable and nonmodifiable factors. So it’s not to say that if someone does not respond fully to treatments for autoimmunity, that we have to do this exhaustive lab analysis to figure out what other things we can treat. We have things that we can treat. We have established things that we can treat. But there are also things that you cannot treat.

You can’t treat if someone was Cesarean birth or vaginal birth. You can’t treat if someone was breastfed or formula fed. You can’t treat their genetics. You can’t treat their early life environmental factors that dictate how fully or non-fully their microbiota and immune system globally develops.

So why this is important is even in some people who have done everything perfectly—they’re eating well, they’ve cleaned up their gut, they’ve done detox if you’re into that kind of thing, they’re stress managing, they’re doing everything perfectly—they may still have autoimmunity that does not fully respond. And that’s important so that they can undergo other types of treatments. For example, using inflammatory bowel disease as an example, they may need to be on some kind of medication.

Now, the chance that they’re going to need to be on a medication is greatly reduced when going through the work that we do. But it’s not a 100% guarantee. And to think such would really be very ignorant. So this is important because some people may need to be one some kind of medication.

And there comes this point in the clinical process where you have to know when you’ve exhausted the capabilities of complementary and alternative medicine, and it may be time to add in something like mesalazine. Humira is most likely what someone may need small doses of in inflammatory bowel disease if they’ve failed out of everything else because many of the therapies have been shown to be equivalent to the 5-ASA class anti-inflammatory autoimmune drugs for IBD.

So it’s important to draw the distinction because what you don’t want to do is have someone needlessly suffer and pursue non-validated labs and treatments because their worldview and their paradigm is such that they couldn’t conceive of potentially using a medication. You want to try to mitigate the amount of medication that someone may need but not completely avoid any medication if someone’s case seems to dictate that they may need a medication.

Antibody Testing

So more specifically, what autoimmune markers do I use, what ones to consider. I think for autoimmune thyroid, we probably have the best data in terms of utility of the thyroid antibody markers. And this is because autoimmune thyroid, most namely TPO antibodies, do correlate with risk of hypothyroidism. And there’s also some evidence showing that the antibody levels correlate with one’s wellbeing.

Now, the question that we don’t really have an answer to, is will lowering the antibodies improve someone’s outcome? Because what we have is mostly correlation data, showing that high antibodies correlate with higher risk, faster disease progression, and lower wellbeing. We don’t really have data, except for a couple of studies—I’ll come to those in a moment—showing that someone comes in with high TPO antibody +1000, and then six months later their TPO antibodies is now at 225 and they’re feeling a lot better.

Now, anecdotally, observationally—or I should say anecdotally and what we see in the clinic, that will likely be proven true at some point. But we don’t really have evidence to support that right now which is why we should all be a little bit open-minded. But again, I think it’s fairly safe to say that if someone takes vitamin D, goes on a gluten-free or gluten-restricted diet, cleans up their diet in general, maybe takes some magnesium, CoQ10 and selenium, and they go from a TPO antibody of +1000 and then they’re in the low 100s that that’s going to correlate with a person who’s a lot healthier and that antibody treatment will be something that we could sanction. I think that’s pretty reasonable.

Now, evidence to date is sparse. There is one dietary trial showing a carbohydrate-restricted diet can help with lowering thyroid antibodies by 40-44%. Mainly avoiding grains, eggs, legumes, fruits, and focusing mostly on meat and vegetables. So there’s one study. There are studies using selenium, showing the ability to lower thyroid antibodies. And there’s some evidence showing an improvement in wellbeing, but I don’t believe that’s been consistently shown.

So I think for thyroid autoimmunity, we have the best evidence, and I think it’s very reasonable to be tracking antibodies. But it’s important to understand that getting someone to a normal level of antibodies, at least in my observation, does not happen in the majority of cases. What happens in the majority of cases is we see the antibodies hover in the low 100s from what, in many cases, was initially in the high 100s or above 1000. That’s something to keep in mind.

Moving onto—I’m sorry. Before I move onto gluten sensitivity. So just let me recap that. We don’t have to keep beating someone over the head with repeat serial thyroid antibody testing if they’ve gotten to the low 100s. And if you miss that distinction, you could keep testing thyroid antibodies needlessly and keep a patient stuck in fear and keep treating them when they really don’t need to be treated. So that’s a really important distinction regarding thyroid autoimmunity.

So now let’s move onto gluten sensitivity or, said another way, non-celiac gluten sensitivity. Antigliadin antibodies, specifically the IgG fractions. Those are the blood tests that can essentially show antibodies against gluten. In this case, they’re called the antigliadin antibodies. The IgG fraction may help identify non-celiac gluten sensitivity.

We recently reviewed a paper in our clinician newsletter where we’ll go into more detail about this. This will publish in the February edition, if you want to know where to locate it. And essentially, they found that marker—in a very well-performed, multi-center prospective study looking at 34 centers and over 12,000 patients, found that marker to be the most representative or having the highest corollary to non-celiac gluten sensitivity.

They also found that the HLADQ2 and 8 gene testing was not helpful in parsing out non-celiac gluten sensitivity. So that may be helpful. The antigliadin antibody IgG fraction for sussing out if someone’s non-celiac gluten sensitive. The highly advanced assays for gluten that look at all these different peptides and fractions and what have you, I really don’t know how much they’re going to help beyond elimination and reintroduction.

And this is because for those with non-celiac gluten sensitivity, according to this same paper I’m referencing, most patients, meaning over 90% of patients, saw a reaction within 24 hours. So to say that you may be having this delayed reaction that’s very hard to parse out, it doesn’t really seem to be substantiated.

Now, for celiac disease, that’s a different story. For celiac disease, the reaction may be very delayed. But fortunately, to diagnose celiac disease, it’s a little bit more clear-cut. You have to be eating some gluten, but it’s able to be done in a much more clear-cut way. Non-celiac gluten sensitivity doesn’t really have clear-cut lab markers to diagnose it, so symptoms are more important.

And fortunately, you will see a symptomatic response in over 90% of cases within 24 hours. Now the argument is sometimes made that you’ll be feeling this autoimmunity. But again, coming back to my earlier posit—and this has yet to be proven, but I think it’s a very reasonable assumption—is that if someone is fueling an autoimmune process, they are most likely not going to feel well when they’re eating in such a way that fuels that process.

So I think it’s very reasonable to say, with the exception of celiac disease, that if someone’s having a reaction to gluten, they’re probably non-celiac gluten sensitive and that they’ll be able to notice that reaction within 24 hours. And the argument that there’s this smoldering autoimmune fire brewing underneath the surface and you must diligently avoid all gluten and your symptoms will not be a good predictor, I don’t think that that holds up. And I think that comes from a very overzealous fringe of the community, and I would not agree with that.

Again, if the right evidence were to be presented to me, I’m happy to change my opinion. But I do not see the evidence. And what I see is harm to people being done in a psychological and social setting.

The antiparietal cell antibodies theoretically make a lot of sense, and we’ve reviewed some of the information showing that if you catch those antibodies elevated you can use administration of B12 to lower those antibodies. And that may help prevent someone from losing the ability to release hydrochloric acid. You may protect those parietal cells which make hydrochloric acid.

But I found it challenging clinically because normally we find that along with other things in the gut that are more pressing. And so we focus on those, and then by the time we get to a point where those other factors like, let’s say, H. Pylori and SIBO are found… By the time those things are treated, someone’s usually feeling so well that they’re not super compliant or they don’t have a high degree of desire to want to go on injectable vitamin B12 to lower those. So I think there’s some utility there; it’s just in the clinic I haven’t done a ton with it.

Now, there’s also markers—about five markers. These are the ASCA, ANCA, p-ANCA markers that are used to help identify inflammatory bowel disease and may be able to subtype Crohn’s versus ulcerative colitis and may aid in further investigation to help diagnose microscopic colitis. So I think there’s some utility for the IBD antibodies, especially if you’re trying to, again, subtype or diagnose one of the harder-to-diagnose types of microscopic colitis.

Then there’s the whole neurological suite, these anti-cerebellar antibodies, and I have seen some published in the research literature, showing that people will experience anti-cerebellar antibodies in various conditions. But again, I’m not sure how much they’re going to help guide treatment because these people are likely experiencing reactions to foods that are driving this or they have other conditions that may be driving this, these neurological symptoms, I mean.

I’m not sure how much the neurological antibodies offer above, one, just using their symptoms to guide “Am I histamine intolerant? Yes or no. Can I have gluten? Yes or no.” I’m not sure how much they would help. Again, I’m open there, but I don’t run these antibodies because I don’t know—if you just treat someone and get rid of their brain fog, their feeling of incoordination, what have you, ataxia, how much will the antibodies help you further that? I don’t know.

And if someone was non-responsive with those symptoms, what would those antibodies tell you to treat? If you come out of the model of this pseudo-fearmongering, you have to track these antibodies to know if you’re going gluten-free hard enough, which is the main party line… If you leave that model, I don’t know really where a lot of these things have their utility. There’s also rheumatoid arthritis, and you can make an argument for that to test to diagnose their condition. But how it changes treatment, again, I’m not really sure. So maybe as a way to monitor treatment, but using symptoms may suffice there also.

So that’s the, I guess, long, short of the antibody testing. I mainly use thyroid antibodies and screening for the anti-parietal cell antibodies, although it hasn’t been super fruitful in terms of using it, using the results, and also inflammatory bowel disease are the main ones I use. And more to come on that in the future.

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How to Become a Functional Medicine Practitioner?

So shifting over to the next question. This is a question I get a lot, and I’m happy to answer this question now so I don’t have to answer it again and I can just refer people to this. Let me just…

“Hi there. Thank you so much for your information. My question is what is required to be a functional medicine practitioner? I’m a holistic nutritionist, and I lean towards functional medicine. I only went to school for two years, but I’ve been practicing nutrition for over 15 years. And I’m always keeping up-to-date with research. I’m always looking for root cause when dealing with my clients. I mean, I feel that I’m a functional medicine practitioner, but what do I need in order to call myself that?”

So good question. Understandable question. Functional medicine is a newer field, so people are not sure what they have to do to be able to practice functional medicine. A few things here. Firstly, the term as far as I understand it is completely unregulated. So anyone could call themselves a functional medicine practitioner. So that’s great because there are some people who’ve done a lot of work and some people who haven’t done a lot of work, and if everyone gets to call themselves the same thing, it kind of really detracts from the potential credibility of that name, not really a credential, pseudo-credential.

And there is an academic program I believe at Western States is now offering a master’s in functional medicine—so that’s a step in the right direction. And I do hope, at some point, that there is a regulatory crackdown on this because I do not think it’s a good idea for someone who’s done years in an academic setting and also spent tens of thousands of dollars and gone through the rigors of proving that they can do this gets to have the same label as someone who did a weekend seminar. It’s not something that I think is helping the movement.

But there is also, I think, room for different types of providers in there. It’s not to say that if you’ve only done a weekend seminar that you shouldn’t be able to do this or help people, but we should start having a way to delineate along the spectrum of providers. So I’m going to come back to that in a second.

I want to answer the question of what you have to have—well, I actually already answered that. You have to have nothing really. And how to—I think what this more so hints at is—how to find your path in functional medicine and how to become a good, competent functional medicine provider. So the first thing I think that is helpful is to realize that there are different credentials. And those credentials will be a better or worse fit for different people. So you should first do a self-assessment to determine which credentials may best suit you.

So let’s go through some of the credentials. You have a minimal credential which would be a guru, a health coach, a short-term nutritional certification. You have a moderate credential which may be something like a conventional nutritionist that might go to school for two, there, four years, depending on how heavily they’re credentialed.

You have a heavier credential, and that would be something like a naturopathic physician or a doctor of chiropractic. And then, you have the heaviest credentials which would be something like an MD, a DO, a PA, an NP. And these are just proximations, so don’t send me hate mail if you’re a nutritionist with master’s of public health and a PhD in nutrition. Just a general gauge here. So bear with me a little bit.

So there are pros and cons on each side of this. So if you have the minimal credentials, the pro is that it’s easier to obtain and it’s faster to obtain. And you have essentially more freedom and less responsibility. You can kind of do whatever you want, and the FDA’s not going to come knocking on your door, within reason.

But there’s cons to the minimal credential. There’s less recognition. You’re less revered. There’s less potential for income. Usually your hourly rate, people won’t pay as much to see someone who has no credential as someone who has a credential. Usually you must have business skills. You also will have a very difficult time performing research. You can’t use insurance, and you’re not guaranteed a job. But again, you have control over what you do.

Now with the heavier credential, you have more recognition, more reverence. You have a higher potential for income. You don’t require the same business skills because oftentimes a structure is in place there for you. You can perform research. You can use insurance. But the cons of the heavier credential are there’s a longer schooling period. There’s much more cost associated with that. You have less freedom and more responsibility/liability. But again, back to the pro—kind of a pro/con—you’ll always have a job, but you may have less control over that job. A surgeon would be a good example of that. They’re always going to have work, but they’re not going to have a lot of control over their work.

So what do you do? What do you like? Do you like academics? Are you good with business and marketing? Do you want to be the leader/risk-taker? And careful, before you jump on that wagon wanting to be the leader, it sounds so great. But it comes with a lot of stress, a lot of financial risk, long hours, everything comes down on your shoulders, and sometimes you have to work around the clock. So it’s not all glory.

Or would you like to just show up, help people, and then go home. And you’re not the leader, but maybe you’re an NP that plugs into a successful clinic. You show up. You help people. You go home at night. And you don’t have to worry about systems breaking, hiring, firing, financial hardships. So it’s definitely important to assess all these things.

Do you want to be able to prescribe? Do you want to be able to perform research? Are you anti-medicine, moderate, or pro-medicine? How old are you? If you’re 55, getting your MD or your DO may not be a great move. Not to say you can’t, but you’re going to not have a lot of earning potential to earn back the money that… You’re looking at least probably $150,000 to do that. So you’re not going to have a long working span necessarily where you can earn that back.

Do you want people to be impressed with our credential? Or do you want to be your own boss? It sounds cool to say you’re a surgeon, but then it sucks sometimes to have to be called in on a Friday night. So all these things are things to really factor in. And I hope this is kind of making sense. But you can enter, you can plug in anywhere you want. It just depends on what is most important to you.

So once you’ve figured that out, where you want to be in the spectrum, you should learn what you didn’t learn in school. Because you’re not going to learn everything you need in school, so you have to then go learn what you haven’t learned in school. School gets you your ticket to ride, but learning really starts there in my opinion and starts when you end your schooling.

So I would start with free/cheap resources to get the lay of the land, to get the sense for what appeals to you. Listen to podcasts. Watch for YouTube videos. Read free articles online, and you’ll be exposed to a lot of different information. And you’ll start to get a sense for, “Man, all this methylation stuff sounds really appealing to me, and I love getting into all this mechanism and what have you. I want to go into this biochemistry.” Or you may say, “Digestive disorders really fascinate me, so I’m going to go in that direction.” Obviously, that’s the direction that I lean in.

Then, once you’ve got a lay of the land and you kind of understand what you like, then I would go to short courses and seminars where you’ll probably get better information, where you’ll have information that’s curated and also compressed, where a lot of information will be compressed into that short course or that seminar. But the cost will also be minimal. You’re maybe looking at $50 up through $350 to $550 for a seminar or a short course, mostly. That gives you a little bit more information.

And then the final point would be a full clinical training program. It might be a post-doc specialization. It might be a board certification or it might be something like the Kalish Institute or the Kresser Institute programs which are six months to I think a year in duration. All along the way, make sure to always be reading and make sure to be reading other people’s stuff but also directly from the research papers because that’s going to be important to give you a grounded perspective.

Also, adjust along the way, meaning that what you think today may change as you learn. And you may think that you want to be the boss, and then you get an experience of being in the boss’s shoes and you realize the grass isn’t always greener. This happens with a lot of new graduates. They think they can do everything, and then the world slaps them down. And they realize that, Yeah, maybe I’m not the person to be in the leadership role. And it’s important that you just make that assessment, because you don’t want to try to force yourself into a position that you’re not constitutionally-endowed to perform.

And when in doubt, I would aim as high as you can for the credentials because you’re better off being over-credentialed than under-credentialed in my opinion. So when in doubt, get yourself the most credentials that will give you the most ability. And if you’re over-educated, you’ve wasted some time and money, yes, but at least you’ll be able to do mostly whatever you want.

So, hopefully, that helps. It’s a great field, but it is very important that you determine where you should be in the field. And the thing that I see happen most often is people don’t want to do all the schooling, so they do schooling to bring them to the lesser end of the credential range. And this puts them in the position where they, in many cases, not in all cases but in many cases, have to have entrepreneurial skill and ability which they don’t have. And they really get their clock cleaned because they don’t have the ability to build a business.

So that’s really something to keep in mind. That’s one of the nicer things about plugging into the more conventional system. A lot of that is done for you. Or if you have a higher credential, there’s a better chance that you’ll be able to become part of someone else’s wheel that they’ve built. And that’s not a bad thing. I know there’s a little bit of a negative social stigma against that. But it is not for everyone to build something from scratch and take all the risks associated with that.

So it sounds cool. And when you hear about people who have done it and done it well, it’s easy to want to emulate that. But you also would do well to heed the warnings of people who’ve attempted that and failed because they were essentially given the constitution of a figure skater, and they’re trying to be a linebacker. And I don’t mean that in a derogatory sense, just purely you have to use your constitutional strengths and play to those rather than using your weaknesses.

For example, for me, I hate working for other people because I always feel like I find a better way to do things in a lot of cases. And that was always the thing that I struggled with, even being a lifeguard in high school. Just a quick way off topic, but we would always have a problem with the filter clogging. And we’d have to close the pool and then go…I believe the maintenance guy his name was Rick or Ricky. And we’d have to chase him down. And sometimes the pool would be closed for hours because of this filter issue.

And he essentially would back-flood the filter to unclog it and then everything would be fine. I’m sorry, it was to vacuum the pool now that I’m thinking about this. So in order to vacuum the pool, the filter has to work, and sometimes the filter would get clogged. So we wouldn’t be able to perform the maintenance on the pool before the pool opened, so we’d have a dirty pool. And then management would get irritated. And essentially, what I did was I said, “Ricky, can you just show me how to do this so we don’t have to chase you down?”

Because he may have been way out on the greens at this country club I worked at and doing something and he couldn’t get back to us for a day or for several hours. He showed me how to do this. And I thought, Great. Now instead of having to go through all this rigmarole, we can just solve the problem and move on. But the manager of the pool did not like that. And the backstory there is I think she was probably very insecure and didn’t like the fact that her subordinate made a better call than she did.

And that was one moment where I said, “Ok, if this is the way life is going to be where I’m going to solve a problem and my superior is going to essentially tell me I can’t use that solution because she didn’t think of it, then I’m not going to be able to work for somebody else.” And I was also ok with taking risk and working really hard, so it worked for me. But it’s important to do the self-assessment to help figure out where you should be.

Dr. Ruscio Resources

Hey, everyone, this is Dr. Ruscio. I quickly wanted to fill you in on the three main resources that are available to you in case you need help or would like to learn more. Of course, I see patients both via telemedicine, via Skype, and also at my physical practice in Walnut Creek, California.

There is of course my book, Healthy Gut Healthy You, which gives you what I think is one of the best self-help protocols for optimizing you gut health and of course understanding why your gut is so important and so massively impactful on your overall health.

And then finally, if you are a clinician trying to learn more about my functional medicine approach, there is The Future of Functional Medicine Review, which is a monthly newsletter. Which is a training tool to help sharpen clinical skills. All of the information for all three of these is available at the URL  drruscio.com/resources. That’s D-R-R-U-S-C-I-O. And in case you are on the go, that link is available in the description on all of your podcast players. Okay, back to the show.

Crohn’s Disease and Eczema Better When Eat Off Plan

All right. You probably got more than you wanted on that one, but here it is nonetheless. Another question here and this is about Crohn’s disease and eczema and diet. So here’s this one.

“Hi, Dr. Ruscio. My name’s Valerie, and I suffer from Crohn’s disease and atopic dermatitis, both of which are the same disease as I’ve now have a lack of defenses  in the skin and gut lining. And I’ve been experimenting with the SCD, AIP, and paleo, and also I’ve cut out a lot of other foods that aggravate my eczema like apples, kiwis, nuts, sesame, and others. I’ve had mixed results so far. I’ve been doing this for three years maybe. But what I’ve noticed is that whenever I’m on long business trips where I can’t really take care of what I’m eating except that I try to avoid gluten and dairy, sometimes my digestion seems to be actually better than when I am at home and try to focus on fiber and fermented foods and everything that’s supposed to be healthy. And now the other day I had this study in my RSS feed that where they had fed mice with induced Crohn’s disease a high-fat, low everything else diet and noticed that while microbial diversity decreased, the symptoms also decreased which got me thinking. And funny enough, on the same day, I heard you say on a podcast by Robb Wolf that your Crohn’s patients don’t react well to probiotics and the like and are better off with a low FODMAP diet I think. So I’ve switched to low FODMAP a couple of weeks ago because it made total sense to me. And I feel ok, I guess. Now, my question is though, does it make sense to combine SCD and low FODMAP? Or is maybe the low FODMAP diet what the SCD always intended to be because both have this idea to starve the bad bacteria, whatever that means? And my second question would be, I thought that fiber was the favorite food for bacteria so should I avoid that too? And if so, what would I be ending up eating then if not fiber and not carbohydrates? And finally, I wonder how all my eczema-inducing food sensitivities, none of which I have like IgE antibodies for, fit into the picture and if those maybe clear up once my gut heals, if that’s even possible. Sorry for the longish question and thanks for hearing me out.”

All right. So there is another one, and I look at this—and it’s a great question by the way. And it’s not an uncommon observation for people to have, which is the “gut gurus” tell me to eat a bunch of fiber. I saw something on PBS with Dr. So-and-so telling me how great fiber was and blah, blah, blah, blah, blah. And I go eat lots of fiber, and I feel poorly. And this is because when you look at observational and mechanism data only, you have a very high probability of making a recommendation that’s off the mark.

And so, I look at this on three levels. Level one: Dietary changes should consist of the standard complementary and alternative medicine recommendations, or depending on what circle you run in, but a paleo diet, great place to start. But that may not work because, for some people, that may be too much fiber and too much roughage and too much FODMAP. So it definitely can be a very health-promoting diet but not for everyone. But it’s a place to start.

Now, going a little further in that direction, there’s the autoimmune paleo diet which restricts other foods that have inflammatory potential. And there has been one published trial showing great benefit in inflammatory bowel disease, using the autoimmune paleo diet. So that can be helpful, but it won’t be helpful for everyone. And in fact, some people actually feel a little bit worse on the paleo diet.

And this is where we may want to steer in a little bit of a different direction to a low FODMAP diet which starts removing some fibrous foods, yes, but mainly foods that are high in prebiotics. Oftentimes, these are similar. High fiber foods are also high prebiotic foods. And it sounds like you’re already experiencing some benefit from that, and that has been also shown in the published literature.

And, yes, there’s also a diet where—and this was created by Allison Siebecker—that’s a combination of the low FODMAP diet plus the SCD diet. So that takes you a little further in the direction of a low fermentation diet, that is the low FODMAP plus SCD diet.

And in addition to all this, you may want to consider probiotics and enzymes. So it sounds like you did not respond well to probiotics. Not everyone does. Enzymes may or may not be helpful. I’m a little bit more gun-shy with enzymes in some cases of Crohn’s or ulcerative colitis because sometimes they may cause irritation. But that’s our level one. And my book will walk you through this.

So it includes recommendations for trials of these diets, including the low FODMAP plus SCD diet which you asked about and recommendations regarding fiber and also dispels myths regarding fiber, meaning that if you eat a low fiber diet, will it cause things like colorectal cancer? And the evidence does not support that. So that’s level one.

Level two. If you haven’t optimally responded to level one, then you may need to sort out dysbiosis. And so, the book will walk you through this also, and this includes various interventions that nudge dysbiosis, including herbal antimicrobials and even, for tougher cases, an elemental diet which is a liquid meal replacement diet which is, by the way, very low fiber, low residue. Almost no fiber, actually.

And yes, to your question, fiber is not always good. You will see some people improve from higher fiber diets. And no matter what diet you eat, you’ll get some fiber in. But you may need to focus more on having less fiber in your diet and less fermentable sources of fiber in your diet. And we lay out a few of those. There’s another diet to potentially consider. It’s called a LOFFLEX diet which is the low-fat fiber and limited exclusion diet. So it essentially is a low-fat, low-fiber, exclusion diet that cuts out some common allergens. So it’s not very dissimilar to what you could figure out by going through the protocol in my book, as we dip through some of these different diets and try to determine what diet might be best for you.

And to your question, yes, food intolerances should get much better as your gut heals. And this is because, one, your gut produces enzymes that’s needed to digest and absorb some of these foods. And when your gut is damaged, you secrete less of those enzymes. Two, dysbiosis in your gut can cause some of these reactions. And as you heal the dysbiosis, you’ll then, therefore, have less reactions. And as you address both of those things, the immune system in your gut should also calm down. And you should be less reactive as you have improved all these things and your immune system is a little bit more harmonious.

So, yes, you should be far more tolerant to foods. And I see that all the time in the clinic. And then, level three would be considering other dietary changes, potentially low histamine, potentially low sulfur. Heidi Turner was on recently talking about both of these. Potentially low oxalate. These are a little bit more—I don’t want to say fringe. I guess they are fringe. They’re less common, but other things to consider. And/or other immunomodulatory treatments like low-dose naltrexone, over-the-counter antihistamines as Dr. Afrin laid out when he was interviewed about mast cell activation syndrome and histamine intolerance. Potentially considering helminth therapy or even FMT, fecal microbiota transplant therapy.

So you’re definitely on the right track. And if you’re already responding from a low FODMAP diet, that bodes very well for how far down the track you’re going to have to ride this train. And I think you’ll probably do pretty well with just the changes you’ve made. But if not, grab a copy of my book. It’ll walk you through how to implement those other factors that I discussed.

Hashimoto’s

So transitioning off of the audio questions now to some written questions. This is from the Open Skye Fitness Facebook group. And someone asked,

“I know with Hashimoto’s you’re supposed to follow a specific autoimmune paleo diet. But what if you’ve had your thyroid taken out? Does that make any difference?”

Well, I wouldn’t agree that you need to follow the autoimmune paleo diet if you have Hashimoto’s.

Now, it may certainly help you. But it’s a misconception to think that you have to follow an autoimmune paleo diet forever. It’s a tool that’s used to help you identify what food intolerances you may have. So you can use it in application of a few weeks, maybe even a few months, although I don’t think most people will need to go nearly that long. I think four weeks is a decent gauge. And then you can reintroduce foods and simply eat more of what you notice agrees with you and don’t eat much of what you notice does not agree with you.

And in terms of there being a study, there is no study anywhere that I know of—and I’ve looked fairly closely on this—that says that people who have thyroid autoimmunity need to be on an autoimmune paleo diet. Diet can certainly help, and we’ve even in this podcast discussed the one study that found an improvement in thyroid autoimmunity by reducing some foods Trusted SourcePubMedGo to source. But that wasn’t as restrictive as an autoimmune paleo diet.

So simple dietary changes can make a large difference. And again, in that study, the one I mentioned earlier that led to a 40-44% improvement in thyroid autoimmunity, they essentially avoided eggs, legumes, dairy products, bread, pasta, fruits, and rice. So not nearly as restrictive as an autoimmune paleo diet and there was a good outcome.

Again, you can use the autoimmune paleo diet as a tool to help you eliminate and then reintroduce and find the foods that will work for you. So essentially, avoid potential allergens and do that irrespective of if you have had your thyroid out or you still have your thyroid gland. Because it’s not to say that the thyroid is the main gland that reacts. You eat a food that’s inflammatory and irritating to your body and the only thing that’s impacted is your thyroid.

Typically, we see multiple symptoms and, oftentimes, multiple systems of the body produce symptoms when one eats a food that doesn’t react well with them. And as an example, let’s say you don’t do well on dairy. You may get bloated, and you may also notice that you’re a little bit irritable. So the thyroid may not even be directly involved. Or you may also notice that your thyroid antibodies do improve when you go off dairy. But your bloating and your irritability also go away.

So, yes, you should avoid foods that don’t agree with you irrespective of if you have had your thyroid removed or even had your thyroid radioactively ablated. Okay, moving on.

Leaky Gut and SIBO

“What diet do you recommend for someone with leaky gut and SIBO with constipation?”

Well, again, paleo, a good place to start. Not the only place to start but a good place to start. And then, again, potentially that same dietary hierarchy I outlined a moment ago would be the same thing to consider. And, again, the book goes into detail on this. But paleo, then maybe consider autoimmune paleo if you don’t see optimum response.

Now, low FODMAP and/or low FODMAP plus SCD may help, but it can cause constipation in some people. And I think—well, I don’t think. Here’s what we know. We know that fiber and prebiotics can help with constipation. So it would make sense that a diet that’s lower in fiber and specifically lower in prebiotics may lead to a flaring or a worsening of constipation.

So you do see this sometimes in people that have constipation plus other IBS symptoms, like abdominal pain or bloating. That the abdominal pain and the bloating go away, but someone becomes more constipated. So you may want to experiment with increasing your overall carb intake and trying to eat allowable carbs.

Sometimes people end up going too low carb and too low fiber when they go low FODMAP. And they just stop eating generally the class of vegetables and fruits because many of the ones that they were eating before are not allowed on the list, so they don’t replace them with others. So you may just want to make sure you’re getting adequate amount of vegetables and fruits in as you were previously. And you may even want to experiment with bringing grains into your diet because sometimes people also cut out all the grains, and they find that when they add grains back in, they actually see some regularity ensue because of that.

Now, you may also want to try a supplemental fiber because that may help with the constipation. And again, in the book, we give you guidelines in terms of when to try this and how to try this. But a mostly soluble fiber is the best way to go. You may also want to treat SIBO because SIBO might be the underlying cause of that. You may also want to try a probiotic. Probiotics can help with constipation. Magnesium and vitamin C are two fairly inexpensive and very helpful laxatives that can also be very helpful here. Another thing to consider.

And peppermint oil may also be helpful. It can help with some of the IBS symptoms plus constipation. So there’s a number of things that you can do. In terms of diet, I laid out some considerations there for you, but also remember if diet does not adequately address this, there’s other things to think about also. All right.

Thyroid Antibodies

And coming to our last question here. Megan asks,

“My thyroid antibodies were 39, so slightly below the normal range. My doctor said they really shouldn’t be above zero. I’m having them re-tested, but I’m worried about what could be going on. Is there a reason why you would have antibodies present? Is it normal? Thanks in advance.”

Okay, so you probably know what I’m going to say if you’ve been following the podcast for any period of time which is for someone to be in the low hundreds is probably okay. To the best available evidence we have to date, it seems that if your thyroid antibodies, specifically your TPO antibodies, are in the low hundreds, you’re probably okay. If you’re over 500, you have moderate risk. And if you’re over 1000, you have the greatest risk.

So I strongly disagree with what your doctor is saying. And I had a thyroid antibody profile done a number of years ago. And I think my TPO came back at 18. And I remember being very distraught at thinking I had an autoimmune condition because the moron doctor I was working with told me that “it looks like you probably have Hashimoto’s.” And I just can’t tell you how bad I think that advice was.

This is to a pointed criticism at the doctor. I’m assuming the doctor was learning this from somewhere, the doctor wasn’t just cooking this up. So it’s the people educating the doctors that are really at fault. And even they probably have good intentions with this but don’t understand the amount of damage this does to people psychologically.

So if you have some antibodies present, that’s not a bad thing. Dr. Nick Hedberg was one of the first ones to turn me onto a paper that essentially showcased the positive housekeeping function that antibodies have. Antibodies are used to clean up dead cells, deranged cells, and generally perform housekeeping in the body. So you need some antibodies to clean shop. That’s important.

So to have a low level, even a positive low-level antibodies in the low hundreds, it’s not abnormal. Now, that may be indicative—having a positive score in the low hundreds may be indicative of Hashimoto’s, yes. But that would be Hashimoto’s with a very good prognosis, compared to someone with TPO antibodies above 1000. It’s also Hashimoto’s but Hashimoto’s with not as good of a prognosis.

So be careful with thyroid alarmists. And again, on any of these things, I am open to changing my opinion. If someone were to show me a study showing that when someone has TPO antibodies of 39, they’re at the same risk as someone that has TPO antibodies of 1039, I will change my opinion. But unfortunately—or I guess fortunately, in this case—what the evidence shows is that for those with antibodies above 500, they have a moderate risk of progression of the disease and that the initial level of elevation of antibodies correlates with the prognosis.

Again, usually being above 500, moderate. And my observation being above 1000 being higher as compared to when people have responded and are feeling much better, we oftentimes see those antibodies in the low hundreds. So again, for you to be at 39 is not something I would be concerned about. Now, does that mean that you shouldn’t improve your diet and maybe use some vitamin D, what have you? Yes, you should still do those things.

But I would be careful not to stay on this thyroid merry-go-round where you’re always trying to drive your antibodies down to zero because you’ll likely never get anywhere with that approach. You’ll likely feel a lot better if you follow I’m assuming some of the prudent recommendations your clinician may make which is basic diet and lifestyle advice. Yes, all for it. But be careful with going too far there because, unfortunately, this is one area that’s very excessive in functional medicine and I think is doing a fair amount of disservice to patients.

Episode Wrap-up

All right, guys. I’m starving. I’ve got to go eat. There’s another episode of the listener questions. Thanks for your questions and keep them coming.

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.

Discussion

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!

20 thoughts on “Listener Questions: Tests for Autoimmunity, How to Become a Functional Medicine Practitioner, Thyroid Antibodies & Eating Worse but Feeling Better

  1. >>by people that like teaching stuff but aren’t really practicing clinicians anymore

    I wonder who specifically this might be?

  2. >>by people that like teaching stuff but aren’t really practicing clinicians anymore

    I wonder who specifically this might be?

  3. I just read the transcript for today’s questions. Would you please explain what you mean about TPO antibodies over 1000 being a high risk and over 500 being moderate risk?
    Last fall mine were over 2500. February’s test they were in the 900’s. I’m back on my B vitamins, Vit D and starting a new multi Vit to get them down further. I think mine are related to my B vits. If that’s even a thing?
    But my doc hasn’t told me if any “concern” or “risk” with them that high. Please explain?
    Thank you for being a voice of reason, clinical experience, and science in this crazy autoimmune/Functional Medicine world.

    Sincerely,
    Gayle

  4. I just read the transcript for today’s questions. Would you please explain what you mean about TPO antibodies over 1000 being a high risk and over 500 being moderate risk?
    Last fall mine were over 2500. February’s test they were in the 900’s. I’m back on my B vitamins, Vit D and starting a new multi Vit to get them down further. I think mine are related to my B vits. If that’s even a thing?
    But my doc hasn’t told me if any “concern” or “risk” with them that high. Please explain?
    Thank you for being a voice of reason, clinical experience, and science in this crazy autoimmune/Functional Medicine world.

    Sincerely,
    Gayle

  5. Hi Dr. Ruscio. I found this podcsst very interesting. I have been on a semi strict Paleo diet for 5yrs. The last two years, my body aches and pains have been resurfacing and I have gained all the weight back that i kept off for the first couple of years. I eat no grains, dairy, nuts, sugar and i exercise, So the weight gain, hair loss, which I forgot to mention, is really, really bad now, and aches are very disheartening to feel coming back. To replace the lack of fiber I’m not getting, I’ve been taking organic, raw flax with chia about 15 grams plus all the veggies i eat. I added the fiber as advised by my doc because of colon polyps. I’m wondering if SIBO is causing these problems. What is your suggesting for moving ahead? And if I need to cut out the fiber, where do I get it for colon health?

    1. Hi Debbie,
      There is a lot you could do. I would start with dietary experiments, then consider gut support, finally consider treating dysbiosis. My book will walk you through exactly how to do this. I will also speak in detail in the book about fiber and colon health, a whole chapter is dedicated to this.

  6. Hi Dr. Ruscio. I found this podcsst very interesting. I have been on a semi strict Paleo diet for 5yrs. The last two years, my body aches and pains have been resurfacing and I have gained all the weight back that i kept off for the first couple of years. I eat no grains, dairy, nuts, sugar and i exercise, So the weight gain, hair loss, which I forgot to mention, is really, really bad now, and aches are very disheartening to feel coming back. To replace the lack of fiber I’m not getting, I’ve been taking organic, raw flax with chia about 15 grams plus all the veggies i eat. I added the fiber as advised by my doc because of colon polyps. I’m wondering if SIBO is causing these problems. What is your suggesting for moving ahead? And if I need to cut out the fiber, where do I get it for colon health?

    1. Hi Debbie,
      There is a lot you could do. I would start with dietary experiments, then consider gut support, finally consider treating dysbiosis. My book will walk you through exactly how to do this. I will also speak in detail in the book about fiber and colon health, a whole chapter is dedicated to this.

  7. Hi Dr. Ruscio,

    I had a question about a recent study and news story that has come up in the last few days. It appearently found that the “root cause” for autoimmunity is the bacterium Enterococcus gallinarum, which migrates outside of the gut and leads to auto antibodies in certain tissues. They report that vaccines and treatments directed at the bacteria helped patients with autoimmunity. As a gut specialist, what is your take on this?

    No need to read this anything after this aloud if you answer this on the podcast, but as an aside, I’ve listened to a previous podcast of yours on the subject of autoimmunity with a known scholar in the area. He spoke about leaky gut and food allergies/intolerances being the main trigger of autoimmunity, which takes hold based on your genetic predisposition. This in mind, could the bacterium have another function related to underlying inflammation? Do you think it is truly the “root cause”, or a signal/response by the body for other issues that are more related to lifestyle, such as leaky gut and diet?

    Thank you, and I love your podcast!

    1. I’d like to see this study, I am assuming the study had a very narrow finding that is not as broadly applicable. Autoimmunity is multi-factorial, which includes gut health, and bacteria but is not limited to those. Hope this helps!

  8. Hi Dr. Ruscio,

    I had a question about a recent study and news story that has come up in the last few days. It appearently found that the “root cause” for autoimmunity is the bacterium Enterococcus gallinarum, which migrates outside of the gut and leads to auto antibodies in certain tissues. They report that vaccines and treatments directed at the bacteria helped patients with autoimmunity. As a gut specialist, what is your take on this?

    No need to read this anything after this aloud if you answer this on the podcast, but as an aside, I’ve listened to a previous podcast of yours on the subject of autoimmunity with a known scholar in the area. He spoke about leaky gut and food allergies/intolerances being the main trigger of autoimmunity, which takes hold based on your genetic predisposition. This in mind, could the bacterium have another function related to underlying inflammation? Do you think it is truly the “root cause”, or a signal/response by the body for other issues that are more related to lifestyle, such as leaky gut and diet?

    Thank you, and I love your podcast!

    1. I’d like to see this study, I am assuming the study had a very narrow finding that is not as broadly applicable. Autoimmunity is multi-factorial, which includes gut health, and bacteria but is not limited to those. Hope this helps!

  9. Hi Dr. Ruscio,

    I found this post when looking for your recommendations on functional medicine training. I’m a PA and am considering becoming IFM certified. I know there are other programs as well (Kresser, Kalish) and am wondering if you have any recommendations on which program you most recommend? I greatly appreciate your middle-of-the-road approach and hope to not get tied up into erroneous dogma.

  10. Hi Dr. Ruscio,

    I found this post when looking for your recommendations on functional medicine training. I’m a PA and am considering becoming IFM certified. I know there are other programs as well (Kresser, Kalish) and am wondering if you have any recommendations on which program you most recommend? I greatly appreciate your middle-of-the-road approach and hope to not get tied up into erroneous dogma.

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