Insights: Pancreatic Insufficiency, Limbic Retraining and More

Intro:

Welcome to Dr. Ruscio radio, providing practical and science-based solutions to feeling your best. To stay up to date on the latest topics as well as all of our prior episodes, make sure to subscribe in your podcast player. For weekly updates visit DrRuscio.com. The following discussion is for educational purposes only and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking with your doctor. Now let’s head to the show.

Dr. Michael Ruscio:

Hey everyone. Welcome back to Dr. Ruscio radio. This is Dr. Ruscio. Today let’s discuss a few things. First, a review of exocrine pancreatic insufficiency, an imbalance or lack of secretion of enzymes that may lead to a number of GI symptoms. We’ll also go over a case study on how making the recommendation for limbic retraining therapy at the right time can lead to substantial improvements and ostensibly prevent someone from going down the rabbit hole of functional medicine, testing, and intervention. Finally, we’ll go into a study on the significance of predictive antibodies in thyroid disease. There are some juicy details in here that sadly showcase if someone is looking to mislead you via how they report numbers, that can be done quite easily. We will frame this example showing how a given number can be presented in different ways, eliciting different responses. One way, your jaw drops to the floor in fear. Described another way, you don’t have nearly the same fear reaction.

DrMR:

But unfortunately, sometimes when people are trying to make their case, they fall in love with a hypothesis, and they’re not fettered by, in this case what we could term loosely, the effect size or the magnitude of the impact or lack of impact. Said another way, if someone is all about thyroid causing all disease, they may not do a good job of fact checking, or restraining their enthusiasm by saying there is an association, but the magnitude of that association is not supremely substantial. We will jump into that here in a second. Also, just to remind you, the month of April, we are running a promotion for our clinicians’ newsletter, the Future of Functional Medicine Review. It is $1 for your first month of all access, which includes years of back issues, case studies and research reviews, which have really led to how I practice current day. Reading these studies, taking the pearls from those studies, incorporating those into our clinical model, embodying them and exemplifying them in a case study, reflecting back on the case studies, learning from them. This is really the underlying data set that has led to the clinic and the clinical practice. It’s something I’m quite proud of and I do hope you’ll join.

Pancreatic Insufficiency

DrMR:

With that, let’s go to a review of pancreatic insufficiency. This appeared in the November, 2020 issue. Let’s go into some of the details. What is EPI? Exocrine Pancreatic Insufficiency. It’s a reduced production of pancreatic enzymes. It affects roughly 0.005% of the population. So not highly prevalent. Symptoms include gas, bloating, pain, diarrhea, and potential weight loss. The treatment is quite straightforward. A titration of pancreatic enzymes. An important clarifying note on these last two points. Even though this condition affects 0.005% of the population, it seems to me that more than that are testing positive. So we’re going to cover a few of those details behind why some patients may have a false elevation so we can distinguish true cases from false positive cases.

DrMR:

Regarding the enzymes themselves, this would be just pancreatic enzymes, not a multi ingredient formula, which can be helpful and do have their merit, their time, and their place. But if we ramp and titrate up the dose of a multi ingredient formula, meaning HCL plus enzymes plus bile, the bile may flare someone’s diarrhea, the HCL may flare reflux or burning. So for this condition, specificity does matter with the therapeutic. Now what causes this? This is predominantly caused by lifestyle factors, namely alcohol use and smoking. About 20% of cases remain idiopathic, meaning there’s no known cause. Autoimmunity is also one underlying cause. There are also rare causes such as pancreatic cancer or cystic fibrosis, and it is important to delineate that those causes are rare. Again, the symptoms are all too common, gas, bloating, abdominal pain, greasy or floating stools is one potential indicator, as is diarrhea and looser stools, as is foul smelling stools.

DrMR:

Remember that the underlying cause of this, perhaps in the majority of cases, is either lifestyle or unknown and the risk for something like pancreatic cancer or cystic fibrosis is fairly minimal. So of this 0.005% of the population, only 0.02 will have pancreatic cancer. Only 0.009 will have cystic fibrosis. So a referral to a conventional gastroenterologist, or if you are a conventional GI, you’re probably going to have this in your differential. There’s the door for the referral and the likelihood that a referral will find X, Y, or Z. There’s another thread here that is important. Diarrhea can cause a false positive. So this is kind of a conundrum. One of the symptoms of this underlying insufficiency is diarrhea, but the diarrhea can also cause a false positive to diagnose the condition.

DrMR:

It’s kind of this circular diagnostic logic, which can be, in some cases, a bit challenging to parse out. Another reason why lab testing is one third, one fourth of the data needed to make a decision. This is also why various papers in PubMed and I believe also in the position statement from Up-To-Date quotes the following “clinical suspicion is often sufficient to make the diagnosis without formal fecal fat measurements in the proper clinical context with titration of pancreatic enzymes to improve symptoms”. Said more simply, if someone has these symptoms, we can administer pancreatic enzymes in a dose titration. If there is a response to that, then that may be adequate to diagnose.

DrMR:

Now again, diarrhea may cause these false positives. There’s another layer here that we should look at. This is more my observation, and I’m trying to do a better job of delineating that this is just one example and it should not be conflated to be the rule, but SIBO, small intestinal bacterial overgrowth is also known to cause diarrhea and it can also deconjugate bile, which interferes with fat digestion and it can cause malabsorption. So if we’re going to put these items into a framework or into a hierarchy, like I often advocate for, we would put the treatment of dysbiosis or SIBO first or in an earlier position in the hierarchy than treatment of pancreatic insufficiency. Now sure there are times when you can violate that. Let’s say someone has been through three rounds of Rifaximin with no response, or oodles of probiotics with no response and a few rounds of herbal antimicrobials with no response.

DrMR:

Then SIBO is less likely. This is where we kind of personalize, and this is why in the new patient intake process asking the right questions is so critically important. Knowing that someone’s been through three rounds of Rifaximin, numerous probiotics, a couple rounds of antimicrobials and seeing no response tells us that there is a very low probability that there is underlying dysbiosis or overgrowth. So that’s where using the EPI treatment of enzymes earlier would make sense. Or you could say this another way. You’ve already satisfied that facet of the hierarchy. Now the next step in the hierarchy is really going here. In terms of how you test this LabCorp, Quest, Lab Tests Online, Mayo Clinic, Doctors Data, Diagnostic Solutions and Genova, conventional and functional labs all offer this. Sometimes the functional labs, due to trying to be more sensitive in what they find, produce false positives.

DrMR:

That does not seem to be the case here. This is just my opinion. Also in discussion with other clinicians, including other clinicians at the center, no one seems to be suspicious that one lab versus another, meaning conventional versus functional, is more prone to false positives. It is important to keep in mind, and this actually is a clinical pearl, you do not routinely see someone always coming back positive for this suppressed elastase. You don’t often see, if someone’s had more than one test for pancreatic insufficiency, you won’t often see test one, test two and test three are all positive. Perhaps this is because some of the cases that I’m seeing are more borderline. So they’ll kind of weave in and out of positive, normal, positive, normal. That’s possible.

DrMR:

It also may have to do with how someone’s bowels are fluctuating. So the labs, whether it’s conventional or functional, don’t seem to make much of a difference. However, you won’t often see high level of consistency amongst testing. There’s been a couple of patients that have frustrated me because I wanted to try to better quantify this. It’s just a good reminder for patients that while it’s easy to think that labs are totally conclusive, have some patience with your doctor because there’s a lot that needs to be woven together here to make a decision. And, um, you know, I, I think most doctors who are at least kind of following the work here that we’re doing are on the same page of being minimal with testing. However, if someone wants to try to firm up, let’s say pancreatic insufficiency, humor them in repeating that test.

DrMR:

Let’s say you had it a year ago. I understand where the patient says, well, I had that a year ago, why are we doing it again? It’s because we’re trying to see, is there more of the consistency for this finding or less of a consistency? Now, all that being said, there is also the option of just trying the enzymes there’s pros and cons to going fully empirical or going fully objective. I like a blend of the two, which is why I say one third to one fourth of the data needed to make a clinical decision is lab tests. So that, that doesn’t mean fully empiric, no testing, but it doesn’t mean just treating the labs which would be objective.

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DrMR:

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Treating with Enzymes

DrMR:

There are a few different options in terms of the enzyme that you use. I believe it’s Vital Nutrients has an enzyme that I like just called pancreatic enzymes. You can take anywhere from two to eight capsules per meal. The dose titration is take two capsules per meal, give that a day or two, reevaluate symptoms. I typically have patients instead of going from two to three to four, I have them double. I shouldn’t say doubling, but an increase by two capsules at a time with the over-the-counter enzyme. So two per meal for a couple of days, then four per meal for a couple of days. Whatever point they notice a substantial improvement in their symptoms, they stop at that dose and that is their titrated ideal dose, stopping at a ceiling of eight. Now there’s also Creon that can be used at one to three capsules per meal.

DrMR:

Creon prescription, a little more potent, little less of a dose needed. A few closing thoughts from this write-up. I’m just going through this write up from the FFMR and trying to kind of pull out a few of the choice comments or bullets. One thing I think providers should be cognizant of is to frame this diagnosis correctly. If someone goes online and they start reading about this, they may work themselves up into quite a worried position, looking up cystic fibrosis or pancreatic cancer. Unfortunately it doesn’t seem that some of the medical and health educational websites do a good job of assigning a probability percentage, so people just see cancer and they’re a little bit scared. Framing this correctly I think is really important. Be mindful of false positives. Don’t over interpret from the test.

DrMR:

And use those other two or three of the data points needed to comfortably vector this diagnosis. Consider referrals for Frank cases. For someone who’s gone through referencing the Healthy Gut, Healthy You program and the algorithm in that book as kind of a loose framework, we also use it in the clinic in a bit more robust way. But you start with your diet and lifestyle basics. By the way, what’s one of the causes of pancreatic insufficiency, it’s lifestyle. Could diarrhea because by a dietary trigger? Yes. It may sound a bit trite at this point, but diet and lifestyle will be your step one, then gentle and supportive interventions like probiotics would be step two, then three, perhaps consider dysbiosis or overgrowth.

DrMR:

Then after that is now when I really try to hone in more on something like digestive insufficiency. Now in Healthy Gut, Healthy You, I recommend a lower dose of a multi ingredient acid enzyme in bile. That’s a good general hedge. In the clinic, since I’m able to be a little bit more precise, I typically wait on a trial on either HCL or enzymes until about phase four. After we’ve gone through 1) diet and lifestyle, 2) supportive interventions, like probiotics, 3) antimicrobial or antibiotic therapy or elemental dieting, and then 4) is when you’ve kind of cleared these other factors out and now you can get a better empiric read on those that HCL helps with the symptoms in question. Do enzymes help with the symptoms in question. That is from the Future of Functional Medicine Review November, 2020.

Limbic Retraining

DrMR:

Now let’s move on to this case study. It appears in the January, 2021 Future of Functional Medicine Review. It’s entitled Brain Gut Connection: An example of When Limbic Retraining Can Yield Substantial Improvements. The patient here was Rebecca. She is a 38 year old female, previous diagnosis of pan ulcerative colitis, on no medications. Chief complaints: urgent diarrhea (4-16 per day). Could this be EPI? Bloody stools on occasion and fatigue that was intermittent. Other symptoms, remember I add the section called other symptoms where you have someone’s primary complaints, but in their paperwork, I’ll also be looking for other symptoms that I feel could change their care in a meaningful way that they may not be complaining about. So in this case, I’m assigning her a moderate severity of female hormone imbalances based on the severity of the pain and cramps, PMS and heavy flow that she has checked off on her paperwork.

DrMR:

So that’s something I’m going to have built into my differential and be considering at every successive follow up visit and considering if or when some type of intervention to help coax the female hormones into balance will be warranted. At her first visit, the history exam visit, there were a few remarks. Rebecca is a 38 year old female on a very restrictive diet, quite fearful and in need of support and reframing. A few notes. Rebecca’s paperwork is partially revealing of two things, 1) the waste in functional medicine, and 2) subtle early indicators of limbic imbalance. So here’s a few examples. Using STEM cell therapy for someone with IBD (inflammatory bowel disease) instead of recommending something like an elemental diet. So STEM cells, to my knowledge have zero evidence for IBD, not to say that they’ve been disproven, but there is a plethora of evidence for an elemental diet in IBD.

DrMR:

This is extremely wasteful and frustrating that someone would undergo, I’m assuming a few thousand dollars at least for the STEM cell therapy, and they haven’t even done an elemental diet for their IBD. Point 2: We ask patients to give us a concise timeline of their health history. I screenshot this and what you can see is that it’s very long and the level of detail and worry that comes through is fairly apparent. Food appears to be blamed. If you could see this, you would see that I actually included a screenshot. Her name has been removed so we’re protecting her identity, but you can actually read what this looks like. Hopefully this helps clinicians have a better ability to identify this and put in their differential, the need for limbic retraining, so we can get this person the support that they need.

DrMR:

So my notes show that on her answers, food appears to be blamed a few times for how she is feeling. She has done paleo, SCD (the specific carbohydrate diet), low FODMAP, even low FODMAP with SCD. She does not eat poorly, but seems to have an unrealistic standard and a propensity to blame food. She is motivated, perhaps scared enough to spend what I’m assuming was a lot of money on STEM cells. So with all this in mind, I will have limbic imbalances in my DDX and be listening very carefully during our initial exam and history. Remember, all this analysis is done before I even walk in, or anyone at the center walks in to see a patient. In my opinion, you should have as much information, and the patients that have had a chance to give you as much information as possible. On their own, without someone right there, asking them a question and them having to command all that information on the spot.

DrMR:

Then that’s organized and put into a differential. Now, from what I know, there’s a fairly high probability that limbic imbalances could be a problem. Let’s just see what they are like, how they present, how they speak in their exam. That usually either reaffirms or rules that out. So I’ll be listening carefully on the one hand, but also, and this is in the best interest of the patient, as a clinician, you want to be careful not to allow this person to vent or to monologue. This is one way in which this patient type makes it harder for the clinician.

DrMR:

I make a note here that as a clinician, it’s our responsibility to focus them and not allow them to waste the time that we have together, just because it feels good for them to vent. So it took me a little while to fully wrap my head around this. We don’t want to be curt. We want to be supportive and empathetic. We want to be kind and supportive, but firm and refocus them. One of the things I often remind my patients in this situation is this is a branch question, and I’m trying to focus this down to the root cause. I oftentimes paint the analogy of a tree with all these branches that’s stemmed down to a trunk. It’s that trunk or that root that we’re trying to identify. So it’s not an issue of dismissing the questions, but it’s rather focusing them on the questions that I need to answer so as to be able to help them. My apologies. I’m just getting through these notes, trying to pull out everything relevant for you guys, but also not make this to detailed and laborious.

DrMR:

So here’s an interesting note from the patient. “I worry that the inflammation is just depleting me overall and sucking any amount of life from every part of me”. So it’s kind of a dark statement, but it also reflects how much and the degree of emotionality associated with this. So all these things help to paint the picture of where this person is. Learning to recognize this early can really help you. Let’s say you do a few tests, the tests produce some findings, but this person is so reactive and so fearful about reactions that any little hint of turbulence causes them to not follow through on your recommendations. Then you follow up six weeks later and they say, well, I tried intervention X for three days, feel like I got a little bit bloated, got nervous, went on the internet read about XYZ.

DrMR:

It said that you shouldn’t do this if you have that. So I stopped. It’s very frustrating on the clinician’s behalf of that point, because you’re trying to run a mini experiment. When you don’t have follow through on the experiment, it can be challenging. In this case, identifying the limbic imbalanced early can help the clinician make the recommendation of limbic retraining earlier so that they can better follow through on subsequent therapeutics. Getting to the bottom line here. Recommendations. A few kind of rationale notes here before the recommendation. We will consider testing at a later date. So regarding testing, none. Why? We already know the primary diagnosis, IBD. Could there be SIBO? Yes. Would this demonstrably impact how I treated her right now? Probably not. Would the testing delay her initiation of treatment? Yes.

DrMR:

Would the test results likely stress Rebecca? Yes. So in short, we need to quell her symptoms including emotionality quickly and not further her worry or fear. So our recommendations: Start on an elemental diet (you can see the exact clinical recommendations in the write-up), and also start on either the standard low FODMAP diet or the low flex diet. The low flex diet is the low fiber and fat diet, which can be helpful, especially helpful in some IBD cases. We put her on a vitamin D, a curcumin, a fish oil. She was on previous probiotics. So as to impart minimal change, I just had her continue with the previous probiotics she was on. The main thrust here was “please start on the DNRS limbic retraining program”. I made a note next to that for her “very important” and follow up in four weeks.

DrMR:

Some more rationale here, we see obvious signals from her history that elemental dieting could help due to the fact that it’s one of the things that she hadn’t tried and we know is very helpful in this cohort. She had also reported improvements from, from intermittent fasting prior. She had also reported that low FODMAP might have been the best of all her prior diets. This is one of the question to be also now have incorporated into our paperwork again, so that clinicians at the center really walk into that initial visit very well primed. ut of all the diets you’ve tried, which one seems to have been the best. Now, sometimes people don’t know, but in this case low FODMAP was helpful. She also remarked that most vegetables flared her. So a lower FODMAP combined with lower vegetable intake is somewhat embodied by either the low flex diet or the standard low FODMAP diet, which allows more grains.

DrMR:

We also use some basic inflammatory support, but the real thrust here is the DNRS. We follow up with her about four weeks later, and she reported that the DNRS /limbic retraining was hugely helpful for her mood, her stress and her gut. Reporting included improved urgency, bloody stools, fatigue, mood, and the female hormone symptom of spotting. Nothing was the same. Nothing was worse. In my impression here, diets were a slight help, but DNRS was the real game changer. All chief complaints have improved, and most of them markedly improved. Today we will continue the plan. Add in probiotics to give her a little bit more structure. Remember we carried forward her prior probiotics. So now we’re going to start fitting her into the clinical probiotic protocol that we use at the office, and then follow up again in two to three months.

DrMR:

So we started her on the lacto bifido blend, the Saccromyces boulardii and soil based probiotics, all three categories. Then we followed up in two, three months. It was essentially more of the same. In this case, the only item needing to be addressed here was the limbic piece. Dietary changes were mildly helpful. Probiotics were helpful. But here it was probably underlying constitutional predisposition combined with how one can really work themselves into a frenzy, sometimes compounded, I think inadvertently by functional medicine with all the diagnostic tests that they do. It’s not abnormal to leave a functional medicine office thinking that you’re a little bit banged up initially, and then leaving there feeling like you’re on death’s doorstep. Because you’ve been diagnosed with MTHFR, adrenal fatigue, histamine intolerance, oxalate sensitivity, candida because of an organic acid finding, SIBO, dysbiosis, parasites, inflammation. Then if you’re running some of these auto-immune assays, you have auto-immune to seven different tissues of your body. So for a person like this, that can really be damaging. So we really saved her from that fate. This was a good example with choice screenshots from her paperwork of what it looks like when someone would benefit from some limbic retraining fairly early on in the process and really helped get this person, the care that she needed.

RuscioResources:

Hi everyone. This is Dr. Ruscio. In case you need help, I wanted to quickly make you aware of what resources are available to you. If you go to drruscio.com/Resources, you will see a few links you can click through for more. Firstly, there is the clinic, which I’m immensely proud of. The fact that we deliver, cost-effective, simple, but highly efficacious, functional medicine. There’s also my book, Healthy Gut, Healthy You, which has been proven to allow those who’ve been unable to improve their health, even after seeing numerous doctors, to be able to help them finally feel better. There’s also our store where there’s a number of products like our Elemental Heal line, our probiotic line, and other gut supportive and health-supportive supplements. We now offer health coaching. So if you’ve read the book or listened to a podcast like this one, or are reading about a product and you need some help with how or when to use, or how to integrate with diet, we now offer health coaching to help you along your way. And then finally, if you are a clinician, there is our clinicians’ newsletter, the Future of Functional Medicine Review. I’m very proud to say, we’ve now had doctors who’ve read that newsletter, find challenging cases in their practices, apply what we teach in the newsletter and be able to help these patients who were otherwise considered challenging cases. Everything for these resources can be accessed through drruscio.com/Resources. Alrighty, back to the show.

DrMR:

All right, here, and then rounding the corner one or two final points from the January, 2021. We review a study entitled: Exercise and Gut Immune Function, evidence of alterations in colon, immune cell homeostasis and microbiome characteristics with exercise training. There are a few items here that essentially boiled down to, we know that exercise impacts the immune system, it therefore impacts the microbiota because remember the immune system kind of regulates the microbiota. It’s kind of like the, the gardener who clips certain branches pull certain weeds. An overzealous gardener could kind of yank everything out.

Hypothyroid Disease and TPO Antibodies

DrMR:

So there’s a couple of choice details there, but I do want to move over briefly to the thyroid. I want to clarify one thing. So this thyroid review came from the May, 2020 edition. We’ve already discussed in the podcast, but I did want to just briefly speak to it one more time. So again, May, 2020 is when this published and the name of the study in question is: Significance of Anti TPO as an Early Predictive Marker in Thyroid Disease. You’ve likely heard me mention this study before. Essentially it boils down to the finding that in this prospect of follow-up only nine to 19% of patients with positive TPO antibodies became full-blown hypothyroid. Why this is important is there is this crucial delineation between Frank or full-blown hypothyroid versus subclinical hypothyroid.

DrMR:

This is where trying to be intentional in how you report the data really matters. If you took all the patients who became Frankly hyperthyroid and all the patients who became subclinically hypothyroid, you would then conclude that 73% of patients with thyroid antibodies became hyperthyroid. But there is a crucial distinction between subclinical and Frank hypothyroid as evidenced by the fact that the majority of subclinical hypothyroid cases spontaneously go back to normal. The majority of the data show no clinical benefit in giving subclinical hypothyroid patients thyroid hormone medication with the exception of the very young, and those who have a history of infertility and are trying to get pregnant. So very important to read the details here and this likely wasn’t something that the researchers were trying to spin. It’s more so how you would interpret this if you just kind of read the abstract quickly.

DrMR:

So when we take out of this lumping, both the subclinical hypothyroid plus the overt hypothyroidism, only at what we really care about, which is the overt hypothyroid ,that remains at a 9 to 19% risk, which is so different than 73%. Interestingly, the TG or thyroglobulin antibodies were not predictive, only the TPO. One other note I’d like to point out here, and I should probably further sharpen this up in my own discussion. I’ve often cited that about 4.6 of the US population is hypothyroid, but I should clarify, and I will clarify it to the best of my ability going forward, of that 4.6%, 4.3 is subclinical and only 0.3 is full-blown hypothyroid. The reference for that is Oxford Academic, a paper entitled Serum, TSH, T4, and Thyroid Antibodies in United States populations from 1988 to 1994, the N Haynes dataset.

DrMR:

So it’s a pretty good dataset. When we examine this in juxtaposition to the fact that IBS affects 10 to 15% of the US population, and more broadly functional gastrointestinal disorders affects up to 40%, hopefully you start to see why I become a little bit frustrated with how quickly a hyperthyroid diagnosis is thrown out there. When an actuality, 0.3% are what has been documented. Whereas 10 to 15 or 40% with IBS or functional gastrointestinal disorders. Not to say that hypothyroidism doesn’t exist. It does. For the patients who want better and are potentially frustrated by their family practice doctor or their endocrinologist, because they’re saying I’m hurting, I’m not feeling well, I need help. And they feel like their clinicians aren’t listening. We are listening, but we also want to be careful not to just take what you read on the internet and entertain that as a viable diagnosis.

DrMR:

There are cases, and we talked about one last week where a child really responded to T3. What we don’t want to do is be mislabeling people as hypothyroid or giving people combination T4 plus T3 therapy earlier than they should. If we administer a therapeutic at the wrong time, then we potentially miss the more important underlying cause. This happens all the time where people move on to more nuanced or exotic findings in thyroid at the expense of the GI. So if you just look at the numbers here, you can see why we take the stance at the clinic that we take. A gut forward, but not gut dogmatic or gut zealot approach of making sure we do our best there, because this is going to be more common, much more common by a couple orders of magnitude.

DrMR:

Also many of the symptoms that one may think is being driven by their thyroid could actually be driven by their gut. So it’s not all or none. It’s not all gut and no thyroid, there’s no absolutism here. It’s looking at these various entities and trying to codify them into an approach so that we’re starting with the suspicions and differentials in our differential diagnosis list that are most likely, and then working our way from there. Hopefully this has been helpful and insightful. Again, remember that if you have not joined the Future of Functional Medicine Review clinical newsletter, I hope that you will. It is something that would even be accessible for an enthusiastic lay person who just wants to better learn how to handle their health and be their own health care advocate. In the month of April, for just $1, you can have an all access membership, read around, see if it is beneficial for you.

Episode Wrap-Up

DrMR:

I hope you’ll check it out. I hope you will join us in this mission that we have to really help bring people more effective, more cost sensitive, and limbically or emotionally sensitive care in the sense that we’re not going to run up an array of tests, many of which are meaningless, but still carry a heavy emotional weight for an individual. We’re trying to get people healthy quickly and be progressive, but also have a really fine filter and not let things through into our clinical practice model that may do more harm to a patient than good. Also understand that we want to do everything that we can help someone. But we’re not willing just to jump into whatever-ville and throw things at people that haven’t been put through a filter. So in any case. There you have it guys. Curious to get your feedback on any of this, and I will look forward to.

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