Evidence-Based Functional Medicine Case Studies from Dr. Robert Abbott & Dr. Joe Mather.
In a study of 291 patients in Greece, researchers found that around 60% were incorrectly diagnosed as hypothyroid. While true hypothyroidism does exist, it’s a diagnosis that clinicians need to take a closer look at. Many clinicians are prescribing thyroid hormone when it’s not necessary, or when a patient’s symptoms could be resolved by healing the gut. The effects can be harmful, both to patient health and to their wallets. Patients themselves may exacerbate the problem by requesting it based on something they’ve read. Hear case studies from two functional medicine doctors who are modeling an evidence-based, cost-effective approach to curb some of these issues commonly seen in treating the thyroid.
Dr. R’s Fast Facts Summary
Joe’s case study:
Oftentimes the cause of the symptoms someone is attributing to their thyroid is actually a problem in the gut
A switch from Levothyroxine or Synthroid to a compounded or combination, like Armour, Nature Throid, or WP Thyroid doesn’t seem to produce improvements
There is no overwhelming evidence showing that T3/T4 combination therapies are working better for most people
In this case by focusing on the patient’s gut, they were able to see systematic improvements
Rob’s Case Study:
Hypothyroidism is often incorrectly and over-diagnosed
Patients who feel worse on Thyroid medication should consider a second opinion on the treatment and the diagnosis itself
In this case Rob asked more about the diagnosis and had the instinct to retest the patient
Patient did not have hypothyroidism
Slowly titrated patient off meds and 8 weeks later her TSH was in normal range and she felt better
Tweaked the diet w/ fasting and keto
Patients and clinicians should be aware that hypothyroidism is being over-diagnosed and it is important to ask more questions
Clinicians, take the time to learn more about the original diagnosis, consider retesting
Patients, do not put pressure on your clinician to be on medications just because you’ve read or heard somewhere that it’s helpful
Steer clear of practitioners who
Conduct way too many lab tests
Try to fix 10 things at once
Are not cost effective or efficient
Learn more about Dr. Ruscio’s functional medicine approach
Episode Intro … 00:00:40 Over-Diagnosis of Hypothyroidism … 00:05:32 Thyroid Function Improves with Gut Health … 00:09:09 Overuse of the T3 T4 Combo … 00:19:29 Case Study: Incorrect Diagnosis … 00:28:35 Clinicians Should Ask About Diagnoses … 00:33:38 Dangers of Unneeded Thyroid Hormone … 00:44:44 Practicing Cost-Effective Func. Medicine … 00:49:35 Episode Wrap-up … 01:00:19
Dr. Michael Ruscio, DC: Hey, everyone. Welcome to Dr. Ruscio Radio. This is Dr. Ruscio. I’m here with Dr. Robert Abbott and Dr. Joe Mather, both of whom are guys who I am just continually impressed with in their ability to apply what we discuss in our clinicians’ newsletter, The Future of Functional Medicine Review.
They’ve both contributed what I have found to be fantastic case studies to our monthly publication. They were able to help patients who seemed to be otherwise floundering and not getting the response and result that they wanted to, using—shocker—cost-effective, simple, evidence-based functional medicine. I’m so excited to have them both here to discuss the good work that they’re doing in the world of functional medicine. So, Rob, Joe, welcome to the show.
Dr. Joe Mather, MD: Thank you very much.
Dr. Robert Abbott, MD: Yeah, thanks.
DrMR: Let’s first just have you each give a quick snippet on your background. Then, please tell us, in case anyone in the audience is looking for a func med doc—since I can definitely recommend both of you guys with confidence—where your website is, or where they can track you down, just in case they’re in need.
DrJM: Rob, you want to go first?
DrRA: Sure, I guess so. I’m always alphabetical, so I’m used to going first. My name’s Rob Abbott. Some of you may remember, the first time I was on the show was back when I was a medical student. Michael was gracious enough to have me come by when I was doing some residency interviews. I was in California for over a month, but got to spend a day and just really loved it.
My background is a traditional medical education. I have a MD from the University of Virginia School of Medicine. Ended up doing a family medicine residency, completed my internship year, and part of my second year. And to keep the story short, basically I just did not fit in. I was a round something, you know… round peg, square hole. Whatever analogy you can pick, I did not fit in. And was wanting to do research. I was getting patients who wanted to do functional medicine, and it was not being received at my residency. I don’t have any hard feelings. It just wasn’t the model being practiced.
So I decided to leave and go back home. That was about two hours away, at the time. I came back home to start my own collaborative functional medicine clinic, using principles of functional medicine from the newsletter, from some training with Chris Kresser in the Institute for Functional Medicine. Keeping it simple and evidence-based, not trying to do anything fancy.
We’re in a very simple office. I don’t do fancy treatments. So, using the core foundation from my medical school training, and some family medical residency, along with all the other training I’ve sought, in addition to that in functional medicine, the continuing education has been really wonderful. We opened in November of 2018. The clinic’s based in Charlottesville, Virginia. We now have, I think, 70 or 80 patients, the majority of which are local. I do have some tele-health people. It’s just been a pleasure to be able to work with folks who are motivated, and to do what I love every single day, versus residency, which was definitely not that.
DrJM: I’m sure. And the website for anyone who wants to connect?
DrRA: The clinic is called Resilient Roots Functional and Evolutionary Medicine. It’s in Charlottesville, Virginia, but we do tele-health for folks. So I can do full-scope practice in Virginia, but also tele-health functional medicine. The website itself is a little bit convoluted, but it’s resilientrootsfxevomed.com (“evo” is short for evolutionary). From there, you can get directed and make appointments, get connected with us and get started. We do have folks across the country.
DrMR: Awesome. And Joe?
DrJM: Yes, similar to Rob, I’m family-practice-trained. I’m an MD and found functional medicine in my residency. The impetus was really that I wasn’t finding conventional medicine was helping me fix my patients. And that’s what I was interested in all along. So kind of fell into functional medicine and looked for a different set of tools to be able to get my patients better. I practice outside of New Orleans, a place called Metairie. Let’s see, anything else you want them to know about me?
DrMR: What’s the name of your clinic and the website?
DrJM: The website is www.doctormather.com. I don’t have a fancy name for my clinic. I run a solo practice. I try to just make everything personal to my patients. So I run a one-man show at the moment.
Over-Diagnosis of Hypothyroidism
DrMR: Great. So we’ve been in communication for, gosh, a few years now, at least. For the audience, what I’m talking about next is in the clinicians’ newsletter, if you’re saying, “Well, what’s he talking about?” If you’re not a subscriber, you haven’t been seeing this. But I’ve talked about this in other contexts, so it should not come as a shock to anyone in our audience when I say I’ve been writing in detail in our clinicians’ newsletter about how (amongst other things) hypothyroidism is incorrectly and over-diagnosed. Oftentimes the cause of the symptoms someone is attributing to their thyroid is actually a problem in the gut. Again, it’s not a panacea. I’m not trying to paint this as a heretical statement, but it’s fairly shocking how commonly this occurs.
This has been evidenced by three researchers, actually, at three different hospitals in Athens, Greece. They looked at about 200 patients and found about 60% of those patients were incorrectly diagnosed as hypothyroid. So there is some research evidence to support this. But what’s been so reassuring is to see other clinicians, such as Rob and Joe, finding similar things in their practices and being able to right these wrongs. They’ve both contributed case studies, which are just beautiful articulations of applying some of these concepts that I feel to be so crucial—that we cover in the newsletter—in their practices, and just hitting home runs.
I want to open up the floor to each one of you to expand upon this a little bit. Since, Rob, you went first on the intros, let’s have you go first, Joe, with your case study. I’ll just make a couple of general remarks before we jump in on that. In this particular case, I think you went through a lot of the right steps. And admittedly, you were learning how to use some of this stuff. This was, I think, a case study from earlier on in your career. Early on, we’re all trying to grapple with, “Okay, here are all the options. How do I best sequence these?”
It was fascinating to watch you figure out, through trial and error, observation, listening to the patient, and taking good chart notes, that it didn’t seem like this patient with symptoms acquired a “better form” of thyroid hormone prescription. Meaning, switching from something like Levothyroxine or Synthroid, which is just a T4 thyroid hormone, to a compounded or combination, something like Armour, Nature Throid, or WP Thyroid. That sort of switch—which is held as so sacrosanct in functional medicine circles—didn’t really seem to produce improvements.
You could even make an argument, maybe a slight regression, that it wasn’t until you got things right in the gut that there was this improvement. Not to steal too much of your thunder there, but that’s kind of the high-level view. Can you expand upon that a little bit?
DrJM: Yeah, well, first of all, I’ll try to keep up with you guys. You guys both have excellent podcasts. So this case study, Michael, was so much fun to write. And it made me appreciate the review so much more because of how long it took me to do it.
DrMR: They are not quick to write up! Yes, thank you for that.
Case Study: Thyroid Function Improves with Gut Health
DrJM: We get so many good case studies from you. It made me value them more. This was fun to write up because when I started treating this particular patient, it was at the beginning of my functional medicine experience and education. And as I learned more (much from your review), I got better and better, finally getting her home and getting her symptom-free and better.
When I first started treating her, I was throwing more of a conventional functional medicine toolkit at her: strict elimination diets, targeted supplements designed to improve thyroid function and conversion, evidence-based nutrients. But just really not getting any ground whatsoever. In the case study in your June review, you’ll see I kind of floundered around, just tried to switch thyroid medicine, tried different doses, different formulations. And it wasn’t until I finally got my head straight and really focused on gut, that just completely turned the case around, cracked it open, and made huge systematic improvements.
One of the cool things was watching her TPO enzyme go from over 700, steadily down to 200, when it had been all over the place. As soon as we treated the gut, she really responded well. It reinforced what I’d been seeing in many other patients that, when you get the gut right, so many other systems get better, particularly thyroid. So, particularly helpful for thyroid, but across the board, my autoimmune patients, my toxicity patients, weight loss, energy, chronic fatigue, migraines… It’s the place to start in almost everybody.
DrMR: One of her symptoms that was most pressing was fatigue. And oftentimes, I think we’re quick to say, “Well, gosh, fatigue’s got to be more a thyroid issue than a gut issue.” I think the ability of the gut to drive fatigue is so grossly underappreciated.
And, as you said, you did everything “right” according to formal functional medicine dictates, in that you put her on the T4 plus T3. Again, the philosophy here is that the fatigue is probably because your T3 levels are too low. Ironically, it seems that she even felt a little bit worse on that.
There is one philosophy that, if you give too much thyroid hormone to someone who already has a degree of fatigue—since the thyroid hormone increases metabolism, and increases metabolism of cortisol—you could actually lower their cortisol inadvertently and make them feel like they were hypoadrenal. That’s admittedly speculative. I don’t know if there’s any great evidence to support that. Nonetheless, the observation seems to stand true that, when someone has fatigue, the answer isn’t always (in some cases it is, but it’s not always) a need to really press forward more into pushing up their thyroid hormone levels. I would argue it’s not in the majority of cases. But rather, trying to get the gut right in order to correct the fatigue.
DrJM: Yeah, I agree with that. I see something similar happening with practitioners pushing methylation. That maybe it’s just counterproductive to put too much gas on in the patient.
DrJM: It was a real fun thing to write up the patient and realize how much I had progressed. Because we’re all trying to learn and do best by our patients. So the question is, “How are we going to get there the quickest?” That’s where your training has been very helpful.
DrMR: Exactly. It is amazing when you look back on case studies, how much you can see—as you just said—when you write up a case study. Wow, you can really see what you’ve learned and appreciate it more. That’s why I’m a big advocate of practitioners slowing down, not ordering too much testing, not trying to grapple with too many conditions, and also really listening to the patient and reflecting. If you can learn how (even though this may sound kind of trite) to learn from the cases that you see, boy, you will really accelerate. And as this case shows us, she was actually feeling her best on Synthroid. Many would say Synthroid is a suboptimal thyroid medication. However, she felt best on Synthroid, but we had to combine that with fixing her gut.
DrJM: That’s one of things I had written down to thank you for. It comes across in your case study that you’re changing your approach as well. You’re not content to just sit on what’s worked for a couple of patients. I think, recently, you made a point of mentioning that you’re doing more ferritin and iron studies in your thyroid patients and updated your algorithm. That’s been very helpful.
DrMR: Yes. Thank you. Yes, you’re absolutely right. It’s a constant evolution. This is why I try not to ever hang my hat too strongly on any one position or statement but, rather, say the totality of the evidence suggests this. Because that’s more of cautious statement, knowing that the totality of the evidence could change or new evidence could emerge. And in this case, I came across pretty compelling evidence for the importance of looking at iron—specifically ferritin, a marker of iron—in some of these non-responsive hypothyroid cases.
The evidence here is preliminary. But Soppi (who’s in Finland) has shown in one well-performed study that, when patients with ferritin below 100, who were also hypothyroid, were supplemented with iron to get their ferritin to above 100, 70% of those patients—that were still complaining of things like fatigue—saw those symptoms improve.
When we look at the fact that that’s just a nutritional intervention, it certainly moves pretty high in the hierarchy for me, to look at someone’s ferritin to see if it’s suboptimal, and then put them on an iron supplement for a few months. Now, we have to also be careful not to overuse iron, but it’s interesting…
DrJM: I find you don’t even need to push them to 100 before they start improving.
DrMR: I think that’s very likely the case. And we know, in patients who have autoimmune thyroid, that there’s roughly a 30% prevalence of autoimmune gastritis. So certainly there seems to be this connection where these people may not have optimum stomach function. If you don’t have optimum stomach function because of autoimmune gastritis—meaning autoimmunity against your stomach tissue—you may not adequately release hydrochloric acid. That may prevent you from adequately absorbing iron, and that may be why this ferritin marker of iron is low in these patients.
DrJM: Yeah, I’ve seen that.
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DrMR: Anything else here on this case study that you want to mention, before we move over to Rob?
DrJM: No, let’s hear from Rob.
DrMR: All right. So, Rob, you also contributed a great case study. This one was similar but different. Again, I’ll just give it a quick preface here, so as not to steal too much of your thunder. Another issue that we’ve talked about is erroneous hypothyroid diagnosis, meaning you were not truly hypothyroid and unfortunately a provider is taking, perhaps, a sub-optimal conversion. So when we diagnose hypothyroid, we need to see high TSH and low T4, according to the conventional lab ranges. In functional medicine, they’ll oftentimes use these more sensitive assays that look at all of the downstream conversions of thyroid hormone, into things like T3 and reverse T3. What sometimes happens is this conflation, where someone has low T3, and the practitioner will say, “You’re hypothyroid,” and put them on medication. That, in my mind, is getting so egregious.
There was even a Medscape paper, looking at a BMC panel conclusion on this, that this should be almost considered malpractice (in my opinion). The main reason for that, as this was articulated in the BMC panel, is that many of these patients end up on medication for years needlessly before figuring this out. That was kind of the type of case that you saw, Rob, where she was incorrectly diagnosed hypothyroid, and the cause of the problems was actually in her gut. So why don’t you launch us in?
Overuse of the T3 T4 Combo
DrRA: Yes, so before I get into the weeds of that, I do want to provide one reflection from Joe’s case study around using T4 and T3 combinations. I think, and this is a general concept that I’ve noticed, we recognize that we treat individuals, and at each visit are sitting with the individual that has individual needs. The difficulty comes in trying to use evidence used across populations to help treat individuals. So you have to, as a clinician, combine both that population evidence and the evidence created larger scale with the individual sitting in front of you. One of the things that I recognize, and I think it’s taken the wrong direction in functional medicine, is conceptual frameworks. Like you said, speculative. This idea that thyroid hormone may be over-utilizing cortisol. I’m not saying that that’s true. It’s just, is it clinically relevant, a mechanism actually manifesting in a clinical issue?
So T4/T3 conversion. Yes. Do folks have issues with that? Clearly, it’s a real problem. So it would make sense to potentially use combination T4/T3 medicines. Now, when you look at the literature, if combination T4/T3 was significantly better, even equal to, T4 therapy, there’ve been enough well-designed large studies looking at that with different markers of thyroid function, quality of life symptoms. If it was a large enough effect that that’s what we should be doing, we would see it in these studies. We don’t.
We see inklings that it could be better in some people. But we don’t see it as, “This is what you should be doing.” Therefore, as your guidelines and the larger guidelines, what the endocrine societies appropriately say is, “Start with T4 therapy. Then, from there, you can use other things.”
So we see this phenomenon play out with different medications. Everyone’s like, “Oh, statins cause all sorts of problems. Tylenol is starting to create empathy issues in kids and can do problems with your liver. NSAIDS have all these problems.” I’m not saying that they don’t have problems. They clearly do. But when you look at the populations, the large volume of people that have used things… if things were so egregious, or causing issues in everyone, we would see it.
Same thing goes, if it was clearly the best therapy, we would see it. And those studies have been done and it hasn’t shown up. So you have to take that individualized approach, recognizing that if you start with combination therapy, you’re making a mistake as a clinician.
DrMR: Rob, I think that’s incredibly well said. And you speak to a confusion that I think occurs in the field. Which is, when we don’t have answers for patients, we can go looking into the literature for nuances and, as you correctly said, there are some inklings in the literature showing that combination therapy may be better. But—and this is the key miss—that that “may be better” seems to apply, and this is a generous labeling of this, in 10% of patients.
I would argue it’s probably even less. But you can make the argument, again, being very generous and giving the most liberal interpretation of the literature here, that about 10% of people don’t respond adequately to something like Levothyroxine or Synthroid (which is T4 alone) because they have altered conversion of T4 to T3. But that’s 10% of people. If we then factor in some of those patients who may be exhibiting symptoms because their gut is out of order, I would argue it’s probably closer to maybe five percent.
Also, to your point, yes, sometimes we look for nuances. I’ve made this criticism several times in the podcast, that the answer to the question is already in the evidence. It’s just we’re ignoring the evidence. Up to 2009, there have been four meta-analyses of the trials looking at T4 alone (Synthroid or Levothyroxine), compared to various combination formulas, whether you add a T3 to that, like Cytomel, or you use something like Nature Throid, or Armour, or what have you. All four meta-analyses have concluded that there is no favorability toward combination therapy. And there was a review paper published, I believe, in April of 2018. The review paper doesn’t go through the same rigor as the systematic review, but they also concluded the same thing.
We’ve also discussed this in the newsletter. There are some studies that look at patients who have failed on T4 therapy and found favorable results on combination therapy, but that’s a specific group. That’s just the failure patients.
And there’s one other thing here that I want to piggyback on. Because even though when we look at patients who fail on T4, there’s a fairly high preference for combination therapy of T4 plus T3, we should juxtapose with this other observation, which says, “Look at patients who are hypothyroid and also have an H. pylori infection. These patients oftentimes can achieve the stable dose, and they also have these symptoms that are up and down.”
Now, one study, in particular, looked at giving half these H. pylori patients Tirosint, this liquid gel tab that’s highly absorbable and much more easy to absorb than Levothyroxine. And in the other half, kept them on the Levothyroxine that they’re not really absorbing, but treated their H. pylori. The patients that had the best outcomes—shocker—were the patients that stayed on the Levothyroxine but treated their H. pylori. The patients not treated for H. pylori, but on the easy-to-absorb gel tab, did see improvements. But not as much improvement as the patients who didn’t change their medication but treated their H. pylori.
So even more hints that what we may want to do is optimize gut health first, before then tinkering into optimization of a type of thyroid hormone used. And that’s codified in the thyroid algorithm that we discussed in the newsletter.
DrJM: The only pushback is that I think in functional medicine, we’re seeing patients who fail six, 10 other physicians. And I think if 10% of the population, say, are not doing well on Levothyroxine, I would estimate maybe one in four of my patients seemed to do better on Armour.
DrMR: That’s a great point, Joe. Absolutely.
DrJM: But to your point that we have to figure out the most deep-rooted cause, that’s when the real medicine happens.
DrJM: Why is this person not converting, compared to someone else? That’s the real fun.
DrMR: Yes, and I think that’s very well said, and you’re right. We should consider that the population that we will see in functional medicine will oftentimes be a higher concentration of failure patients. So that five to 10 percent of the general population may jump up to 25% or even higher. And that’s where I do see the merit of the combination therapy, and that’s why I have it in the algorithm. And I fully acknowledge that that could be helpful.
But we want to find that right balance of not going so far as to put every patient on combination therapy. And perhaps, taking a moment to go through some of our due diligence in gut, in ferritin, and then considering the combination therapy after those things have been squared away.
DrRA: Yeah, as you said, the key thing that you mentioned was, a patient that fails begins this. It’s not the patient that comes to you. And you can maybe argue if they’re coming to you, as Joe’s saying, and they’ve seen a provider, and they’ve failed various treatments, maybe the first visit with you is after failure. You have to make that clinical judgment. But it certainly has to be after multiple steps of failure.
I always come back to, as Joe was also saying, even if the person is having a failure with conversion, why is that happening? Do we immediately jump to support them with T4/T3? I would once again say that the evidence isn’t telling me they’re going to say, “Yeah, I feel way, way better doing this.” And maybe they’re going to feel way, way better by spending that time and effort to address the gut health, or address other sources of chronic inflammation that’d be good in driving down that poor conversion.
Traditional medicine, I will say, I’ve been reading a few editorials starting to recognize that measuring TSH alone, is like, we’re missing the boat there. And also that there are at least some genetic predispositions to different iodinase function, so different function in the enzymes that are converting things in the periphery, T4 to T3. Once again, that’s still going to be a minute set of folks, as you were talking about, Michael. But we can’t just create our own medicine based on what we want to work and when it’s not appropriate.
Case Study: Incorrect Hypothyroid Diagnosis
And jumping back to the case that I was working on, I’ve been starting to use the term functional medicine therapy in my practice, when I see folks who have been in to see functional medicine providers or alternative providers, and seeing the absolute horrid amount of tests that are being done for no great reason and not using foundational principles. People usually come in on 17 supplements or at least 17 supplements that have been recommended. They are usually not taking them at this point. Just going through all the charts and the records.
And honestly, if not for your first review, that was really beginning to highlight the inappropriate diagnosis of hypothyroidism, I probably wouldn’t have gone digging for a misdiagnosis in this patient. Not that anything is just a hundred percent accepted, but of the diagnoses that are fairly accepted when you’re inheriting a new patient, hypothyroid is one of them. It’s like, “Oh, what’s your dose? Okay. Call in your medicine to continue that,” without even questioning where the diagnosis was, what were the levels when the diagnosis was made.
Going back to what traditional modern medicine folks are beginning to realize, it’s that, “Yes, there’s a lot of people who are inappropriately taking medication for either subclinical hypothyroidism or other conditions.”
We have a huge obesity epidemic. So I see this phenomenon called obesity, or the endocrinopathy of obesity, which often times leads to dysfunction of the thyroid that’s not autoimmune in nature. People can get put on medication because maybe things look a little sluggish and you’re trying to help them lose weight. So this isn’t just in the functional medicine community. There’s actually a thing in the wider community. When I was a resident, it felt like every person I saw had some diagnosis of that. And I was like, “Good God.” I know this is the number one prescribed medication, Levothyroxine, of all medications in America, but I feel like this is just insane.
So if not for the case study, when this patient came in, I wouldn’t have really inquired into the circumstances of the diagnosis, and simply asking that. It was eight, nine years ago, and the patient wasn’t able to get the labs for the diagnosis because it was in California at the time. She recalled very vividly the encounter with the provider. They said something to the effect of, “Well, you’re not technical hypothyroid, but there are other markers in this blood work that look to show that it needs some support. So we should put you on medication.”
And guess what? She was put on a combination medication that eventually—the one that she was on, when she came to me—was compounded. So, just talk about the expense! She was having issues with anxiety, other psychiatric concerns. I would have a really hard time believing that the extra thyroid hormone didn’t have some kind of negative contribution to that.
She had a very interesting story too. Once again, this came out in taking the space and time to hear someone’s story. There was a period of time, because of poor communication—not on her part, but with the clinic just not having their practice together—she went without thyroid medication for a while. And after an initial little hump was pretty rough, she actually started to feel better. But she sort of dismissed it, as a lot of people do, because it’s just a natural process.
So then she got put back on the medicine. When she came to see me and I started asking and got these stories, I’m like, “Man, I just really don’t think you have hypothyroidism.” She had some inklings, previous autoimmune diagnoses. And she didn’t have any recent antibody tests. So I said, “All right. Let’s just do a full panel. Let’s look at your antibodies. Let’s look at your TSH, free T4, free T3. Let’s just look and see where you’re at.” And she had no antibodies.
And I was like, I would be really hard pressed to see someone with autoimmune thyroid to now have—it’s possible, I see them—normalized their antibodies. But with her state of health being somewhat still out of balance, I was like, “There’s just an infinitely small chance that you could have autoimmune hypothyroidism. I just don’t see it.”
She also intuitively was like, “You know what? I don’t think I need this stuff.” So we said, “All right. Let’s titrate down, let’s get you off,” and retested about eight weeks later. The thyroid TSH was in the normal range but, more importantly, she felt fine. She was like, “I am not hypothyroid. My issues are not hypothyroid.”
We started doing some tweaks around macronutrients, following a ketogenic diet, doing some fasting to try to get some weight loss, because she was having some weight loss resistance. She was able to do that. And her energy felt a lot better. All this, sort of concurrently, while just doing some basic digestive supports. It was further reassuring to us that, “Guys, we’re going to find people who are misdiagnosed.” She also had an erroneous rheumatoid arthritis diagnosis as well (just for fun).
Clinicians Should Ask About Diagnoses
We’re going to find these people! And it’s not cynical as clinicians to go searching or asking about the circumstances of diagnoses. Because you know what? I’m probably going to make a mistake. I’m probably going to diagnose somebody with something maybe they don’t have, and they go see a provider down the road. I’m not saying any of us are immune to this. But we have to do it from a positive viewpoint. I want to know the circumstances of your diagnosis because—just as I might un-prescribe things or de-prescribe things—I’m going to un-diagnose you with things that are inappropriate.
So it’s a big message which I’m glad you began, sharing that to the whole community. Honestly, and I’ll repeat this, I probably wouldn’t have gone looking for that if you hadn’t mentioned it in a case, or we hadn’t had some dialogue back and forth to really get this on our radar. And as I said too, before, this isn’t just functional medicine. We’re talking about the patients we see within our community. We can only really talk to that regard. But there are editorials and other things noting that, yes, this is still inappropriate practice on a larger scale. Maybe it’s being done with T4, but people are being inappropriately put on medication. So start to pay attention to this!
If you’re a patient, you should also do your due diligence. Be aware of those levels and don’t just go see somebody, like a functional provider, who tells you to take this after their labs and doesn’t really go in depth with things, and it just doesn’t seem quite right to you to get put on. It may be alluring when you’re in a state of illness: “Oh, all my problems are going to be solved by a thyroid hormone.” Well, guess what? They’re probably not.
It was rather enlightening when I was doing some research for this study with Hashimoto’s. One of the papers I found to compare our study to was a study looking at newly diagnosed patients with hypothyroidism, or subclinical hypothyroidism. They put them on medication, standard T4 therapy, and they followed them for six months. They monitored quality of life, using a standardized quality of life questionnaire, and then a new thyroid-specific questionnaire that they were developing. So they were trying to validate their questionnaire.
You would’ve thought, after six months with these diagnoses, being put on medication, people would’ve just been doing awesome. There were only two of the sub-scales that showed significant clinical benefit. I was like, “Man, this is just showing us that even thyroid hormone, when someone’s newly diagnosed or even later on a diagnosis, isn’t going to solve everything.”
Maybe there’s a case here and there where, yeah, that’s the big missing link, then everything gets in line. But this is a pretty well-done large study of a large population comparing quality of life to a standardized, healthy population. And people did not make massive gains from the hormone replacement.
DrMR: Yeah, so many great points there, Rob, that I want to dig into. The first would be, for someone who’s saying, “Well, I’ve read so much about how important this is, and one of my friends told me she felt so much better,” sure, these cases do exist for someone who goes on thyroid hormone. Especially, of course, if they’re hypothyroid. It’s probably a little over-hyped as you’re alluding to, but certainly helpful.
There are also those cases that go on combination therapy and will notice they feel better. However—and this was looked at in a 2005 paper that we’ll be reviewing in the newsletter soon—there was one paper that tracked patients for three months and, then again, up to twelve months when patients changed medication from standard T4 (like Levothyroxine) to combination therapy. Or it went from combination therapy back to Levothyroxine. It was a crossover trial. They found that pretty much everyone who just changed their medication—it didn’t matter what type of change it was—reported benefits at three months that then disappeared at 12 months. Which tells you almost for certain that this is a placebo-driven phenomenon.
So we also have to factor in that, if a patient goes to a doctor’s office, and the doctor tells them, “You’re going to feel better from combination therapy,” and then they ask them a month later, “How’re you feeling?” there’s a very powerful placebo that you will see in the short term. As this study found, up to three months, that seems to be gone by 12. So we also want to be careful not to rely too heavily on anecdote. Although we should also listen to anecdote because we can learn from that, but we want to be careful not to put too much into anecdote, because the placebo effect is powerful.
One other thing I just want to piggyback on that. This is something that’s been an evolution over maybe the last year and a half. Again, starting with things that I had seen in my practice, and then the paper published out of the three hospitals in Greece, and then even more so with some of the feedback I’ve gotten from people on our newsletter like both you, Joe and Rob. Now, any time a hypothyroid diagnosis has been made by a provider who is alternative in their scope—I don’t mean alternative in training, they could be conventional MD all the way through an ND, it doesn’t matter the degree that they have—if they’re practicing more in an integrative model, then I ask to see the labs that made the diagnosis.
I’m going to assume that, if you’re an in-the-box endocrinologist… in my experience, I haven’t seen the in-the-box endocrinologist typically doing this. But I typically look at the labs to double-check any time there’s ambiguity around the diagnosis, or if it’s someone who’s practicing in an alternative model. And it’s no disparagement at all to the alternative model. I just think this is one imbalance that’s going to be rectified in the future, and these discussions are the ones that are going to help us get back on track.
DrJM: I’ll just chime in to say I agree with you both. And I can think of two patients, just off the top of my head, where all I needed to do was take off inappropriate thyroid medicine to give them to make a significant jump forward. So I agree completely.
DrMR: So can you expand on that a little bit? I think that would be interesting for people to hear about.
DrJM: Very similar to Rob, I can think of one female here who was having a lot of anxiety, insomnia, the two predominant symptoms that she came in to see me for. And just like you said, she had seen a functional-oriented… an integrative physician, who gave thyroid support: “I think you’re not in the ideal range of your thyroid labs, and you’re feeling bad. So as part of many things I’m doing, I’m just going to put you on thyroid medication.”
And looking back at her labs, she didn’t need it. I took her off and her labs stayed fine, and she felt better. She slept better, anxiety was better. Palpitations, again, that was another thing she had. Anyone who’s prescribed Cytomel more than a few times will know how common that can be. It’s the key sometimes. And they’re fun for us, because you look like a genius just by pulling the medicine off. You get real good benefit in the patient. Those are some of the best cases. So that was an easy fix. Does that help?
DrMR: Yeah, absolutely. I’m glad that you made that pointed remark, in that sometimes T3 is so coveted. “Oh, if I could only get my endocrinologist to prescribe me the T3 that I read on every blog is so important.” But while there are cases where that is the truth–
DrJM: They are the minority.
DrMR: Yes, they’re the minority. And unfortunately, what you can see is a fairly marked amount of negative side effects, whether it be insomnia or anxiety. Or even fatigue, ironically. But what happens to hyperthyroid patients? They have insomnia, fatigue. Ironically, fatigue. That is observed. So, yes, there’s a time and a place for T3, but I think we really need to recalibrate the thinking that it’s going to be this miracle breakthrough that relieves all your symptoms. In a small percentage of cases, yes, but in the majority it doesn’t seem to be the situation.
DrRA: I have one final case example of T3 mismanagement and what, maybe, the negative side effects of doing T3 therapy are. The individual was part of the AIP Hashimoto’s study that I recently completed. She had just started care with me (but all the other patients were study participants, and not my patients previously). So we were doing baseline labs at the beginning of the study to assess function, and found out that she was on only T3 medication. She was taking something to the order of 20 or 25 micrograms throughout the day. I asked her about it when I saw her labs. She essentially had zero T4. Her thyroid was doing nothing. So of course, she had reverse T3, and none of the downstream metabolites. She wasn’t doing great. She had a lot of weight gain issues, and other issues.
So I talked to her and I was like, “I just don’t think this is safe.” We are beginning to see… and it was actually just this week, a paper was put out calling for more research on cardiovascular disease outcomes with hypothyroidism and hyperthyroidism. Saying, could there be a harm from thyroid hormone replacements at really high doses, if there’s an issue with absorption or some other issue with conversion? Is there actually harm to bodily tissues? Because you’re basically revving up the metabolic engine, which you need to be aware of. Risk/benefit when we’re treating folks.
So, I told her. She didn’t have any overt hyper- symptoms. I said, “I don’t think this is safe, and you have zero T4 which is an important feedback hormone to the rest of the HPA axis, whether you’re making it or it’s exogenous.” This was midway through the study, and I gave her some alternative dose combination things that she could do, based off her weight and values that seemed reasonable to go back to her practitioner. We even read a letter. It sounded like he was pretty confrontational. And he said, “Well, the conversion argument. This says I’m circumventing the conversion problem by doing this.” I was just like, “This is such garbage nonsense, and I don’t want you to be able to practice anymore with this nonsense.”
So she came to the end of the study, and they got her repeat labs. Her T4 had actually come up in low normal range. My first question to her was, “Which of the combinations did you start?” She goes, “Oh, I didn’t actually start a combination. I just started taking a little bit less of the T3.” So then that opened up this combination of suppression of her thyroid with the T3. And also, I think the intervention itself improved her overall health. So she was beginning to see some restoration of thyroid function.You can’t really prove… I’m sure it was a combination of the two, both the intervention and removing of a little bit of suppression.
Dangers of Unneeded Thyroid Hormone
But goes to show you that trying to suppress your TSH with either T4, combination therapy, or doing T3 alone, are just ridiculous clinical practices. You can see downregulation of hormone receptor sites when you bathe the whole body. So you’ve suppressed your TSH. You think you want more thyroid hormone? Those are the people, like you said, Michael, that are going to get fatigue or are going to get weight loss resistance. Like, “Well, my thyroid’s all normal.” I say, “Well, actually, your body is saying there’s too much in your system.”
So I am definitely not an advocate for global suppression. I want to listen to people and use the minimum amount required. Thinking back to what I said earlier, is there something downstream, or actually, is there harm in doing too much, versus harm in not having a thyroid hormone to begin with? To try to balance that.
I pose these questions to say I don’t really have the full answer. I’m just presenting the cases and, like you said earlier, trying to learn from the people in front of me. So I think that’s the greatest mistake we can make, to not learn from the patients that we have, and just stay rooted in our practices that don’t have the evidence and are not helping people.
DrJM: Think of our insulin-resistant patients. We know that there’s tremendous metabolic damage in insulin resistance, when you have too much insulin. Think of your patients that come in with crazy levels of hormones and hugely elevated sex hormone-binding globulins. The body will respond to inappropriate therapies and medications, and not in the way that we usually want it to.
DrRA: It’s totally true. Insulin is a great example. We have a lot of Type 1 diabetics and there’s a phenomenon of, “Well, I want to be able to have a…” It’s more in kids, because you want kids to be normal, be able to eat whatever they want. It’s like, there’s a downstream effect of using more insulin than your body physiologically needs to control blood sugar.
I’m saying this globally, things like BPH. Any kind of enlargement of tissue is downstream of high insulin. If it’s because of endogenous insulin resistance or it’s because of exogenous insulin being used, we have to realize that. Because if we’re trying to get glucose into muscle, we’re trying to get glucose into adipose tissue, and we bathe those tissues with insulin that need more of a signal to get it in, that insulin is going to be in the rest of the body. It’s going to be affecting other tissues, and they’re going to respond.
As you said, I’ve seen some really high sex hormone-binding globulins that basically made free testosterone zero and estradiol through the roof. I’m like, “This was pretty dumb.”
DrMR: I guess the take-home for the audience is, more is not better. The appropriate balance is really best. And I think it’s important for patient and provider to champion this message. I don’t want to put this all on the providers. Of course, patients—and this is also being seen in the commentary of the published literature—are putting immense pressure, in some cases, on their doctors for thyroid hormone treatment or combination therapy, when there may not be a good case for that.
I think a doctor who has a degree of open-mindedness is a good thing. Sometimes, these doctors are saying to themselves, “Well, nothing else I can see here that’s causing the problems. Maybe I’ll humor this patient and let them try combination therapy or a trial on thyroid medication.” So unfortunately, sometimes I think it’s unintentionally exploiting the compassion of doctors, having a patient who really wants a thyroid hormone because they’ve been led to believe (from internet readings) that that will solve other problems, that’s creating this runaway issue.
So I just want to make sure we don’t put all the culpability on the doctors here. For the patients listening, know that your narrative and how you talk to your doctor about this is also important in influencing where the field goes.
One other thing, guys, I just want to come to in the close here, or as we’re coming up on close, because this is something else I think is important to at least quickly touch on. How do you feel this minimalistic, cost-effective, no-nonsense application of functional medicine helps you to grow your practices?
You’re both fairly new in the practice. So from some of what you’ve told me, it’s been, I guess, ironically helpful. Where instead of saying, “I’m the guy who can fix all your problems,” and this dog-and-pony show, super high-promising, high-falutin model, you have a more, “Well, we can help you, but we can probably do it for a whole heck of a lot less.” It seems to be pretty appealing to patients. And I was just wondering if you guys could both speak to that briefly.
DrJM: Yeah, happy to. Last time we spoke, Michael, I was still working two practices. And I’ve been able to grow my practice to where I’m a functional medical practice full-time. So I see it working. The problem with our field, I think, is—Rob, you touched on this—just way too much lab testing that wastes resources. It’s not fair to patients. And then a treatment approach that’s not thought out very well. People are trying to fix 10 problems at once, with 10 supplements or 10 protocols at once. Instead of systematically building a healthy foundation for the patient, fixing any nutrient deficiencies, healing the gut, and then working at some of the tertiary aspects that some of our sickest patients really need to work on, be it mold or metals.
When you have a foundation where you’re treating the basics first, the simplest, most low-cost, easy interventions, a huge number of patients just gets so much better doing that, that you don’t need to give adrenal support, and methylation support, and nutrients, and medications for sleep… and and and. There’s so much waste.
So I’m really grateful for your guidance in figuring out a cost-effective, efficient way to work up a patient, particularly in relation to the gut. So I hope that answers the question a little bit. Our field needs to do a lot better job at being cost-effective, less testing, and focusing on the treatments that give the most benefit to the patients, because they deserve it.
DrRA: Yeah, I can echo everything Joe said. Going back to making that point about if it wasn’t for your case study and the review about hyperthyroidism, I probably wouldn’t have been looking for that in patients. It’s not about looking for something that isn’t there. It’s looking for something that is there and having the awareness of it. So I completely agree. Being able to have a framework to construct a clinical practice, and how to approach people, and specifically gut-focused and thyroid-focused, which is a big proportion of people, has been invaluable.
I’ll say that my clinical practice—I mentioned was getting started in November of 2018—is a unique practice. I’ve been really lucky to work alongside a functional nutritionist, Ryan Hall. He’s just my best friend, a wonderful human being. All he’s ever done is functional medicine education. So we have a great synergy. He’s got a great background in contemplative religion and psychology. It’s been so wonderful to learn from him and he learns from me. We actually designed our initial intake and series of visits which are really time-intensive. It’s the beginning of my practice. Will I be doing the same thing in a year or two years from now? Probably not, but I’ve seen some tremendous value in spending a lot of time with folks in the very beginning, alongside Ryan.
So in our visits, Ryan and I are sitting together with patients. It’s been showing people that my role is not any more important than his role. And it is so awesome, at least in my opinion, to basically have two heads working for one person. To be able to bring synergy to the way we ask questions, and in a very practical aspect. I share this for folks to really think about.
I had such a tough time in residency being able to work with patients… and much of my interest is also in the psychological realm and I’m pursuing greater training in psychotherapy and psychoanalysis. One of my biggest issues was having to take computers into rooms and just feeling like I couldn’t connect with my patients. And even though I had more time, not being able to connect. One of the things that’s been so wonderful working with Ryan, since both of us are in there, is that I can do all of my notes in the room. And there’s always somebody that the person can make eye contact with. You think that’s a silly thing. I’m telling you, I think it makes a difference. And I know I feel more comfortable as a clinician being able to make those notes.
I’m usually done with very, very thorough notes, which is going to be one of my last points. As a clinician, I want to be very thorough in how I make notes, and make notes not something I am afraid of or dread doing. I want to think about the person in a very organized, systematic way and start to make a differential, which is one of the things I saw from you when I was a student and the way you were organizing things and constantly going back. You should be able to look at your notes to get a quick assessment, to understand where this person is and have an idea where you’re going so you don’t miss things. Keep it broad in the beginning, because you’ll see certain things fall away, other stuff stick around, and it’ll help you in constructing a path.
As Joe was saying, a lot of people I see and that do function medicine therapy for, they didn’t have a direction. It was just, you know, “Oh, try and do all these things at once,” and maybe this would get better, this would get better, and you throw the kitchen sink at them. Then maybe some stuff gets better, or some stuff gets worse. Then, they’re stuck with 17 supplements and never actually got to the root of what was going on. So you need to really lay out a very practical plan.
I don’t pretend to tell people that everything is going to get better in a month, or two months, or three months. Some of these are really sick people. It’s going to take some time, and we have to do it methodically. If you go trying to find every problem in the beginning, and you’re broken, you’re going to find a lot of problems. Well, what’s going to go away if you fix the gut first? So if you give people a systematic plan of what you’re going to do, they’ll feel okay if they come in and they wanted food allergy testing, and you tell them logical reasons why that’s not a good choice right now.
If you don’t get defensive about things, and you’re open-minded, you can set out a plan that the patient will understand and meet you halfway on, probably really help them. So this was kind of a long ramble. But going back, I’m trying to figure out a new clinical approach. One of the reasons the newsletter is so helpful, from a practical aspect, is we don’t fully know how to really practice functional medicine. It is still so new.
Now, when I was first getting started, I was like, “Well, what do I ask at this visit? Do I give them these recommendations, do I just worry about diet, do I do this?” Those practical issues. So in figuring this out and working in this model, and having a close partner, we have quite a good structure that is giving a lot of people a lot of value and doing it with very minimal testing. Maybe some stool testing, very cost-effective blood work. On the whole, someone might work with us for an entire year, and spend $3,000, and they get better, versus $3,000 in a month. It’s just been really gratifying to get some positive feedback from people that have been really happy with the care that we provide, and that we have their time and their money in mind. It’s not just, do everything possible, just because you can.
DrMR: In your case study, Rob, you administered antimicrobials without performing any testing, which I think it was a totally justifiable maneuver. Because while, sure, we could say that, “Oh my gosh, we need to do these tests before we intervene in the microbiota,” you have to be a little bit foolish to think that you are getting all of the data relevant to the gut, from even the best that’s currently available.
DrRA: Yes, this is another whole podcast about what percentage is in the stool, how valid is breath testing if you suspect SIBO? The thing I’m starting to do now is, if I’m suspecting dysbiosis or small intestinal bacterial overgrowth, I’m not even doing breath testing. I might do a stool test to see, is there something else funky that I should be aware of? A PCR-based stool test. If that doesn’t show anything, you treat someone clinically. Or treat someone clinically from the beginning, because if they don’t want it, if they don’t have the money, it’s just inappropriate, or you’re not going to ask a good question.
So if someone doesn’t have suspected methane-predominant SIBO, I’m moving away from the breath test, just because of what things seem to be pointing to. Then, recognizing there’s still limitations with the stool test. We’re not sampling the gut along the small intestine border. So that’s another podcast.
DrJM: I’ve actually moved in somewhat of a similar direction. I’ll usually either advise a breath test or a stool test, based on the predominant symptoms, knowing that for most of them, I’m going to use broad-spectrum herbs that are going to fix both issues at the same time, if I’m formulating it well. That’s been able to save a lot of money. I tell patients, “Look, we can always go back if we strike out on the first round, and look at a deeper level.” But most people are just so grateful that I’ve thought it through with them. They see that we’re trying to save them some money and they appreciate it. It helps build a lot of rapport and trust, which is critical if you want to get people better.
DrMR: I agree with that wholeheartedly. To your earlier point, Joe, of seeing my evolution throughout the writings of the case study over the past two-plus years, you see now, in the more current case studies, that I’m listing tests as optional. I have the conversation with the patient, “I can’t tell you that a SIBO breath test is going to be earth-shatteringly important. I also can’t say it’s not going to be helpful at all. So, if you’re someone who likes data, if you’ll feel better about the process if we do the testing, we can do it. I can’t say I one-hundred percent need it. So, I’ll leave it up to you in terms of what resonates with you.” Just involving the patient in that decision-making process, to your point, builds a lot of trust, which is very important, especially when people are parting with hard-earned money for this care. It’s really important that we honor all these decisions.
DrJM: Yes, so well said.
DrMR: All right, guys. Well, this has been a fantastic conversation, as I knew it would be. I really want to thank you guys both, for just doing such a great job with the work that you’re doing. It’s a real breath of fresh air to see people championing this message of just practical, cost-effective functional medicine. I truly believe it’s the future of functional medicine. I think the field, of course, is growing. As part of that growth, we’re going to realize that some of the things need to be cut off and other things need to be more embodied. And I think you guys are just really embodying all the right stuff.
So, Joe, Rob, really, really appreciative of your time and speaking with us today.
DrJM: Thank you. Thanks for your guidance.
DrRA: Yeah, thank you, Michael. I’ll leave people with one last thought. I think it can be easy to feel like, “Michael brought on the two of us to showcase, and we’re in this echo chamber.” And I’ve loved the clinical reviews. I’ve loved all that content, but I still look at it with an objective eye. There’s going to be stuff we’re going to get incorrect. There’s a difference between being incorrect in the moment and then changing your view when new evidence arises, versus making a poor conclusion and being incorrect in the first place and sticking with that.
So it’s not like everything that he puts out in a newsletter I think is gold and magical. That’s what science needs. It’s all about engagement and positive, critical disagreement. I want to say that, just so people don’t get a sense that a hundred percent of everything that we do, we’re all in agreement on. No, we’re still trying to figure this out, and I can’t applaud Michael enough for doing the work.
As Joe said, taking all the time to do these case reviews is both internally helpful as a clinician to go through that process, also externally helpful for the greater community. We need that radical authenticity to really move this forward. If we all stay in a true echo chamber, then we’re just not going to help anybody.
DrMR: I agree. It’s always good to have healthy discourse. That really helps us to see the strong and weak points of our arguments, when we can have a conversation with someone who may expose a blind spot that we were previously unaware of. So, absolutely, that’s why I try to be as open-minded… and I think we all are as open-minded as we can be, do the best that we can every day. Maybe another way of saying it is, trying to be the least wrong that you can, haha!
DrRA: Yes, that’s great. Haha. Totally. I like that.
DrMR: All right, guys. Well, thank you again, and keep up the good work.
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