- Kyle, 7 y/o, male
- Previous Dx:
- Hypothyroidism (2012)
- Hypotonia (2012)
- Global Developmental Delay (2012)
- Speech Delay/Apraxia (2015)
- Levothyroxine 37.5 mcg
- Chief Complaints:
- Abnormal thyroid labs
- Food allergies/sensitivities
- Cognitive Functioning, attention in school
- Kyle is a 7 y/o male weighing around 45 lbs who comes for his first visit in August 2019 with his mother. He is outgoing, interactive, and happy. He cooperates with all aspects of my exam.
- Congenital? Hypothyroidism
- Speech Delay
- Levothyroxine 37.5 mcg
- Previous Testing:
Blood Chemistry July 2019
- TSH: 7.060 (H)
- Reverse T3: 30.0 (H)
- Free T4: 1.68 (H)
- Total T3: 141 (nl 92 – 219)
- Free T3: 3.8 (nl 2.7 – 5.2)
- TPO: 9 (Normal)
IgG Food Allergy Testing October 2018
- Beef (Elevated)
- Wheat (Elevated)
Blood Chemistry Testing October 2018
- Negative Celiac Screen
- Normal iron panel
- Negative TPO and TGA
- Elevated Free T4, normal TSH
Organic Acid Testing
- Elevated lipid peroxides
- Vaginal, term, uncomplicated delivery, home shortly after birth
- One week into life, they went to ER for poor feeding, potential hypotonia. He was worked up for sepsis/meningitis where he received multiple antibiotics for potential sepsis, despite no infections being identified. Discharged
- Started to breastfeed and functioned well. Of note: newborn screen results at this time were unremarkable. No clear congenital hypothyroidism.
- Around months 4-6, he seemed to be developmentally delayed. Formally diagnosed with hypotonia and global developmental delay. Had a work up that found subclinical hypothyroidism at this time, but did not start medication.
- Stopped breastfeeding at 12 months. Has challenges introducing foods and developed severe constipation. Eventually started levothyroxine at that time.
- Developed frequent ear infection treated with antibiotics. Ear tubes were placed. Evaluated for absence seizures around at age 2, negative. Additional partial genetic work up for cognitive and developmental delay was also negative.
- Around age 3-4, he had another suspected episode of sepsis and was given more antibiotics without conclusive infection or diagnosis.
- July 2019, elevated Free T4 (while on medication) prompted labwork which also showed elevated TSH.
- Mother- Acquired hypothyroidism?, food and environmental allergies
- Father – Healthy
- Siblings – Mostly healthy with some mild eczema and seasonal allergies
- Omega 3 supplement
- Children’s Multivitamin
- (Thyroid) hormone replacement medication
- Occupational Therapy
- Thyroid Insensitivity vs. Impaired Conversion T4-T3
- TSHoma (TSH secreting tumor)
- Pituitary Dysfunction?
- Gut Dysbiosis
- Intestinal Permeability
- Nutrient Deficiencies
- Food Sensitivities
- Hormone Negative Hashimoto’s Thyroiditis
- Mast Cell Activation Syndrome (MCAS)
- Kyle is a sweet, young child with an interesting pattern of findings on his recent thyroid tests as well as chronic constipation with food sensitivities. While I suspect he will do well with some gut directed therapies, it is unclear exactly the etiology of his thyroid condition.
- Paleo Diet (no gluten, dairy, etc)
- (Complete in approx 8-10 weeks)
- CBC, CMP, GGT, Uric Acid, LDH, Iron Profile, Vitamin D, Full Thyroid Panel (w/o antibodies) Insulin, Lipid Profile, FSH, LH, Prolactin, Alpha Subunit, Homocysteine
- Thyroid Ultrasound
- Given the elevated TSH, Free T4, and normal/low normal T3 and Free T3 with high reverse T3 , I am suspecting some form of thyroid insensitivity. There is also an interesting note of increased lipid peroxidation in those with thyroid insensitivity, which was a finding noted on a previous OAT. These lab findings and the thyroid insensitivity could possibly be related to a rare genetic cause that would have been present around birth to some extent.
- See UpToDate: Impaired sensitivity to thyroid hormone
- As there is no clear evidence for an autoimmune cause of his hypothyroidism (from previous antibody testing), I would like to perform a rudimentary evaluation of his pituitary function, seeking to rule out a rare TSH secreting tumor (TSHoma) or other pituitary abnormalities. Lastly, given the abnormal thyroid history, I would like to perform a thyroid ultrasound to assess for structural abnormalities to his thyroid gland.
- Since he is a child, I am very prudent about doing labwork only when necessary and doing it at one time point if possible. While there are some labs that I would like to have now, I am choosing to wait to group them in with repeat thyroid labs that I would like to see after a new course of treatment.
- Continue with Paleo Dietary Template
- Start Liothyronine 2.5 mcg daily
- Decrease Levothyroxine dose to 6 days a week.
- I would like to see how the T3 affects his TSH and overall health. If my suspicions are correct about possible thyroid insensitivity, this therapy should result in a decreased TSH and also normalize his Free T4 and Reverse T3 levels
- Has overall been doing quite well
- No major illnesses
- Has done well with Liothyronine 2.5 mcg added to current Levothyroxine
- Stools have still been irregular in consistency, but overall likely improved, likely having BM’s every other day. There is an occasional accident. When he does go his stools are generally larger volume.
- Has been doing well in school, still needs direction and help with multi level tasks but is otherwise doing very well.
- Thyroid Panel
- TSH: 3.74
- Free T4: 1.57
- Total T4: 11.3
- Free T3: 3.6
- Total T3: 135
- Eosinophils (8%, elevated absolute)
- BUN: 20 (H), CO2: 16 (L)
- Vitamin D: 51.3
- Homocysteine: 8.2
- Insulin: 1.2 (L)
- Serum Iron: 150 (H)
- Ferritin: 112 (H)
- Mildly elevated eosinophils
- Mild iron overload
- The initial dose of 2.5 mcg T3 seems to have helped normalize his TSH. There are no signs of pituitary dysfunction/tumors. He appears to have some slight iron overload and elevated eosinophils that are worth following and addressing.
- Given his history of chronic constipation, immune dysregulation with frequent antibiotics, I believe he will do well with some GI directed therapies.
- Continue previous chewable Lacto/Bifido probiotic
- Continue previous DHA liquid
- Add GI repair nutrients powder
- Add Vitamin E liquid
- Add Mast Cell/Anti-histamine children’s supplement
- Add Target Gb-X Probiotic (Klaire Labs)
- Increase Liothyronine to 5.0 mcg
- Repeat CBC, CMP, Iron Profile, Insulin, Homocysteine, thyroid panel in 8 weeks – Note patient tolerated lab work well and this does not appear to be an issue going forward
- Constipation is improving, fewer accidents
- Seems to have fewer episodes of abdominal pain, food reactivity
- Tolerating supplements and medicines well
- Thyroid Panel
- TSH: 4.6 (nl, 0.6 – 4.84)
- Free T4: 1.36
- Total T4: 8.9
- Free T3: 3.4
- Total T3: 127
- Eosinophils (7%, elevated absolute)
- BUN: 16, CO2: 23
- Homocysteine: 6.0
- Insulin: 4.2
- Serum Iron: 81
- Ferritin: 108 (H)
- The gut-directed therapies appear to be helping him and improving bowel motility
- There are still fluctuations in his thyroid function that we are seeking to optimize
- There were no signs of dehydration on recent labs, insulin is more ideal, homocysteine has also decreased, and iron is mostly within normal limits
- Increase T3 to 7.5 mcg
- Resume 37.5 mcg Liothyronine daily
- Continue current supplements (stop chewable Lacto/Bifido when complete and continue other probiotic).
- Introduce boulardii powder
- Repeat lab work in 12 weeks
- He is having normal Bristol #4 bowel movements every other day
- Trial of boulardii provided some increased gas
- Is still social and interactive with siblings and in school
- Otherwise doing well without acute illness through winter
- Thyroid Panel
- TSH: 2.4 (nl, 0.5 – 4.3)
- Free T4: 1.2
- Free T3: 3.4
- Eosinophils: 4%
- Serum Iron: 123
- Ferritin: 92 (H)
- Kyle is a pleasant now 8 year old boy with a history of suspected hypothyroidism secondary to thyroid insensitivity, who makes a virtual follow-up visit after beginning work with me in August 2019 given continually increasing TSH. We have been able to decrease his TSH with the use of T3. His most recent TSH is 2.4 with stable thyroid hormone levels on 37.5 mcg Levothyroxine and 7.5 mcg T3. I have also been encouraged by his improved bowel regularity and overall functioning at home.
- Continue retrial of boulardii powder at smaller dose
- Continue other supplements and current medications
- Repeat labs in 3 months
- Kyle has continued to do well with more regular and predictable bowel movements. He enjoys home-schooling with his mother. He has had no major acute illnesses. He has been taking Vit E, histamine support, and previous probiotics while trying to introduce very small amounts of boulardii powder. He remains a happy and sociable child despite changes in the school environment with COVID-19. He continues to do well with bloodwork.
- Thyroid Panel
- TSH: 1.75 (nl, 0.5 – 4.3)
- Free T4: 1.3
- Free T3: 3.5
- Eosinophils: 7%
- Serum Iron: 97
- Ferritin: 81
- Vitamin D: 54
- Kyle has done very well with the medication and supplement regimen with his TSH now below 2 despite the same dose of medication and gaining a few pounds with growth. His iron metabolism and labwork is now entirely balanced. Vitamin D is optimal without supplementation.
- Continue current regimen
- Space out labwork to 6 months unless there is an acute change in his health
Dr. Ruscio’s Comments
Kyle has done extremely well over the last year after presenting with concerning thyroid lab findings, chronic constipation and food sensitivities. He is having regular, predictable bowel movements and is eating an expanded diet, feeling safe to try more new foods than ever before. He responded very well to the thyroid hormone replacement regimen that included T3. While I cannot be certain about the formal diagnosis of the relatively rare thyroid insensitivity syndrome, it was interesting to see how his TSH normalized with the use of T3 instead of T4 as has been chronicled in individuals with this rare condition. A simplified GI-directed, functional medicine approach was able to provide synergy with the appropriate use of thyroid medication.
I feel it is also important to note that I performed more frequent (every 8-12 week) labs over the first 9 months as I wanted to more closely monitor his clinical trajectory after establishing he could tolerate blood draws without major issues. We utilized liquid and powder supplementation for the most part to ensure his ability to take supplements. It is always important to personalize protocols for children to ensure their capacity to adhere without traumatizing them with overzealous testing and treatment regimens.
Health coaching has arguably been growing faster than functional medicine as a whole, and it has likely been challenging for you as a clinician to understand how health coaching could positively impact your practice. While on the surface it seems obvious how a health coach could support patients in making positive lifestyle change, it is likely less obvious what skills exactly you should expect the health coach to perform and what the current evidence indicates about the efficacy of health coaching for chronic disease. In this introductory review, we will seek to provide you with a foundational understanding about health coaching training and health coach skills, what the current evidence suggests about the utility of health coaching and how functional health coaching may be helpful in your clinical practice.
Key Clinical Questions
- What exactly is health coaching?
- How are health coaches trained/certified?
- Is health coach training standardized? If not, are there certain health coach trainings that are more rigorous or suited for functional medicine?
- What skills and competencies should I look for in a health coach?
- Is there evidence that certain health coaching interventions/skills actually translate into improved patient outcomes for chronic disease?
Defining Health Coaching
At this point you have likely seen various buzzwords for coaches of all sorts such as “life coaches” , “wellness coaches”, “relationship coaches”, or wellness professionals. But do these fancy definitions really mean anything?
When it comes to health coaching, there are many potential definitions, but I personally like this statement from the National Society of Health Coaches.
“Health Coaching is the use of evidence-based skillful conversation, clinical strategies and interventions to actively and safely engage clients in health behavior change to better self-manage their health, health risk, and acute or chronic health conditions resulting in optimal wellness, improved health outcomes, lowered health risk and decreased healthcare costs.
It would be hard to argue against employing someone with formal training to help achieve these goals for our patients, but where exactly does one go to get this type of training and can I trust that this training is actually providing the skills necessary to perform these tasks at a high level?
Health Coaching Training – Overview
At this point, health coach training is still very much a “wild-west” with numerous organizations and companies marketing trainings of varying lengths and intensities for individuals interested in becoming health coaches. Given this relative chaos, the first question you likely have is: “Is there any form of centralized training or oversight for health coaching?” The short answer is yes, and the process is evolving rapidly.
An organization known as the National Board of Health and Wellness Coaching (NBC-HWC) has become the leading organization seeking to certify and standardize training for health coaches across the world. As part of this standardization process, the NBC-HWC has outlined the necessary steps an individual would need to take to obtain a “board certification” in health coaching from their body. The process essentially involves 4 steps.
- Obtain at least an associates degree in some field
- Complete a health coach training program that is certified by the NBC-HWC
- Provide proof of “practicum” health coaching sessions
- Pass the NBC-HWC certifying exam
While there are obvious pros and cons to standardized education, it appears at this juncture, after reviewing the identified competencies for health coaches as set by the NBC-HWC in this document, that functional medicine clinicians seeking to employ health coaches should identify whether or not the individual has graduated from a NBWHC certified program and/or completed the post-graduation certifying exam.
Health Coaching Training – Individual Programs
For functional medicine clinicians, I feel it is important to recognize and ask these three questions when examining the specific training organizations for a potential health coach.
- Is the training created primarily from the vision of one individual or a larger organization?
- Does the training have a focus on any particular dietary or lifestyle training or a larger emphasis on nutrition than general coaching practice?
- How long is the training and how intensive are the clinical requirements?
1. Kresser Institute
- NBC-HWC certified health coach training program built from the vision of Chris Kresser
- Year long program with intensive practicum elements
- Trainees will likely to be well-rounded coaches with a focus on ancestral and functional medicine
- Trainees’ clinical approach may be narrowed (neither positive or negative) based on Chris Kresser’s personal focus on evolutionary (Paleo) health
2. Institute for Integrative Nutrition (IIN)
- NBC-HWC certified health coach training program built from a larger organizational vision
- Year long training with some practicum elements
- Broad exploration of numerous dietary patterns and arguably a greater focus on health coaching strategies outside of nutrition alone.
- IIN’s training may be less scientifically rigorous than the other trainings from the Kresser Institute or the NTA
3. Nutritional Therapy Association (NTA)
- No NBC-HWC certification, the nutrition training is built from larger organizational vision
- 9 month intensive training with some practicum elements
- Strong scientific underpinnings and a focus on nutrition, more specifically on ancestral nutrition
- Proponents of the NTA report that trainees are able to facilitate positive behavior change in clients beyond nutrition despite not being an official health coach training program.
4. Functional Medicine Coaching Academy (FMCA)
- NBC-HWC certified health coaching program with a larger focus on utilizing functional medicine principles
- The organization has a formal partnership with the Institute for Functional Medicine
- Year long training with clinical elements
- Trainees receive a solid understanding of their clinical role as part of the larger medical team and their legal scope of practice
While there are obviously many more programs than just the 4 listed above, seeking out individuals who have trained in one of these programs and/or completed the NBC-HWC certification exam, if applicable, is likely the best start for you as a functional medicine clinician looking to utilize health coaching in your practice.
Health Coaching – Clinical Skills and Competencies
Before exploring attributes in specific health coaches, it’s important to examine what clinical skills health coaches should have and whether or not these skills even translate into improved patient outcomes.
A systematic review by Singh, et al. highlighted that one of the challenges with current health coaching organizations/practices is the establishment of evidence-based core competencies. While the authors of this review state that there is significant evidence for health coaching to improve health outcomes for those with chronic disease (we will come back to this opinion statement a little bit later as I disagree with their conclusions), it is unclear what are the essential core competencies for a health coach and which of these skills actually translate to improved patient outcomes.
An additional systematic review by Wolever et al. as well as research by Hill et. al. also highlight that the challenges for rigorously evaluating health or wellness coaching stem from the lack of consensus regarding what health coaching actually is or what types of interventions fall under this therapeutic domain.
To get a better idea of health coaching competencies and skills, let’s return to the previously mentioned National Society of Health Coaches (NSHC) and examine their purported core competencies for health coaches (noting that healthcare practitioners not trained specifically as health coaches can develop some of these competencies as part of their training).
- NSHC Code of Ethics & Standards of Practice (*Semi-specific for the NSHC organization)
- Active Listening
- Communication Styles
- Transtheoretical Model of Change / Change Readiness
- Societal Influences on Behavior Change
- Cultural Competence
- Guiding the Agenda
- Use of Evidence-based Practice Interventions
- Motivational Interviewing (MI)
• Open-ended questions
• Managing resistance
- Telephonic Coaching
In reviewing this list, it seems clear that the health coach must:
- Be able to engage in active listening using various culturally sensitive and empathetic communication styles.
- Be able to guide the patient to set realistic goals with techniques such as motivational interviewing.
- Be able to work alongside the patient to address challenges while he or she seeks to make the desired dietary or lifestyle changes.
- Be able to work and communicate as part of a collaborative team.
Health Coaching – What is the Clinical Evidence?
As arguably the most comprehensive review of health coaching interventions to date, an 89 page review prepared for the Department of Veteran Affairs by the Evidence-Based Synthesis Program provided some rather interesting conclusions about the efficacy of health coaching.
- The review included a total of 41 studies with over 11,000 subjects. The trials were conducted between 2002-2016 across 9 countries with just over 60% of the trials occurring in the US.
- 18 of the 41 trials focused on Type II Diabetes and related health outcomes like HbA1c.
- Most of the remaining trials focused on individuals with a mixture of obesity, cardiovascular disease, diabetes, or metabolic syndrome.
- Broadly speaking, the clinical significance of health coaching across all of the studied diseased states was remarkably mixed and underwhelming.
- While there were some statistically significant findings in some of the pooled analyses with respect to HbA1c and blood pressure, the clinical significance of these findings were marginal to non-existent.
- “Results were mixed for the impact of health coaching on a variety of clinical health outcomes. Health coaching demonstrated a small, positive, statistically significant effect on change in HbA1c (-0.30; 95% CI -0.50 to -0.10) compared with an inactive comparator.”
- In addition, for health coaching interventions that used an active control versus an inactive control such as a wait-list, the clinical differences between groups were essentially non-existent.
- “Physical activity: We found a small, positive, statistically significant effect of health coaching on physical activity measured as a continuous variable in steps or minutes compared with an inactive control; when compared with active controls, the estimate was not significant.”
- “Weight management: We found a small, positive, statistically significant effect of health coaching on reductions in BMI compared with an inactive control. Only 2 studies had active comparators and neither of these had statically significant effects.”
Conclusions and Further Thoughts
- The comprehensive review of the Effectiveness of Health Coaching created for the VA reported rather underwhelming clinical results.
- Limitations of the reviewed studies include a fairly narrow focus on cardiometabolic disease and heterogeneity of intervention style (in-person vs. virtual), duration of each session, total sessions, etc.
- Functional medicine practitioners likely would disagree with some of the habits, dietary patterns, or other practices that “traditional” health coaches would have been seeking to help study participants implement.
- It may be more fair and efficacious when studying the efficacy of health coaching to study patient reported outcomes over clinical endpoints such as cardiovascular disease outcomes and HbA1c.
- For example, if a health coaching intervention sought to help individuals adhere to a medication regimen that even with 100% compliance would at best decrease an individual’s HbA1c by 0.3 points, it doesn’t seem fair to say that the health coaching wasn’t effective because it only resulted in a 0.3 point and clinically insignificant decrease.
- There appears to be potential benefits for health coaching when applied to the right patient population with the right knowledge/intervention to actually implement.
- When looking at the large collection of experimental trials reviewed, I disagree with the statement made in the previously mentioned systematic review by Singh et al. who suggested that there is significant evidence for the efficacy of health coaching for chronic disease.
- As it stands the evidence as collected is inconclusive and likely focused on the wrong outcomes to truly determine the effectiveness of the health coaching intervention versus the actual intervention/behavior change an individual would have been trying to implement.
- Health coaching is a dynamic and newly evolving field that is just beginning to solidify core competencies for clinical practice.
- The NBC-HWC is a new organization seeking to standardize board certification for health coaches participating in trainings offered by various individuals/organizations and likely will become a gold standard certification moving forward.
- A recent clinical review assessing the efficacy for traditional health coaching interventions reported rather underwhelming clinical significance, at least with traditional techniques applied to individuals with diabetes, obesity and cardiometabolic disease.
- With improvements in standardized health coaching practices, research will likely become more effective at discerning practices and competencies that provide clinical benefit to patients as measured by patient centered outcomes.
Perioperative Probiotics or Synbiotics in Adults Undergoing Elective Abdominal Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials
Ann Surg . 2020 Jun;271(6):1036-1047. doi: 10.1097/SLA.0000000000003581
- Probiotics: Microorganisms alone
- Synbiotics: Combination of probiotics and prebiotics
- “Perioperative administration of either probiotics or synbiotics significantly reduced the risk of infectious complications following abdominal surgery [relative risk (RR) 0.56; 95% confidence interval (CI) 0.46-0.69; P < 0.00001, n = 2723, I = 42%].”
- “Synbiotics showed greater effect on postoperative infections compared with probiotics alone (synbiotics RR: 0.46; 95% CI: 0.33-0.66; P < 0.0001, n = 1399, I = 53% probiotics RR: 0.65; 95% CI: 0.53-0.80; P < 0.0001, n = 1324, I = 18%).”
- “Synbiotics but not probiotics also led to a reduction in total length of stay (synbiotics weighted mean difference: -3.89; 95% CI: -6.60 to -1.18 days; P = 0.005, n = 535, I = 91% probiotics RR: -0.65; 95% CI: -2.03-0.72; P = 0.35, n = 294, I = 65%).”
This is a fairly large meta-analysis (34 RCTs, 2723 participants) showing a very powerful and clear benefit from probiotics and synbiotic preparations to reduce post-surgical complication with essentially no risks. This clinical data goes against some previously published mechanistic data showing concerns for delayed normalization of the gut microbiome when certain probiotics were given after an antibiotic course. Remember, clinical data and outcomes trump mechanisms.
Randomized Trial of Lactin-V to Prevent Recurrence of Bacterial Vaginosis
N Engl J Med . 2020 May 14;382(20):1906-1915. doi: 10.1056/NEJMoa1915254.
- Researchers studied in 228 women the use of a specific probiotic, Lactobacillus crispatus CTV-05, given vaginally, daily for 11 weeks following the use of metronidazole vaginally for the prevention of relapse of bacterial vaginosis (BV).
- They found that compared to those treated with placebo, there was a decreased recurrence of BV in those given the vaginal probiotic after intravaginal antimicrobials.
- “The use of Lactin-V after treatment with vaginal metronidazole resulted in a significantly lower incidence of recurrence of bacterial vaginosis than placebo at 12 weeks.”
- Side effect profiles in the placebo and treatment groups were similar.
- “The percentage of participants with local or systemic adverse events was similar in the two groups.”
Association of Daily Step Count and Step Intensity With Mortality Among US Adults
JAMA. 2020 Mar 24;323(12):1151-1160. doi: 10.1001/jama.2020.1382.
- Researchers performed a retrospective analysis from an epidemiological data set (4840 participants) in the National Health and Nutrition Examination Survey (NHANES) seeking to assess associations between accelerometer-measured step counts and all cause mortality.
- They found significantly decreased hazard ratios for all cause mortality in the at least 8000 step per day group as well as the 12,000 step per day group.
- “Compared with taking 4000 steps per day, taking 8000 steps per day was associated with significantly lower all-cause mortality (HR, 0.49 [95% CI, 0.44-0.55])”
- “as was taking 12 000 steps per day (HR, 0.35 [95% CI, 0.28-0.45]).”
While this data is only correlative, and the average step count reported was near 10,000 per day, which seemed a little high for the average American, there was some compelling evidence for at least an association between step count and a surrogate marker for global movement and all cause mortality.
Building a Functional Differential Diagnosis and Treatment Hierarchy
One of the best tools you can use, even as a seasoned clinician, is an expansive pre-populated checklist of common diagnosis/issues you encounter in your patients. One of the issues we see for many in functional medicine practice is the over-diagnosis of certain conditions or the prioritization of certain conditions due to clinical bias. By building out an expansive differential diagnosis checklist that you run through for each patient, you may find that certain clinical problems that were previously overlooked are actually noted because of the checklist. After building your differential diagnosis using the checklist, you can then prioritize the patient’s specific concerns and organize clinically which conditions/symptoms will likely improve by treating certain upstream problems (ex. gut imbalances). The differential diagnosis checklist will ensure you are not overlooking key issues or over-prioritizing problems that could actually have been fixed by addressing more important upstream issues.