Were you disappointed you couldn’t make it to London for Dr. Ruscio’s recent Functional Medicine seminar? Well, don’t worry because this week, we bring you three of the best topics of the seminar!
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Dr. R’s Fast Facts
- Often times a positive lab value has no meaning. It’s important that both doctors and patients realize this because it can prevent unneeded fear and worry.
- We discuss examples regarding thyroid, SIBO and mercury.
- Results some labs call abnormal are actually normal – some labs have even been sued because of this.
- There are a few components essential to reading and interpreting lab work:
- Response to treatment
- Not all studies are created equal. The use of low quality scientific data, while ignoring high quality scientific level data, is one of the main reasons for confusion and disagreement on the internet. We define high and low level science and site examples regarding:
- Prebiotics and Crohn’s disease
- Probiotics and SIBO
- Probiotics with antibiotics
- Iodine and thyroid
Weekend seminar description…..6:21
Are you really sick?…..8:54
Examples of reframing diagnoses…..13:32
Reading lab results…..22:57
Reading and using scientific studies…..32:13
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Are You Really Sick? How to Read Labs and How to Use Science
Welcome to Dr. Ruscio Radio, discussing the cutting edge in health, nutrition, and functional medicine. To make sure you’re up to date on this and other important topics, visit DrRuscio.com and sign up to receive weekly updates. That’s D-R-R-U-S-C-I-O.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, this is Dr. Ruscio. I just wanted to give you your fast facts on this episode, How You Really Sick?—How to Read Labs and How to Use Science. This was pretty much a reflection from some of the things that struck me as particularly useful for the group of practitioners that I recently had the opportunity to teach in London. I think there are some very important concepts embedded in this episode that can help with critical thinking, either as a doctor or as a patient, that can be applied to pretty much everything you read, listen to, and do and really help guide you to be better as a patient in terms of figuring out what to do to become healthy or better as a doctor—kind of, albeit trite, teaching a man to fish rather than giving a man a fish, so to speak. Here are your fast facts.
Oftentimes a positive lab value has no meaning. It’s important that both doctors and patients realize this because it can prevent unneeded fear and worry. We discuss examples regarding thyroid, SIBO, and mercury.
What some labs call abnormal is actually normal, and some labs have even been sued because of this. There are a few components essential to reading and interpreting lab work, involving history, symptoms, context, and response to treatment. Not all studies are created equal. The use of low-quality scientific data while ignoring high-quality scientific data, is one of the main reasons for confusion and disagreement on the internet. We define high- and low-level science and cite examples of this regarding prebiotics and Crohn’s disease, probiotics and SIBO, probiotics used with antibiotics, and iodine and thyroid. That’s it. I hope you guys really get a lot out of this episode. If you have thoughts or comments or questions or challenges, please comment in the comment section that is associated with the post/transcript for this episode, and let me know what you think. All right, here we go. Thanks.
DR: Hey, folks. Welcome to Dr. Ruscio Radio. This is Dr. Ruscio, and I am here with Susan McCauley of Evolve Nutrition. Hey, Susan, how are you?
Susan McCauley: I’m doing really well, Dr. Ruscio. I can’t wait. I know you’ve been to London recently. I haven’t been to London in a really long time. I told you to eat—wait, before we get into all the nuts and bolts, I said to have some fish and chips and British bangers, and I told you that the beer tasted like dirty socks.
DR: Yeah! The beer was actually pretty good, from the beer that I had. The food was overall great, and the city was just beautiful. I stayed right kind of in the middle of… I’m not sure of the name of the region, but it was pretty much where everyone went to take pictures.
DR: That was right outside my front door, so that was really cool. And the weekend, especially the one day that was the training event for the practitioners, was just super well received. I literally almost got choked up at one point because the feeling of just gratitude coming off of the audience was really almost overwhelming. It was just really nice to see so many light bulbs go on and see people really appreciate the information. It was a great group. It was a great day. Everything that could have gone wrong went wrong!
SM: That’s always how it is when you travel.
DR: The power to the building was not working until 10 minutes after I was supposed to start speaking on Sunday, and then two hours later, a fire alarm went off. But the audience knew that there was nothing that we could do about it, and we all had a good laugh at it. We ended up staying a little bit later than we had anticipated, but it was really good.
There were a few things during the weekend that, just noting how important it seemed to be for people, some concepts, it really kind of reaffirmed for me some things that maybe we haven’t talked a lot about and they’re not super-protocol-based or “here’s how you treat SIBO,” necessarily, but they’re a little bit deeper in terms of how we interpret labs, are you really sick, and the whole issue of how we frame things to patients, which I think is really important, and then also how to interpret science. Just some basic rules that are pretty basic principles in interpreting studies, I went over them, and I just saw, like, a thousand light bulbs going on in people’s heads. So I thought we could go over those things now, and hopefully these will be as beneficial for the people listening as they were for the people in the audience on Sunday.
SM: Before we start, why don’t we back up. I know we were putting the promo in for people that were listening to the podcast, but why don’t you tell everybody about what this symposium was—your topic, who was there—so they can kind of get an idea and kind of envision it before you dig in and tell them all the awesome stuff that you guys talked about and the light bulbs and all that.
Weekend Seminar Description
DR: Well, it wasn’t a symposium. It was a weekend seminar. The first day was Melissa Hartwig speaking for three hours about the Whole30 program and then me speaking for two hours after that about, if you do a program like the Whole30 and you don’t see optimum results, what might be some of the next functional medicine steps that you’d want to take to help regain your health or get the results that you weren’t able to fully get with diet. Of course, a lot of that was centered around gut, like a lot of the things that we’ve talked about.
Then the second day was five hours of myself presenting for three hours on the gut and the microbiota and then for two hours on different thyroid disorders. That was pretty much it.
SM: OK. I think that that’s really good, that first day with Melissa talking about the Whole30. The Whole30 is how I got started on this whole journey, and I credit it really for who I am and what I am today, especially Melissa because we have some similar backgrounds. But get the real food part in place first because, like you always say, sometimes that takes you 100 percent of the way there, or sometimes it takes you 80 percent of the way there.
SM: And then what do you do after that? But get the food dialed in first.
DR: Precisely, and that’s why it just seemed like a good fit for her and me to do something together because of that natural progression and also because I think Melissa and myself share the same thinking that sometimes in this space we become a little bit too alarmist, a little bit too fanatical about things, and I think we both share kind of a practical, minimalistic, non-alarmist sort of position, and so our information dovetails together really nicely.
SM: Interesting. I wish I would have been there.
DR: Well, we’re trying to set up something in the States, either a joint event between her and me or I definitely know I’ll be doing at least one seminar in the San Francisco area in probably the fall of this year that will be the gut microbiota and GI. I may do a thyroid component, depending on how long I do. We’ll put notices out through the podcast and the newsletter as it approaches and as some of the details finalize.
Are You Really Sick?
DR: With that, let’s jump into the first point—and this is the term that I used—are you really sick? Maybe another way we could describe this is how we frame things for our patients as doctors and clinicians, or how we interpret things that we read on the internet as patients or just healthcare consumers. I think this is really, really important because we could have, for example, the same person with the same lab values, and they could see two different doctors or clinicians or what have you, but based upon the dialogue of said clinician, that person could be walking around every day for the rest of their life thinking that something is wrong with them when it actually may not be. Or conversely, someone could be feeling happy and carefree because they haven’t been cajoled into thinking that something is wrong with them.
If you really take a step back from everything and think about this, the way you frame things for a patient is very important because you can make someone feel bad about themselves or good about themselves with the same kind of findings. Some lab findings can be interpreted in such a way to make them seem like you’re going to have major morbidity or like there’s going to be no problem at all. This is not a criticism, but where I think this comes from is, as we enter into a more progressive care model, as we leave a conventional model that’s very restricted and we go into a care model like functional medicine that’s more progressive, we’re trying to look at lab findings and signs of imbalances more closely, and that can be helpful, but it can also be detrimental because it can sometimes create this syndrome of thinking that there’s a major disease or pathology or problem there when there actually is not one there.
Does that make sense so far?
SM: I think it does, and I think it’s really super important because your mind is so powerful. That’s why there are so many scientific research papers and projects on how meditation can affect disease, and if you’re portraying something as something very negative to somebody and they take that away as opposed to something, “OK, well, this is what it is,” and not turning it into a fatal something or rather, I think that the mindset of the person… I know one time I got a weird lab result, and I just went down the rabbit hole, and all it was was I’d had a cortisone shot. Why did I get hormonal blood work done the week after the cortisone shot? Everything was out of balance, and I went to three different doctors, trying to find out what was wrong with me, and guess what? Nothing was wrong with me. It was my body’s normal response to something.
DR: Right, and you make a great point, which is if there is a lab finding that seems unusual, sometimes that can just be noise. Something that can be a normal for a patient, which I want to provide a few examples regarding in a moment, but also retesting that marker a lot of times is a good clinical decision. There have definitely been times where I’ll see something that looks abnormal, and before I freak out a patient, I’ll say, “Well, this looks a little bit unusual to me. I wasn’t expecting for us to see this. I think this might be a mistake or a false positive or what have you. Let’s retest this just to make sure this is the case.” And in many cases, it ends up being just a transient elevation or there was some lifestyle factor like you mentioned, Susan, that wasn’t accounted for or what have you.
DR: Here are a couple of examples that, specifically, I see in the clinic that when I reframe these things for patients, I take a huge emotional and psychological burden off of their shoulders. As you said, Susan—you made an excellent point—this is a big deal because this can be the difference between someone walking around every day feeling like something is wrong with them and periodically just looking stuff up on Google that further reinforces this potential disease that they have brewing underneath the surface. It can put someone down that fork in the road, or alternatively they can not have all that stress and all that internal burden and worry.
Examples of Reframing Diagnoses
DR: With thyroid antibodies, after a few years of looking at the antibodies pretty closely, I see that what I would term and unmanaged case of thyroid autoimmunity usually presents around—looking at the TPO antibodies, specifically, which shouldn’t be above 35, typically an unmanaged case, as I believe it, would be somewhere between 700 and 1400. That’s a pretty good elevation. And when we manage someone’s thyroid autoimmunity and we go through all the different items that we can go through to help calm the immune system and turn the autoimmunity around, we typically see someone settle in maybe around 1 to 300 and remain there and have no symptoms as a byproduct of that. And many patients are able to decrease their thyroid medication dose if they’re on thyroid medication, and some can even come off completely.
Now, what I sometimes have to explain to patients is, “No, because you read this article on the internet about how the autoimmunity needs to be fully shut off or it’s going to ruin your thyroid and what have you,” I have the dialogue with them that, “I consider this a clinical win and you’re feeling good. You’re feeling much better than you were four months ago, and I’m very happy with where you’re at, and I don’t think you have to worry about that.” It makes a massive difference in someone’s psychology, and I don’t think that we need to be so fastidious about the antibodies because, again, I see many patients that when they are doing fantastically well in terms of their health and all of their other lab markers, they may settle in at an antibody level of between 1 and 300. Some patients go completely down to zero; however, I’ve seen some patients that have been at zero and still been very sick. It brings me back to this clinical point of practicality, which is let’s get a patient healthy, let’s use the lab work to guide decision making, but the lab work isn’t the end-all, be-all. If someone is feeling really well, then we’ve treated all the modifiable factors regarding the autoimmunity, and if at that point we still have a transient elevation between 1 and 300, then I’m just fine with that.
Now, there are also the partially positive SIBO patients. Yesterday in the clinic was a really interesting example of that. There were three cases that had seen fairly dramatic symptomatic improvement in their SIBO and had maintained it for a number of months, yet they still had a mild positivity of their SIBO values. They were still considered positive, yet they had improved tremendously, and they were maintaining the improvements. And so at that point, we elected not to treat anymore, and patients were happy with that. I think it’s another important concept that if someone has gotten to the clinical endpoint of having no symptoms, we don’t always have to keep treating the bejesus out of them to try to force the lab values into the area that we want it to be. I’ve seen this with a number of patients now.
SM: Yeah, I think you make a couple of good points because when you’re just treating to lab values, then you become like allopathic medicine and just taking one medication to lower your HbA1c or to lower your cholesterol. Even though you may feel fine, the doctor is giving you these medications. Then you become kind of along the same path as them!
DR: Right, exactly.
SM: That’s what functional medicine means! I might be getting ahead of us because you might have this on your list, but when we’re trying, “Are you really sick?” and talking about the frame of mind and how you frame things, that’s the case, again, for not over-testing right in the beginning because if you give them this abundance of tests, a lot of those are going to come in out of range and negative, whereas if you start, like we talk about, with the gut and if you start with one thing, clear that up, you may never even have to test for that other thing. But if somebody gets 20 negative things in one day, they could just think that they’re dying or it’s not worth it or it’s too much, it’s too complicated. Anyway, I just thought that that was another case for that.
DR: Yeah. There are actually two interesting pieces embedded in what you say. One has to do with how to interpret labs, and that’s one of the next things I want to come to in just a minute, and then the other has to do with what does a “positive” on a lab value actually mean? This is another very interesting piece, and this is why I think being conservative in your thoughts and actions is very important.
DR: Elevations of mercury: I spent a few months reviewing all the literature on mercury, and I’ve written a really nice chapter of a book that I’m not sure when it’s going to be released and where or what have you—
SM: You keep promising us!
DR: I know. We’ve talked about it, and I want to get that out. Once the book is written, there’s going to be a flood of articles coming out to the website because that’s kind of the bottleneck right now. Some of these things are 90 percent done, but they need to be looked at by an editor and what have you because my spelling and grammar is terrible. Truth be told, that’s the main reason!
But for mercury, for example, some of the more popular labs regarding mercury toxicity have been very bluntly called on the carpet for what we may term fictitious values, and I believe there’s even been litigation brought against a couple of these labs. Their positives are what we see positive in pretty much the entire population, and there’s very little validity to these values. I may be incorrect, but I’m fairly certain that there’s even been legal action brought against some of these labs for this.
SM: I think I’ve heard this, and it has to do with the range that they’re using for provoked mercury tests. They’re using the same range as they are for the unprovoked, which is ridiculous. It needs to be a whole entire different range.
DR: Yes, and how this can be so problematic is if patient Suzy Smith goes and sees a “functional medicine doctor” who is not well trained or not looking at these things through a more conservative or more science-informed perspective, then that person could leave and be concerned about this heavy metal toxicity that is going to be causing all these problems. However, when we look at a large body of literature, we see that even mild elevations for a large part of the population, like populations that have mercury fillings, do not correlate with any morbidity or mortality or even symptoms.
It’s not to say that mercury is not an issue for some people; however, I think what has happened a lot in this area is that we have these lab values that are really fictitious and don’t correlate with any disease process, and there’s been this over-exaggeration of what is actually a positive and what’s not a positive. Again, why that’s so problematic is you can create the feeling of there being a problem in someone when there really isn’t, and that can create a chronic stress response and chronic psychological worry and distress, and that can be extremely damaging. Hopefully this short little narrative will help people with this issue of not getting too spun out about a positive lab value if you see one as a patient, and as a doctor, maybe rethinking how strong of a language you use when informing a patient as to what a lab value means.
SM: And as practitioners continue to learn and read the literature and don’t get stuck in something that might be something that we knew five or ten years ago, but today, especially with the mercury because that has kind of recently come about over the last couple of years that the way we used to do it was wrong and now there might be a new way to look at mercury and a new way to test and maybe not as many people have mercury toxicity as we thought.
DR: Yeah, it’s a fine line to walk, and it’s a double-edged sword where in trying to help people and looking at these things more stringently, we have to be careful not to create disease or dysfunction where there is none.
Reading Lab Results
DR: With that as a transition point, let’s talk about how to read labs because I think if this principle is well understood and mastered, it can prevent someone from getting pulled into erroneous or fictitious labs. I actually have had two labs to date… actually three, three labs to date, where, based upon using this process and what we might call clinical introspection, I’ve actually been able to determine labs that were later documented to be highly inaccurate or erroneous.
This comes back to something we’ve talked a lot about, which is principles rather than methods. Rather than just following whatever lab is in favor, if you can walk through this process—and we’ll detail it here in just a second—of thinking critically through the labs and how it correlates with everything else, you can really have an intuition as to whether or not a lab is helpful or not, even before the published data arrives, which I was fortunate to be able to do with three labs.
The first thing I look at is actually a combination of three things: the history, the symptoms or what we also call the presentation, and the context.
The history may be… let’s take an IBS case, I guess. The history may be someone—and I’ll just give a very short history—who generally has no health complaints until they enter into menopause and then they start developing all the symptoms of IBS: bloating, constipation, and gas. That’s the history.
The presentation is just all the symptoms, which are we have a 58-year-old female with IBS that’s been fairly constant for the past year.
Then the context would be what else colors or may be influencing this. This person, let’s say they’ve been eating paleo for six months. These symptoms have been present for a year. They said that after six months they went on paleo and they saw a 30 percent improvement in their symptoms. That context is very important because had someone been on the Standard American Diet, based upon that contextual piece of information, I would not recommend testing. I’d recommend going onto a paleo diet and then reevaluating, but since the context here suggests that this patient has kind of qualified herself to go on to the next level, which would be testing, we can now make that next step.
Does that make sense?
SM: Yeah, it really does. It’s funny because sometimes when you switch to a paleo diet, I think with my IBD it delayed my diagnosis because the symptoms started, Kaiser said, “Take this medication for the rest of your life. It looks like you might have something called ulcerative colitis, but we’re not really sure. Take this medicine for the rest of your life,” and left me alone. About a year later, I switched to a paleo diet. Most of my symptoms went away, but they still kept coming back now and then and nobody could figure out what I really had until two years ago August. So, yeah, sometimes it’s good to be on that real food diet, but then that’s when the functional medicine piece comes in.
DR: Exactly, because diet can be as effective as many of the frontline treatments in conventional medicine.
DR: That’s important, and then also, many of the symptoms that may prompt further functional medicine testing and treatment may go away after you change your diet. Exactly, but if they don’t, then you’ve qualified yourself to intelligently move to the next step, which would be testing.
Now, for this patient, I’m not really concerned, let’s say, about mercury toxicity, and I’m not really concerned about thyroid because there’s not a lot in the symptoms that suggest that, but of course, IBS symptoms would prompt me to test for SIBO, and I also am going to be keeping an eye on her female hormones. I may or may not test for that because I think in a lot of cases we have herbs that work really well to kind of modulate the female hormones, but those are the two things right now, based upon the history, the symptoms, and the context that I’m looking at—predominantly SIBO and then the other one. Because the SIBO seemed to start when the hormones shifted into menopause, the female hormones would be the other. Now we use all the information to guide our testing, and the testing, again, would be a SIBO test.
Now we look at the test results, and we should be looking and evaluating together the test results all compared and contrasted with the context, the symptoms, and the history. Let’s say she comes back positive for SIBO and she’s very, very high for SIBO. Now we treat her for the SIBO and she responds. The response to treatment, in my opinion, is almost equally as important as the lab values because you look to the response to treatment to reinforce that that lab values were actually helping you uncover the cause of the symptoms. This is really important because if you’re treating patients and repeatedly noticing that there’s a minimal or nonexistent response to treatment of the lab value, that tells you that the lab value may be skewed. This is one of the main reflections that I use to really help me determine when some of these labs aren’t working very well. The response to treatment is very important because it helps you reinforce if the lab values were actually true problems and things that really needed treatment.
Does that make sense, Susan?
SM: Yes, it does. It really does. It’s another case for overtesting. If you had 30 results but one result didn’t have anything to do with what we were testing, it doesn’t even need to be looked at. So look at your history, symptoms, and context; do the tests that fit with those; and then look at the results and see how they apply to number one—the history, the symptoms, and the context.
DR: Exactly. We use all these things together, and the analogy I used with the group in London is it’s almost like you’re an attorney trying to build a case based upon the evidence.
DR: Oftentimes in clinical medicine it’s not black and white. There’s a lot of gray, and so what you have to do is build the best case—based upon the evidence—that you can. That’s the way I look at these things, and I think by doing this we can achieve something that I think desperately needs to be achieved, which is moving doctors and practitioners beyond a protocol-following model to a model where one can think for themselves and think through these things clinically.
This is definitely the thing that I see people struggle with the most, and I think it has to do with our academic system. Our academic system is very memorization and regurgitation based, and the art and the concept of critical thinking has really been lost. I hope that we’re not harping on this concept too much, but based upon my observations, it seems like this is one of the factors that really needs to be brought to the forefront and done a better job with.
SM: Right. It shouldn’t be A plus B equals supplement protocol every single time for every single patient that you have. It’s never going to be that way. Every body is different. Every symptom, context, and history is going to be different, so if you’re a practitioner out there and you’re giving everybody the same thing, it’s time to step back and look at what we’re talking about today.
DR: Mm-hmm. By listening to your patients and their response and reflecting on everything that you see and hear in your observations and interactions with patients, you can learn a tremendous amount. I’ve learned an equal amount from just listening to and monitoring my patients and observing them as I have from all of this extensive study I’ve done in the medical literature. It’s a very, very important part of clinical practice. And for the patients listening to this, I guess what I would offer you is this would be something to look for in your doctor when trying to determine if the doctor or the practitioner is the right fit for you.
SM: Right. What’s next?
Reading and Using Scientific Studies
DR: How to use science. One of the fundamental strings I think this pulls at is I think the inability or the misunderstanding in terms of how to use science is one of the major reasons why we see so many conflicting opinions and recommendations on the internet. I think it has to do with the fact that what’s termed as low-level science… now, “low-level” is not meant to be insulting.
There’s a great pyramid diagram that will accompany this podcast transcript that I would really urge everyone to go look at. It’s a pyramid, and at the bottom of the pyramid we have the lowest-level science, and at the apex of the pyramid, the top of the pyramid, we have the highest-level science. As I’ve learned and grown over the past several years as a clinician and as a researcher, I’ve realized that when I’ve been off the mark, it’s usually been because I’ve been building a case predominantly based upon low-level science. I’ve learned so much by being able to try to keep my focus to higher-level science.
What we’ll see on the internet is people will be looking at low-level science, making recommendations, writing articles, and this even permeates into functional medicine education, where sometimes the… and again, I say this with all due respect to people who are educating because I think everyone is doing anything in this movement with the best intentions, but it doesn’t change the fact that the wrong things done for the right reason can still be very detrimental. I just want to be clear in saying this is not me trying to tear down someone else, but I’m trying to call attention to something that’s very important for us all to be aware of. This is something I used to be guilty of myself, and I’ve improved as I’ve evolved as a clinician and as a researcher.
What we’ll see—again, both on the internet with blogging and things like that and even all the way up through functional medicine educational seminars—is a case being made based upon really cool, fancy mechanism data. It’s a cell line study, it’s an animal study, it’s a cellular mechanism that’s being cited, and that is considered the lowest-level evidence, and it’s very poor practice to use that type of evidence to drive clinical recommendations. I think what we’re all really after at the end of the day is clinical information because we want to know, how can this help me feel better? That’s the clinical data tells us. So at the bottom of this pyramid visual you will see what’s known as in-vitro or test tube research, and right with that is animal model data. That is considered the lowest level of scientific evidence.
Now, as we come up the pyramid, we see what are known as case reports and case series. This is where doctors start noticing interesting things and say, “Hey, we had a patient with this. Here’s what we found. This is kind of interesting.” That’s a case report. Then this association may be observed with a number of patients, so that’s a case series.
Then eventually, as we come up a little bit higher, we get case-control studies. These are essentially randomized controlled trials, to put it loosely. Now we start using this information. Maybe an interesting cell finding was found and that got someone thinking about, “Let me observe this in patients.” The observation was made in patients, and now we start doing these case-control studies or placebo-controlled studies. Now, a placebo-controlled study is when we gave half of the patients this treatment, and the other half of the patients did not get this treatment—placebo-controlled studies.
Then finally we can get up to the level of systematic review, and systematic review with take a number of clinical trials—and in most cases, they’re clinical trials that are reviewed—and we’ll take a number of clinical trials and look at the aggregate finding of what the placebo-controlled clinical trials showed.
To zoom us out and to help anchor people if they’re getting a little bit lost, the reason why looking at a systematic review is so important, compared to just looking at one clinical trial, is because one clinical trial is like walking down the street and grabbing someone and saying, “Hey, I’ve never been to this restaurant. Have you ever been there? What do you think?” That person will give you their opinion, but what is the likelihood that that person could have had an unusually good or bad experience at the restaurant? Right? Asking one person what they think of a restaurant is like one clinical trial.
A better strategy would be to go onto Yelp and look at what the reviews were from 83 people who went to that restaurant. Now you’re much more likely to get a true representation of what that restaurant is like. That’s a systematic review. A systematic review is looking at the reviews from 83 studies compared to asking or looking at just one study.
Then the systematic review with meta-analysis, which is the pinnacle, is just taking those 83 reviews and giving them a mathematical score. “They got 4.5 out of 5 stars on Yelp.” That’s essentially what a systematic review with the meta-analysis is. It’s just giving what did 83 studies show, what did 83 people think, and giving that a mathematic score.
To tie this all back together, the confusion oftentimes emanates from the fact that people are citing the lowest-level evidence, which is animal data and test tube research and mechanism data, and not citing the clinical trials, the systematic reviews, and most importantly, the systematic reviews with meta-analyses.
Now, I want to be careful to say that in the absence of higher-level scientific data, sometimes we can only speculate from what’s available, lower-level scientific data, but this oftentimes is not what happens. What happens is people are ignoring the high-level scientific data and just getting lost in the details of these cellular and mechanistic studies. The analogy I like to use is that trying to navigate through the clinical process using low-level scientific data like cell studies is like trying to navigate from Massachusetts to California looking through a microscope.
SM: Oh, goodness.
DR: Yeah. You would so easily get misled.
Now, here are a couple of examples to tie this back to how this plays out in the real world. Regarding the microbiota, we see literature being published—observational, oftentimes cell line studies—showing that Faecalibacterium prausnitzii, certain bacteria, has antiinflammatory characterics. Because it’s antiinflammatory, it may be able to help with inflammatory bowel disease, like Crohn’s and ulcerative colitis. OK. Now, I’ve personally seen some people recommend that because of this cell line finding, those with inflammatory bowel disease, ulcerative colitis and Crohn’s, take prebiotics because other cell line studies have shown putting prebiotics into the cell culture increases the growth of Faecalibacterium prausnitzii and it has an antiinflammatory effect. This all sounds pretty good.
SM: Not if you have IBD!
DR: Yeah, until you realize that clinical trials have been done, and harm has been done to the patients who took prebiotics in attempts to help with their inflammatory bowel disease. This is a perfect illustration of how when we look at low-level science we can be misled—even if it looks appealing. This is one of the major reasons why there is so much confusion in this space. It’s because people are making clinical recommendations based upon low-level cellular and mechanism studies while ignoring the higher-level clinical science.
SM: You need to look at the whole body sometimes of work on a specific issue. If you google or you search, if you’re only looking for what you want to find, I guarantee you you’re going to find it.
SM: I do this with ulcerative proctitis, IBD, my diagnosis, so I can see the whole body. If I thought prebiotics would help me, I would just google that or look at that on PubMed instead of looking at the whole body of literature and looking at how many tests have been done, not just taking the best results. You need to look at the whole volume or body of work on a particular issue before going down the rabbit hole.
DR: Precisely. This is why people listening or reading sometimes maybe hear me make a criticism of a standard opinion that’s floating around out there. This is usually after me and my team have gone through an extensive review of this literature from the top down and sorted the evidence from highest level to lowest level and weighed out what the aggregate findings show. This is why sometimes I come down on an issue with a different opinion than maybe the majority, and I think the reason why this happens is because of the misguided nature in which how we use science. There are one or two other simple examples I want to provide people with.
Another example of, again, being misguided when looking through the microscope, is that we shouldn’t take probiotics in SIBO because there’s already an overgrowth of bacteria. It makes sense; however, when we look at clinical trials, we see that with the symptoms of SIBO and IBS, there’s incontrovertible data—again, systematic reviews and systematic reviews with meta-analyses—showing that probiotics help with IBS and also some studies and clinical trials showing that probiotics can be a successful treatment for the gas elevations in SIBO.
Not only that, we also have maybe what we would glean from cell line studies or culture studies again, where when we put probiotics into a medium with antibiotics, the probiotics die, so this leads people to conclude, “Don’t take probiotics with antibiotics,” or, you could also infer, herbal antimicrobials. However, again, we have systematic reviews, which look at multiple, multiple, multiple clinical trials that have concluded that taking probiotics with antibiotics enhances the effectiveness of the antibiotic.
And maybe a final and also interesting but not gut-related example would be looking at iodine and thyroid. In the weekend seminar, I feel like a dropped an atom bomb on the audience with going through how incontrovertible the science is showing that increased iodine consumption fuels thyroid autoimmunity. However, I think why we get misguided is because—and I put a slide of this up on the PowerPoint—we can look at a cellular diagram from Guyton’s Textbook of Medical Physiology where you can clearly see iodine has to go into the thyroid in order to make thyroid hormone. So logic would suggest if the thyroid gland needs iodine to make thyroid hormone, if you’re hypothyroid, iodine would help. But when we go through an overwhelming number of observational studies and, more importantly, clinical trials, we see that iodine fuels thyroid autoimmunity, and we’ve even been able to reverse hypothyroidism and Hashimoto’s by having people go on a lower-iodine diet.
Again, one of the major reasons why I think there is confusion in this space is because people don’t amply understand how to use science to guide decision making.
SM: Then remember when you’re watching television or on the internet or all the different media where the media cherry-picks things out of studies and blasts it everywhere, they haven’t done any of the stuff we’ve talked about today. They have just taken one study and one headline that makes people turn the news on that night or click on that article to get you to click and watch that. These screaming headlines usually end up being not true.
DR: Exactly. To really master this, I think, sometimes might be easier said than done, and here’s an example of this. Someone from the weekend seminar posted a question on my Facebook page about selenium. We talked about selenium in the seminar, and we’ve done videos and other posts discussing how selenium can help treat thyroid autoimmunity. However, this person asked, “What do you think about selenium? Couldn’t this help prevent some of the negative problems from iodine?” which is true, I think, anyway. But they linked to an article, and in the article, I think there are four scientific references. Three of the four are literally cell line and mechanism studies.
So if you want to follow along, go to my Facebook page. My reply to her was, “This is very interesting, but what type of evidence is missing from the references in this article to help you ensure that this is not going to mislead you?” She hasn’t responded yet, but I am hoping to God that she says something along the lines of clinical trials or interventional data because that could show me that she was able to really absorb that concept and carry it forward into her life. It may have been hard for this particular person to absorb that amongst the onslaught of information over the weekend because I gave them, like, drinking-through-a-firehose information on gut and thyroid. I don’t expect everyone to be able to master every principle after one exposure, but that’s why I like to use the Socratic method of asking questions back to the person to guide them to realizing the answer on their own rather than just telling them the answer.
SM: That’s critical thinking again.
DR: There it is.
SM: Instead of telling somebody the answer, teaching them to think through the process to figure it out themselves.
DR: That’s it. Yeah, the Socratic method is a really interesting way to get people to not rely on your brain, but start using their own brain to figure these things out, definitely.
SM: It looks like we are just about out of time… unless you have more stuff, more great information bombshells you want to drop on people today.
DR: No, I think that’s it, and I just want to close by reiterating that these constructive criticisms that I’m posing are not meant to make anyone feel like I’m attacking them or frankly criticizing them as if they’re a bad person or doing something bad if this is something that you are doing because this is something I was doing myself years ago. But I’ve been fortunate to be able to learn and always keep an open mind and be evolving, and so I want to share this and have this open dialogue and this open constructive criticism so that we can all be aware of these things and move in a direction where we get better because I ultimately want us to be able to help as many people as possible, and if we’re all thinking on a higher level, then we’ll be able to help more people. In case anyone is misconstruing where I’m coming from with this, that’s where I’m coming from. Hopefully that was apparent throughout the episode, but if not, I just wanted to close with that thought.
SM: Yeah, and I think, exactly, that our goal here is to make more people healthier. To me, helping people is why I do this. It’s to make people better and healthier and happier, and by continuing to grow and learn, that’s how we can do that.
DR: Exactly. We’re all here, I think, for the same reason, and let’s all try to get better at achieving the endpoint of making people healthier.
SM: Exactly. OK, well, that’s it for this week, guys. We will be back next week with another great episode. Talk to you soon, and be good to yourselves.
DR: Thanks, Susan. Thanks, guys. Bye.
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