How to Improve Fatigue & Constipation Without Thyroid Meds

Episode Intro:

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

DrMichaelRuscio:

Hey, everyone. Welcome back. I am very excited to bring you a case study today with Dr. Joe Mather and myself going through one of his patients from the office wherein we were able to get someone off of a thyroid medication while improving their gut health, reducing their fatigue, reducing their IBS, improving their constipation and improving their food tolerances all by responsibly navigating through our model. So, just a case study chock full of examples of how we can avoid some of the pitfalls of functional medicine. And if we use a science guided algorithmic process, it can improve many symptoms with only minimal intervention. This is because we’re going after the interventions that are the most causal or the most upstream, and we’re avoiding some of those downstream appealing (but, incorrect) traps that people oftentimes get sucked into. So, we’ll transition over to the case study now, but essentially it’s about being able to get off of thyroid hormone medication that was not needed, improved gut health as evidenced by improved bowels and less fatigue, improved food tolerance and even a reduction of heavy metal burden even though no detox therapy was used. So, just a phenomenal case study that really supports the model of functional medicine that we are trying to develop, evolve and pioneer. If you’re enjoying the show, please leave us a review in iTunes. And we will now go to the conversation with Joe and myself, and that will then be followed by a recording where Joe spoke directly with this patient. Her name was Beth, and she gives her account and experience. Okay, here we go.

DrMR:

Hey, everyone. Welcome back to Dr. Ruscio Radio. This is Dr. Ruscio here with Dr. Joe Mather, the medical director extraordinaire from our clinic. We are very excited to bring you today a case study that exemplifies several important points of which we oftentimes harp on the podcast. We’ll go into more detail here in a moment. Joe will give us the once through high level summary and then him and I will go back and forth on unpacking some of the details. So, Joe – great to be with you again, my friend.

DrJoeMather:

Nice to talk to you, Michael. How are ya?

DrMR:

I am great. I’m almost giddy with excitement about this case study because it really does help portray a few of the principles that we harp on and we’ve integrated into the model at the clinic. So yeah, I’m just curious to get your read through and then unpack some of this for our audience.

DrJM:

We’ll have an audio. I actually interviewed Beth, who is the patient we are going to be speaking about, and I had to twist her arm just a tiny bit to get her to do this. I was so excited to do that because her case exemplified so many of the issues that we see in our clinic just in one case. This is a real person – we promise it’s not someone we made up in a laboratory. Would you like me to jump into the case study?

DrMR:

Yeah. Just to apply that really quick for our audience – Joe will do a summary now and we’ll then talk through it. Once Joe and I close our discussion, we’ll actually play the interview between Joe and Beth where you can hear some of her experiences as she went through the process. So, yeah, Joe let’s go through the overview.

Case Study: Overview

DrJM:

Great. She was a 59 year old female. She was menopausal coming into the clinic. The background was a long, long time of GI issues, which had eventually led to a diagnosis of Hashimoto’s. So, not an uncommon presentation in our world. The main complaints were chronic fatigue. So again, pretty common. On the background of that is Beth had a bunch of metabolic issues. There was prediabetes in the form of slightly elevated blood sugars, elevated liver enzymes, a few extra pounds that she wanted to get off and elevated lipid markers. So, right off the bat what we did together was we talked about the importance of getting a whole food unprocessed diet. We put her on a paleo diet and like so many patients are first up at bat to start to combat the gut problems was triple probiotic therapy.

DrJM:

Beth described it as a game changer. Within just a few weeks, we saw a 75% reduction in her constipation. So, her stool consistency started to normalize. With that, a lot of other symptoms started to recede. So again, a very common presentation in the beginning, but the cool thing was that visit by visit we were able to tackle additional issues. So, the first pivot we made once we reset in a new normal for less gut and GI symptoms was pivot over to some lifestyle changes she would need to make to really optimize her health moving forward. In particular, we started doing some intermittent fasting, some periodic fasting, we started to shift her diet slightly by dropping carbs a little bit and I bothered her about weight training. So, we got a few more pounds of muscle on her frame and she started to feel better.

DrJM:

Again, the move there was fixing the gut dropped her fatigue. When she had more energy, we were able to put that energy to good use. We were able to invest it back into her and we saw an additional layer of improvement. So, we tweaked and made small changes around those themes for a few months. The neat breakthrough happened about six months in where all of a sudden she could tolerate foods that she was previously told (I believe on the basis of allergy testing) she would never be able to eat again. She was able to tolerate them without problems – crawfish and eggs. Just a big addition to her life and diet. So happy to see. Seven months in, she was off of her thyroid medicine. She came in on thyroid medicine and despite no thyroid medicine, she had stable labs and no recurrence of symptoms.

DrJM:

Great, great news. Around this time, she was complaining of thinner hair, so we gave her some extra nutrients in the form of collagen and MCT. This made a nice shift in the thickness of the hair, but particularly the extra protein was important for her because of the extra muscle and the weight training she was now doing. One of the most fun breakthroughs was seeing a repeat heavy metal test. I had been running urinary heavy metal tests through Doctor’s Data, and I happened to run one early on in her care. Eight months in, I saw huge decreases in some heavy metals – despite no binders, no detox, no sauna, no glutathione. So, that was very exciting to me and proof of principle that when you get the body healthy, it knows how to heal.

DrJM:

Sometimes we think of these issues as black and white – you have to get rid of the metals or else we’re going to get stuck. And this was just a nice reminder that the body can really heal itself when you provide a nice foundation. At the close of our work together, we reflected and all of her symptoms were significantly improved. It’s not that her constipation was perfect because I think if she slacked a little, the constipation would return. And I think the same story is generally true for the blood sugar. But despite that, we saw nice shifts not just from her symptoms, not just in her diet, but her energy levels were up and metabolically, she was healthier. The liver enzymes had normalized. The A1C had dropped from 5.8 to 5.5. Her lipids were better. At the close of our work together, she found that small bouts of Elemental Heal was really helpful in managing symptoms. So, she kind of left with one final tool and that rounded out the case for me. Michael – It was kind of the greatest hits of the things you and I talk about all the time and see in our clinic every day. So, with that – what thoughts do you have?

Case Study: Unpacking the Details

DrMR:

Yes. I mean, there’s so much here to unpack. I want to flag a few things for our audience. Joe – when you run through this, it’s almost tied up with a nice bow, and I think people may not appreciate all that goes into sussing a lot of this out. Now, it’s not necessarily that at the start of the case we’re telling the patient, “Oh my goodness, you have all these things wrong. And if we do these tests, we can figure out why.” I’m purposefully criticizing this because I think that’s where the majority of the field has gone, and it’s a very destructive position to be in. This is not because anyone is trying to do this – I think we wandered here in a benevolent fashion, but we need to correct some of these things. So, from the patient perspective, it may not have seemed like a whole lot of stuff was happening, but we’re building a case.

DrMR:

One of the first things that would flag in a case like this is someone has a prior diagnosis – and the specifics here really matter – of Hashimoto’s, but they don’t have a prior diagnosis of hypothyroid. So, when we hear that/see that, we’re going to flag that on their problems list or their differential, and we’re going to say, “Okay, this person seems to be on thyroid hormone, even though they don’t need to be.” However – and this is where having a process as we’ve discussed in the podcast is so crucial – we can’t necessarily tackle everything at once. We’re going to make that a mid-level action item for us to move on because this patient (if they’re still having symptoms) may have a very hard time psychologically getting behind the fact that they don’t need this medication. They may be thinking… “If I come off this medication, I’m going to get more fatigued, more constipated…”

DrMR:

And if they’re in the throws of ups and downs in their regularity or in their energy while we’re asking them to go off the medication, they may really have this falsely attributed dependency upon the medication. If their symptoms flare while they’re coming off, they’re going to think it’s because they really need the medication. So, that’s one thing I think we should take a moment and dote on – be on the lookout specifically for someone who has Hashimoto’s (meaning auto-immunity), but they don’t have a corresponding diagnosis of being full-blown Hashimoto’s. That’s very important historical data, and when you act on that is also important. Obviously, Joe, we’re on the same page here, but just for our audience, that’s really crucial. And you’d be surprised how many people come in on medication and the next doctor/doctors they work with just assume that their diagnosis is correct. As we’ve, at this point, harped on the podcast, there was the meta-analysis that found 34% of patients did not need their medication – and also the Livadas paper that found about 60% of patients didn’t need their medication. There’s definitely an evidence base supporting this finding. So, Joe – I think that’s a crucially important part of this case study. I’m curious of your thoughts on that. And also maybe some of her thoughts on that. How did she receive this news?

DrJM:

She loved it because she came into the clinic internalizing a lot of the fears that is pretty prevalent about Hashimoto’s. It was a huge relief and weight off her shoulders to go off the medicine and see that she felt fine. And I actually arranged, and I do this often, for a blood draw a few weeks after discontinuing the medicine just in the case that she needed it. Right? So, I took her off the medicine, re-checked her labs and they were perfectly stable. She was reassured that she felt well and she saw normal labs. It’s really helpful. Just to say – there are some patients that do need their medicine. For example, if we saw a big spike in antibodies off of the medicine – or a flare of symptoms – then that’s a very good indication that she would truly need it. But at this point, my assumption is that a majority of patients who come in – particularly with a trifecta of fatigue, GI disruption and Hashimoto’s – don’t need their medicine. At the three to six month mark, if you’re seeing improvements in digestive symptoms, you’re very likely going to be able to get them off.

DrMR:

Also, thankfully, the diagnostic verification on this is pretty straightforward. There are different nuance approaches in terms of how quickly you wean someone off the medication, or if you just do it cold turkey, but the re-testing after a turn (roughly six weeks of being off the medication), you’re either going to see TSH jump up usually above 10 with a corresponding low free T4 above 0.8 or you’re not. So, I think it’s important for patients to be reassured that it’s not a highly gray area diagnosis. Something like dysbiosis is much more non-defined and still being mapped out. I think dysbiosis is in very large part a clinical suspicion based upon presentation than it is a highly objective decision or diagnosis. But with this, it’s pretty clear cut. So, I think it’s important for patients and providers just to recognize that there’s not a lot of guesswork here.

DrJM:

Absolutely. And I’ll go out of my way to tell them, “Look, if I’m wrong about this and you need it, you’re going to know. In three days, you’re going to feel like garbage.” At which point I say just start the medicine back up. But, yeah, it’s usually pretty darn black and white – as black and white as it gets in functional medicine, I think.

DrMR:

Right. Yeah. Now, the other thing I think would be interesting to share with people is her TPO maintained in this 100-ish level (that’s thyroid peroxidase antibodies for our audience.) That’s really the antibody of choice. There’s another antibody use thyroglobulin as opposed to the TPO. So, thyroid peroxidase (TPO) and thyroglobulin (Tg). Thyroglobulin has some diagnostic merit, but it’s been criticized as being prone to false positives. And I think this case, at least as best as we’re able to read, may have been one of those situations. Yeah, Joe – I’m curious to hear a little bit more about what was going on with her antibody levels.

DrJM:

This was a question of concern and we ultimately decided to just watch it. So, it’s true. Her TPO stayed very low – 100’s… I think 107, which is fantastic. In my mind, that is that the single best marker for disease activity in Hashimoto’s. The thyroglobulin antibodies pretty consistently stayed just above 1000… 1,100… 1,050… somewhere in that range. Given the significant amount of clinical improvement, given that she no longer needed medication, given that all of her metabolic symptoms were getting better – we decided to just leave that be. This is one of those situations where clinical monitoring, I think, is just absolutely the best choice. She has a lab marker of uncertain significance in her case. Do we act on that? Or do we simply just see that in conclusion she’s doing so much better? The best thing to do might just be an ultrasound of her thyroid every few years or blood work every year or so to make sure that she’s maintaining improvement. That seemed to be the best answer for her rather than panicking that there was ongoing damage given her clinical improvement.

DrMR:

Yeah. Again, this is where I think it’s just so important to have a reasonable clinician on one’s team because one could interpret that in a very different way. And the messaging she could have received from her clinician would have been “Well, there’s ongoing inflammation and damage in your thyroid gland, and until we drive this down to below one (which is the cutoff for most of the thyroglobulin antibody labs) you’re at risk for auto-immunity.” And if you want to be really fear-mongering, you could say, “…and that autoimmunity also increases your risk for other autoimmune conditions – MS and rheumatoid arthritis…” While this is true, that’s a whole other conversation. However, the validity of this marker – as you so nicely said, Joe – is questionable in the context of Hashimoto’s in this setting. I mean, it’s a night and day difference between those two areas.

DrJM:

And just think about where she could have been if I had taken that approach. So, right now she is just thriving off living her life, feeling better. It could have been that we got all those improvements, but she still was just worried that her thyroid was being attacked on a continuing basis. Despite all those improvements, she just might have that weight on her shoulders and not truly be as well as she could have otherwise been. So it’s a small difference, but a big deal.

DrMR:

I could not agree more. So, another thing for our audience to be aware of is caution with how much we read into lab work. That’s probably a really important reoccurring theme in principle, which is unweighting the value that we assigned to labs.

DrJM:

Absolutely. And that has to be below clinical response every single time. Without question.

DrMR:

It’s one of a few different data points. Like we often say, it’s one third to one fourth of the data needed to make a decision. Again, for our audience, we can’t repeat this enough because it just seems there’s some messaging that is quite different than the position we take. So, as to provide an antidote to that, we just try to keep surfacing these examples where people can see the difference that the right approach and interpretation can make.

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DrMR:

The other thing I wanted to address is how much you can see someone’s fatigue improve when their gut health improves. So, in this case IBS with constipation, and I think the acknowledgement of this is growing, but I’m still not sure if the healthcare consumer – or perhaps some clinicians – fully appreciate how much fatigue is driven from the gut. And the reason why this is easy for me to say is I’ve experienced exactly this, where I’ve had fatigue, and that was really correlated with what was going on in my gut. I think it’s much more of an appealing and spurious argument to say it’s thyroid, genetics or adrenals. I think those things make more sense to people. They’re actually less correct, but I think they make more intuitive sense. So, there’s a little bit of an uphill battle for us to fight there, but it’s just another shining example of how much fatigue comes back to the GI.

The Issues Around Heavy Metal Testing

DrJM:

It’s so interesting. And I want to pivot towards the metal issue because we saw her heavy metals go down in the course of treatment. Just as a thought experiment, what would have happened if I had said, “Alright, my friend, you are so fatigued. And I just looked at your urinary heavy metal tests and you have an elevated mercury test.” And she did. Her mercury was well elevated over the 90th percent for patients her age. I could have, based on that test, said, “Alright, I don’t care about your ongoing constipation or GI issues or your thyroid, but I know that mercury can cause autoimmunity. And I think that’s driving your thyroid autoimmunity, and until we fix that, we can’t do anything else.” Go fill in your own adventure of what people are going to do for mercury.

DrJM:

And she would’ve gotten stuck. We would have gotten nowhere. Her fatigue would not have been better. I suspect that. This is my bias, right? I think we talk about the order of operations in which you fix problems on patients. And in my mind, this is a great example of why heavy metal should be pushed to the end because in her case, she dropped her mercury levels about 60% without a specific detox program, right? So, she went from the 95th percentile on her Doctor’s Data random urinary heavy metal to about the 30th percentile. It was the same thing with thallium, and she dropped her thallium levels in half. So, she was 0.4 – well above the 90th percentile – to 0.2 with no specific treatment. That to me is awesome.

DrMR:

This is a phenomenal point, and this is something that came up with our recent discussion with Scott and Gavin about how important having an order of operations is. It’s not to say that metals are something that never have a time or a place. I actually want to credit you, Joe with flagging a couple of studies that have actually resurfaced the importance of metals, and you’ve done so in a bit more of a scientific fashion. There have been some studies – I think it was Boyd Haley – but there was a metal detox versus sham detox study, and they found that subjective improvements were equally seen in both groups. That was a pretty telling study. There have also been some labs that have been criticized for narrowing the ranges, so as to make more people look positive. So, there’s some monkey business.

DrMR:

So, I had been – and I think we all had been – shying away from metals, but we’re also keeping our eyes on the research literature and we’ll reappraise issues as the evidence changes. I think we’re starting to hone in on this more that there’s something there to the metals. It’s not something that we should just discount completely, but to your point, because it’s less common, it’s perhaps a little bit more challenging to know if it’s causal or associative, we position it mid to end level in the differential – or the problems – list. This is exactly why because as someone improves their gut function, they may see improvements in detox capacity. And that’s not just a theoretical. We’ve talked about on the podcast before how probiotics may partially function as binding agents. And how probiotics – and there are meta-analyses showing this point – can reduce liver enzymes. This is the gut liver connection, and remember that everything in the gut drains through the liver. So, it would make sense that if your gut is a mess, that mess is being cleaned up by the liver. Therefore, the background capability of the liver to detoxify is likely going to be hindered by all the stuff in the gut. It’s working the process. So, a great case study showing that a lot of detoxification occurred without necessarily doing any direct detox therapy.

DrJM:

Absolutely. That’s the best kind of therapy – the one that happens in the background and the patient doesn’t have to do extra work.

DrMR:

Yup. I guess on the metals piece – without going too far outfield there – anything you want to share with people that you think is interesting? I believe you were the one who initially flagged that. Was it the ‘prove it’ study? They were trying to disprove and discredit metals, and then they actually discovered a few benefits that couldn’t be swept under the rug?

DrJM:

There are a couple pieces here. Just high level – I’ll give you my opinion without going through the studies because I don’t have those on the top of my head. The first is that there’s pretty solid epidemiological evidence showing that lead is directly causing cardiovascular disease because you can find dose relationships and increased mortality. The magnitude of effect is very, very high. What appealed to me about this is this is something you can get with a simple blood led draw. You don’t need to provoke. You don’t need to be using DMSA. You don’t need to be using IV therapies, but a simple blood level is very helpful. And so when a blood lead level gets above two, particularly two to four, you see a massive rise in cardiovascular mortality, and also more heart disease, more strokes and more atherosclerosis.

DrJM:

This is really important when we’re trying to guide our patients to long term optimization of health. We’re always trying to get their fundamental systems in order so that we can then pivot eventually to the least amount of supplements they need/the least restrictive diet, but we also want to be helping them age gracefully. We want to be making sure that that our patients are living optimally, they’re moving in their late years and they’re not dying of heart attacks or strokes unnecessarily. In that context, blood lead level is very important. Is that enough of a soap box?

DrMR:

I think it is. Just to get on the box briefly here next to you – I had reviewed on the podcast and via YouTube video (this must’ve been at least five years ago now), a paper published in the journal of Circulation showing this exact association to what one could call a subclinical elevation of lead, and I believe also cadmium, correlated with higher blood pressure and cardiovascular events. So, there’s something there, but then jump into functional medicine-ville and it’s testing with heavy provocation and you start running these tests and everyone is coming back with high levels of metals.

DrJM:

I’ve never seen a clean, provoked metal panel, which makes me question how useful it is.

DrMR:

Yes. So, that was the exact problem that I confronted – if you are seeing testing in everyone positive, then either you have an incredible skew based on population (maybe you’re living in a mining town) or if that’s not the case, then there’s something up. I think clinicians need to be much more scrupulous if they’re seeing positives all the time – it’s not a good thing. That’s why I thought early in my career, “Ooh, another adrenal fatigue case, ooh, another adrenal fatigue case, oh my God, another adrenal fatigue case, this is as bad as I was told.” And then, after awhile, it’s like, “Is there anyone who doesn’t have adrenal fatigue?” If there is not, then what is this doing to delineate between healthy and impaired populations. So anyway, that’s part of the reason why there was a drift away from the metals, but we’re going to be doing a little bit more investigation and research into this and really try to firm up the best approach. Just as a tangental comment for our audience, that’s something that we’re looking more into. I think we’re honing in on the optimum balance for how we navigate metals.

DrJM:

It’s definitely going to be one of those in the middle answers, right? It’s not the problem most of the time – it’s a problem sometimes. And when and where do we deal with it is going to come clearer into view as we move forward.

Food Intolerance & Elimination Diets

DrMR:

The other thing here that is also important to mention is the ability to tolerate foods that the food allergy testing said could not be tolerated and just how far you can get with a basic elimination. And when I say basic, we should just acknowledge that figuring out those tenants of an elimination diet took many, many years… many, many clinicians… a lot of research. So, we say basic now, but that’s after a lot of observation. Basic doesn’t mean non-validated. In fact, it’s incredibly validated, but now it’s the mainstay of dietary elimination and reintroduction. Just how far you can get with this well performed, validated elimination diet – a paleo diet is one way of getting there – plus probiotic triple therapy, and just how much food freedom people can realize on the back end of that.

DrJM:

It didn’t happen immediately. It took some time. That was six months into the program, and that’s important for people to realize. When you come into a clinic and you have decades of symptoms, we can often get you better quickly, but it’s not going to happen overnight. And the patients who do the best do give a little leeway and allow us to work with them side by side for a period of time. I think that’s important to realize. So, six months in – that was the pivot where she was definitely able to tolerate foods she hadn’t eaten in years. This is a big deal. It’s a big deal in Louisiana to be able to eat crawfish. I mean, if you can’t eat crawfish, you’re basically a pariah – nobody is inviting you over to the backyard barbecue. It’s important. And so I think that patients need to expect results, and when you’re doing the right thing, you should get results. At the same time, you want to make sure you give treatment enough time to really take full effect.

The Differentials List

DrMR:

Yeah, it’s incredibly well said. Speaking for our clinic – and I know not many clinics run this way – but upon the initial exam history and intake process, we’re crunching an immense amount of data, and we’re using that to populate this problems list, this differentials list. Like we’ve discussed today, some items are categorically put more mid to end phase (like metals) and some have to be progressively ruled in or ruled out, and that all takes time. It takes time to either work your way to the mid-level or end-level items, or rule in or rule out a mid-level item. We’re always trying to get people the most response as quickly as we can. However, if unfortunately your main causative factor is one of these mid-level items, the only way to really get there is to navigate through that process.

DrMR:

This would mean a few recommendations, follow up a month later… how are you doing? And every time we follow up, check back in and/or run lab work (which is done minimally, but it is done), we’re working through that problems list and we’re really listening to what people say. What’s improving? What’s not improving? What negative reactions are there? What’s the patient’s psychology like? All of that is helping us build out this list of problems so we know where and what to do next. The main point I’m driving at – which reinforces what you just said, Joe – is that takes a little bit of time. It doesn’t take years, but it takes months. Just as a word of encouragement for people, give your provider some time to work that process. For some people, the first change you make, you get almost instantaneous results. That’s awesome. For some other people, you’re only a few steps away from getting there, but if you jump ship prematurely, then you’ll never get there.

DrJM:

Yeah. So, I’m gonna interrupt you, buddy. So, for example with Beth, she got a 75% improvement within a few weeks – say six weeks. There is a chance that she may not have. So, let’s pretend she’s a patient who got a big fat, zero of improvement, and she’s kind of mad at me, right? She’s running a fairly strict gluten-free, dairy-free, no sugar, no processed food diet. She’s eating all the probiotics, and she’s going nowhere. At that point, the answer is either we’re not doing enough. She still has significant GI problems, but we haven’t hit the right treatment pattern. We haven’t done enough time. Or this is an issue outside of the GI track. Oftentimes, what we would have done had she not responded, but still had that huge background of chronic constipation (still came in with all those years of IBS… all of the abdominal symptoms that were flagged on her initial paperwork) we very likely would have moved up to an elemental diet and perhaps immunoglobulin therapy, both of which are validated for constipation bowel regularity and abdominal symptoms much quicker. In her case, we went to the elemental diet last because she had done so great, and we just wanted a small nudge to get her back in line. If she had gotten a big fat zero at the beginning, it’s very likely she would have gotten to those treatments next. And then at the end of that next visit – “Beth, how are you doing? Oh, okay. We’re starting to move in the right direction. Let’s double down on those things. We’re going to maybe make a few more tweaks and then let’s see where you are next time.”

DrJM:

If she hadn’t gotten any improvement at that stage, then you maybe say, “Oh, okay. Am I missing something here? Do you live in a moldy house? Am I missing a parasite? Do you have a really horrible case of methane SIBO that’s just not going to nudge until I knock it with some antimicrobials?” It’s the general thinking and evaluation that each patient gets in our clinic that we’re so proud of. So, I just had to give a plug for that thinking we’re all doing everyday.

DrMR:

I think it’s so, so important that we have these conversations more because behind the scenes we’re always tinkering, working, problem solving, observing and doing this work on behalf of our patients. But I don’t think we explain it enough. I don’t think we explain the only way to somewhat confidently get to those few conclusions that you mentioned, Joe – parasite, high level of methane SIBO – is by working through the algorithm or the hierarchy. To whatever extent people have not responded to initial therapies, it gives you reinforcement of those other factors likely being present. That’s what’s so vital – making sure we’re not going to treat someone for a parasite who doesn’t have it… for methane SIBO who doesn’t have it. The only way to really get that is having some of the patient’s biofeedback present. How do they respond to X, Y, Z?

DrMR:

I think this really needs to be stated – the labs won’t give you all of it. It will give you some, but not everything that’s going on in the GI can easily be tested on lab work. And then with some of the labs – like mold or metals – there’s some ambiguity in terms of ‘Is a positive always something that’s impactful?’ So again, we have to go through these channels of having a hierarchy. It is personalized to the individual, but there’s also a lot of commonality at the start. The further down the hierarchy you go, the more individualized it becomes. I think that can be frustrating to patients at first, because they may feel this is cookie cutter or route. And that is actually partially true, but it’s true intentionally because we’re starting with the therapeutics that are the cheapest, the safest, the most effective and have the largest body of scientific evidence validating them.

DrJM:

That’s it – rather than what most of the field does, which is spend thousands of dollars on unvalidated tests and then throws a kitchen sink list of treatments at patients and hopes that some of those hit and then retrospectively justifies or makes something up for why they’re better or not better. It’s a mess.

DrMR:

Yeah. Well said. We need to start having these conversations because I think patients come in with a little bit of a skewed expectation, which is testing is going to tell me exactly what’s wrong with me. And I’m going to have a lot of promises upfront because the doctor is going to explain the exact mechanism and thing that’s going on with me. I think that feels really good, but the problem is if it feels good, but it’s not actually valid or accurate – that is by definition what a specious or spurious argument is – it sounds appealing, but it’s not actually true. It’s kind of like ‘Eat fat, get fat” – that made so much sense. It’s probably why that got so much traction. And it’s not to say you can eat fat with no limitation and you won’t get fat, but that general thinking that fat makes you fat and processed carbs should be the foundation of the food pyramid obviously has been heavily, heavily criticized.

DrJM:

Absolutely.

Constipation & Elemental Dieting

DrMR:

Joe – how about a few remarks on her ongoing constipation. Someone who has a little bit of a trend toward constipation is not something abnormal at all. We all have some unique nuances of our systems and also using a little bit of elemental dieting periodically to keep things on track. How does she receive that? How did that feel to her? Any other thoughts about her ongoing care?

DrJM:

Yeah. It’s a great point because although her constipation was in large part resolved, it still would creep back if she slacked on the diet… maybe dropped the probiotics… let the stress get a little higher. That was her tendency. And so we just need a little bit more work than maybe the average person to keep her in normal bowel habits. And I think if we identify that, we can just work with it. She noticed at the end and asked, “Hey, is there something still wrong with me that I’m still tending towards constipation if I loosen up on these treatments?” In my mind, the answer is absolutely no – it’s “you’re going to need a little bit more support.” This is the way that you’re made, and the fact that we can get you so much better with these tools is perfectly fine. The elemental diet – this is how I use it for a lot of patients – is pulse it in periodically. Of course, you can use it everyday safely for all of your calories. We know this from multiple lines of evidence, but I think that the most effective, cost-effective and palatable way to do this is a two to four day kind of pulse. And this can be done as often as is needed. Most of my patients who are somewhat similar to Beth may do this once every few months, once a quarter, once a month, and they just watch their response. Usually that’s all that’s needed to lower the fiber, keep the nutrition high, reset the gut, let the motility apparatus have a rest, clean off dysbiosis and they go on their way. They just pick up where they left off. Do you agree? I think that’s basically how you’re using it in most cases, is that correct?

DrMR:

The two to four day reset as needed on occasion? Absolutely, 100%. Also, for some people, we’ll use an elemental shake as their morning meal. Some people prefer to eat light anyway in the morning. Having that part of their daily caloric intake come from something that’s pre-digested gives them a small dose of support in an ongoing fashion. Another approach, just like you said, is that two to four day reset as needed, episodically. And again, valuable insights because it’s not just this, “Hey, there was one study for SIBO that used Vivonex Plus for two weeks exclusively. Therefore the only way to ever use elemental dieting is two weeks exclusively.” It makes this far more difficult and arduous than it needs to be. When we look at the huge body of literature for inflammatory bowel disease, this approach of relaxed use has been used in two year plus follow up studies and shown great outcomes.

The Importance of Patient Psychology

DrMR:

So, there’s a lot more flexibility with how we can use the elemental diets than I think is sometimes portrayed, and this is just a great example of that. And also that there’s not something wrong with you – you’re not using the elemental diet for two to four days because quote “you have SIBO again.” This is one thing I’m really happy with how we do this at the clinic. We catch people when they start saying things like that. “Oh, so Dr. Joe… Dr. Ruscio… you’re saying that when I improve from a two to four day reset, that’s because I’m helping to beat back my SIBO.” Then we go, “Nope.”

DrMR:

It’s really important that you don’t start associating every time you have symptoms, you have this thing. That’s another kind of mental malware. Listening from visit to visit – the patient’s psychology – is a shining example of how (not to pat us on the back too much) I think we’re really doing patients a big service by interrupting some of those faulty associations that people come up with.

DrJM:

I agree completely. The other thing I’ve learned from you recently is how we speak about patients’ symptoms matters – not saying you have a disease in describing the fact that they do have symptoms, but it doesn’t need to define them. I’m increasingly feeling that’s important as there is more and more fear-based propaganda on illnesses online. I don’t know of any other way to say it really. So, I hope that we can be against that.

DrMR:

This is something that I fell victim to. When I say these things, I am no way above these things. When I was a patient, as the audience probably knows, I had an Entamoeba histolytica infection a number of years ago. I remember – I believe her name was Emma Lane and she taught for the Chek Institute. This was back when I was in college and I was doing a bunch of side coursework partially – I did the Chek exercise coach and the Chek HLC holistic lifestyle coach. Emma Lane also had a parasite, and she said that she was so scared of having another parasite that when she would use a public bathroom that didn’t have the toilet seat covers (many public bathrooms have the lid to put your butt on, but no top lid to prevent splash up), she would put her foot on the thing to flush it and then wrap her body outside the door, push it in and dart out of the stall real quick. And I did that for six months, so I could see me. You could see me doing the stall limbo shuffle, whatever you want to call it, because I was so afraid of acquiring another parasite.

DrJM:

Michael!

DrMR:

I know, I know. Now, nobody sat me down and talked to me and really gave me the narrative on this that E. histo is incredibly rare and that this is not something you should be worried about recurrence. I was also kind of caught up in this community, and this was also 15 plus years ago. So, our understanding has evolved quite a bit since, but in that realm of naturopathic medicine I was plugging into, I think there was a fair amount of lore.

DrMR:

There was a lot of good stuff in terms of, “Hey, your symptoms could be caused by a problem in your gut.” That was huge for me, but there was also this thinking that if one person in the family has H. Pylori or blasto, you’ve got to test the entire family/treat the entire family… parasites are super common and the parasite description was handed out really willy-nilly – like blasto was a parasite – and all these organisms that really aren’t parasitic were called parasites. So, people were finding “parasites” on so many tests and they were responding to herbal antimicrobial therapy so it reinforced the narrative of parasites being common.

DrJM:

Michael, you’re spoiling my FFMR. I was literally writing it today on Blastocystis hominis. So to the audience, please stay posted for an excellent episode – the December FFMR. More on this subject…

DrMR:

Again, this is why I’m so pleased with where we are – we’re taking up that mantle and carrying that torch forward of how important gut health is, as evidenced by this entire case study. But, we’re not going so far as to inculcate people with unreasonable beliefs – like you have a parasite that every time your symptoms flare, it’s SIBO. That’s because I think we’ve observed so much of the negative psychological consequences associated with that sort of framing.

DrJM:

What I love about this is that I really feel we’re on the verge of being able to move the whole field forward. The field of functional medicine was a really necessary course correction for the horrible standard of care in conventional medicine for chronic disease. It just was not shifting anyone forward, and we needed a reset with functional medicine to put an idea that the root causes need to be fixed. Right? But I think that field itself has gone a little askew with the idea that we can rely on so much testing and supplementation. It’s such a pleasure to partner with you to do our very best at moving the field one step farther. What is the most cost-effective, practical way to get patients better? And we’ll keep working on that every day.

DrMR:

Yes, sir. We have a lot of work cut out for us, but it’s phenomenal work to be a part of. And speaking of phenomenal – your conversation with Beth was just fantastic. For our audience – stick around and we’ll now have Joe and Beth’s conversation where you can hear part of her side of the story. Joe, before we wrap up and transition to that, anything else you want to leave people with?

DrJM:

Oh, no. I think they’ve had to put up with me for long enough.

DrMR:

Fair enough. Alright, my friend. Well, thank you and great work on this case study.

DrJM:

Thanks, man.

DrMR:

Bye.

Dr Ruscio Resources:

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

Conversation with Beth

DrJM:

Hello. This is Dr. Joe Mather – Medical Director of The Ruscio Institute for Functional Medicine. With me today is Beth, who has been one of my absolute favorite patients in the last year and a half. She’s been an absolute joy to work with and is a lovely person. Beth – I’m so happy that you’re here with me today. For our listeners, I wanted Beth to join me today for a brief conversation so she could share her perspective on what it was like going through functional medicine treatment. She happened to have a lot of the issues that many of our patients coming into the clinic struggle with. And I really think that hearing Beth talk a little bit about our journey will be helpful to a lot of people. So, as a background, Beth came in to the clinic with longstanding GI issues, notably constipation, as well as Hashimoto’s thyroiditis for what she was taking medication, as well as some stubborn blood sugar and cholesterol issues. Unfortunately, despite trying several medications, an aggressive elimination diet and a lot of other remedies, she was really hurting. So, with that background done… Hi Beth.

Beth:

Hello. Good morning, Dr. Joe. Thanks for having me.

DrJM:

Thank you for being here. It’s so wonderful always to talk to you and thank you for coming on. Would you start by maybe sharing a little bit about where you were a year ago this time – the fall of 2020?

Beth:

Well, I was pretty much frustrated from so many years of trying to reach out for help and trying different things that were ongoing, and I just really never seemed to feel better. It just seemed like I was spinning my wheels. When I found you, I felt so much more hope because I knew that your knowledge of functional medicine combined with The Ruscio Institute was going to be able to set me on the right path. And that has been my total experience since then moving forward.

DrJM:

It’s so much fun to see treatments work and patients make improvements quickly. You really did that. We started you on all three of our probiotics and you found a nice improvement. Do you remember back to when we first got started? Do you want to share a little bit about that time?

Beth:

Sure. The probiotics, I would have to say, were the game changer. Totally. I had been on probiotics before, but I never experienced the help that I did once I got onto the triple probiotic.

DrJM:

It’s fun, isn’t it?

Beth:

Oh my gosh. It’s just an amazing transformation. I was so happy to keep moving forward as things progressed. I think what I’ve learned the most is that lifestyle really is so important in what we do, and it matters what goes into our body. As far as the supplements or probiotics, they simply are not created equal. I find that the supplements that you have recommended to me and given to me and the probiotics have just been top, in my opinion. There are none that surpass them. It just completely changed my world and my well being.

DrJM:

It’s so fun to hear you say that because we say that all the time. We have the privilege of seeing that with our patients, but thank you for sharing that because I really see for patients who’ve had a background of GI issues like you did, you really need to start shifting that before we can build further. So, once we got some relief from the constipation and found that formula that worked for you, then we were really able to go off to the races. And so I’m going to brag for you because I’m not sure if you’re going to brag enough, but in the year or so that we’ve worked together now, you have significantly expanded your diet. You significantly improved your constipation. I don’t think you’re perfect, but you’re much, much better than where you were. You are off of your thyroid medication. You are stronger. From my perspective, your blood sugar has made a huge turnaround and your cholesterol is lower. And this is all while you are now eating foods that you were previously told you could never eat.

Beth:

Right.

DrJM:

That’s just fantastic, right?

Beth:

It is. And I can’t even put into words how much I encourage people to come to you, and Dr. Ruscio, as well because it’s just so life changing, I feel so much better. I was really at a point in my life where I was getting depressed and feeling hopeless. I think my message to people out there is that they do not need to feel that way. There really is help and there really is a game changer, and you just have to do what you guys recommend to us. And it works.

DrJM:

When you think back over the last year of treatment, obviously the triple probiotics were a great tool for you. Were there other treatments that we tried or applied on that looking back, you think were also game changers… were also really helpful?

Beth:

Well, like I mentioned earlier, I know that the supplements that you have given me just to maintain my health have been good on my stomach and have helped to keep me healthy. I have really not been sick at all. And the Elemental Heal has helped if I was experiencing any bloating or just to give my stomach a rest. I tried it and it’s just an amazing help. And it does exactly what I believe it was designed to do – to give your stomach a rest. I felt really good as I was on it. It’s hard to believe that you can just drink something and feel sustained and energized, but I did. Coming off of it, I, I did not feel any bloating. I felt much more energized and I definitely will use that treatment periodically as I feel I might need something like that.

Beth:

And also the protein powders if I might need a little something during the day. Those are very healthy and what’s in them. I know I’m not putting anything in my body that is not going to benefit me because of my GI issues. So, everything I’ve experienced and not only that Dr. Joe, but your availability and you’re so personable and you’re just there to help. Having you walk with me by my side through this whole thing is the flip side of the coin. I can’t do it all and you can’t do it all, but together we were able to accomplish some really huge plateaus. I’m proud of that. I’m proud of the accomplishment that I’ve made. I’m so thankful for your knowledge and capability because it’s just hard to find.

DrJM:

I’m grinning ear to ear over here, Beth. I’m really pleased. And medicine is a partnership, right? It works best when I can listen to you and give you marching orders. And when I have a patient who just goes off and does it, it makes my job pretty easy and pretty wonderful. So, thank you, thank you, thank you. Do you want to maybe talk a little bit about the role of the thyroid/the thyroid disease. I think your perspective may have changed a little bit about this disease through the course of us working together – maybe not – but is there anything you want to chat about that?

Beth:

It definitely has because I think the gut is definitely often the culprit that is misdiagnosed when there are thyroid issues experienced. I know I was thinking once I was diagnosed that I was doomed. I know when I met with an endocrinologist that he just wanted to kill my thyroid and I had absolutely no desire to do that because I knew there was something like, “Why did I have this?” I am one of those people that just wants answers; that things have to be happening for a reason. Anyway, through you and the recommended therapy that you’ve given me – through the probiotics and all – I’ve realized that healing the gut is key. That is key. It takes time – it’s not like a magic wand – but you definitely notice a difference, particularly with the probiotics. And then once your gut is able to heal, you can slowly resume back into things. The main plus was being able to get off the thyroid medication. I feel like – long story short – we proved them wrong.

DrJM:

Isn’t that fun?

Beth:

Very fun.

Episode Wrap-Up

DrJM:

Exactly. The word that I think means a lot and probably will resonate with those listening is doom. And there’s so much fear and misinformation, particularly around thyroid disease, that I’m so glad for you to share that with patients. Selfishly, I was hoping you were going to say that because I think it’s a message that needs to get out there so, thank you for sharing that. Let’s see. Are there any closing points you wanted to make? I wanted to talk a little bit about heavy metals just very briefly, but is there anything you wanted to bring up?

Beth:

I just really want to encourage people who are looking for functional medicine help to seek out you guys and know that it’s real help. That’s just my main message because there are so many things out there and so many different voices, and I don’t believe that functional medicine is all created equal. It can be expensive, it can be a long-term disappointment, and I feel like in this time that I have been with you, I have made leaps and bounds of literally seven years of misery that I was going through. And once I connected with you and this regimen, things turned around and quickly for me – compared to the seven years. It was a short investment and a very wise investment. That is my main message if anybody is hesitant.

DrJM:

That’s just fantastic. That’s the thing that I say to patients all the time, and I feel like sometimes they don’t believe me, but when you give the right treatment to the right patient and you fix the right problem, people get better. And even though people have sometimes been sick for seven years or two years or 30 years, there’s always hope to get better. We are not perfect. We get it wrong sometimes, and sometimes we’re not there, but man, if you get the right treatment in the right patient, it is such a wonderful thing. And Beth, you are exactly a great shining example of that. So, thank you so much for sharing.

Beth:

And also Dr. Joe, I just want to say, patience is a virtue in this whole thing. Sometimes, like baseball, you get up and you strike out. There are times when you try things – If it works out, great… if it doesn’t, you move on and there’s an alternative that you’re able to do. And that’s okay. It’s really okay, but at least, you are totally in tune with blood work and everything that you are doing to help me. And I truly appreciate the full concern that you’ve put in from every angle of medicine to help bring me to the best that I can be. So, I can’t thank you enough.

DrJM:

Well, this has been so fantastic. Beth – thank you so much for joining us. And I think it’s going to help a lot of people to hear your message. Thank you. Thank you. Thank you.

Beth:

You’re welcome, Dr. Joe.

DrJM:

Talk to you later.

Beth:

Okay. Bye.

Outro:

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