The Epidemic of False Hypothyroidism Diagnoses

What Your Thyroid Labs Really Mean & How to Improve Metabolic Health with Josh Trent

On today’s episode of the podcast, I’m sharing a conversation I had with Josh Trent about his personal experience being erroneously diagnosed with hypothyroidism. Unfortunately, Josh’s story is very similar to the stories we hear in the clinic every week. Hypothyroidism is a real condition, but it’s frequently misdiagnosed in functional medicine because of a theory about what TSH and T4 lab ranges should be– even though research and clinical experience continue to disprove this. If you’re wondering about your own hypothyroid diagnosis, lab results, thyroid medication, or how to really get to the bottom of your symptoms and improve your health, I hope you’ll listen to this episode.

In This Episode

Thyroid Overdiagnosis … 00:00:45
Josh’s Diagnosis …00:13:00
Standard Hypothyroid Diagnosis …00:19:06
The Lab-Forward Model … 00:25:42
Thyroid Treatments … 00:28:56
Diet and Sleep … 00:30:57
Cardiovascular Testing … 00:38:47
The Intake Questionnaire … 00:42:02
Strength Training, Mouth Taping and Singing … 00:43:54
Finding the Right Clinician … 00:46:23
Clinic Update … 00:49:01
Episode Wrap-Up … 00:50:28

The Epidemic of False Hypothyroidism Diagnoses - Podcast310 JoshTrent

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Hey everyone. Today I spoke with Josh Trent about his personal story and journey in being given a totally bogus hypothyroid diagnosis. You’ll hear a little bit more about this when we do the intro. It’s actually me going on his show, but I wanted to share the audio here because it’s just one of what’s now a growing, growing number of examples of this egregious but rampant misdiagnosis that’s occurring in the field and is being called out by people on both sides of the fence. I understand that we’re all trying to help people, but this is one theoretical bit that really needs to be amended.

He was diagnosed as hypothyroid, and he even sent me in writing what his provider interpreted for him, which was flat out, no nuance that he has hypothyroidism. This was based upon a TSH of 4.09 and a free T4 of 5.0. Either I am just missing a whole bunch of research, even though a few other research assistants alongside me and I have scoured the medical journals for evidence, but I’ve been unable to uncover anything that is even remotely convincing that we should be diagnosing people as hypothyroid if their TSH is not at the normal, conventional cutoff of 4.5.

I think we’ve discussed this on the podcast in the past. This comes from a mistaken conflation that when someone’s on thyroid hormone medication, their TSH should be suppressed down to 2.0. Therefore, if normally your endogenous thyroid hormone production is not where it should be, and you see a native or non-medicated TSH above 2.0, Then you’re hypothyroid. We’ve talked in the past ad nauseum about how there’s a pretty strong argument against that, namely via the drove of studies documenting that subclinical hypothyroid individuals who actually have TSHs over 4.5 but have normal T4 don’t have more symptoms and don’t benefit from thyroid hormone medication unless you’re infertile or very young.

But apparently this is still being done. Again, I think it’s being done with the best intentions, but it’s getting harder for me to say that, especially if you listen to the way Josh’s provider really came at this hard and said, “You have a disease. You need this medication. Your body’s starving for ‘XYZ.'” It was a very strong, fear evoking way that it was presented, which really isn’t the way, in my experience, that well-versed clinicians handle anything because there are rarely things that are that black and white. I wouldn’t say never, but in clinical practice, there’s often not any one data point that’s highly definitive. Now sure, if someone had a TSH of 88 and a T4 of 0.1, okay, that’s pretty clearly hypothyroid and there’s not a lot of hand-waving or nuance there. But this is not that. This is a theoretical point that perhaps we could better help patients if we started thyroid hormone treatment at a lower level of TSH.

I’m not sure what’s happening where the contradictory data isn’t being looked at. Well, I do know what’s happening, it’s called bias. So there’s the bias, and then if we combine that with these multimodal interventions where there’s thyroid hormone, there’s changing your diet, there’s going on probiotics, fish oil, stress management and exercise, people say, “Oh, well, I feel better.” This is where we run into trouble, which is why I return to looking at the trials on when we give a group of subclinical hypothyroid patients placebo, half placebo and the other half the drug. And what do we see? Hmm, no benefit. Okay. Does clinical trial after clinical trial all finding this same thing sway anyone? Well, I guess not if you have your mind made up already.

So I’m pontificating here a little bit, but it’s disconcerting when someone like Josh sends me an email, notably concerned in reading his email and being told that he has a disease flat out, point blank, when at best that’s a theoretical diagnosis, and I’m being very generous. The gloves off narrative is that you’re an absolute quack and this is damaging the patient. Now it’s quackery when it’s done that dogmatically, when there’s fear and when there’s an absolutist remark. I could excuse someone who said something along the lines of, “There’s some emerging evidence that suggests if your TSH is below 2.0 that you may benefit from thyroid hormone replacement. Let’s do a short trial and retest your metabolic markers via your cholesterol panel, because you had cholesterol a little bit high, and see if you’re feeling any better. This may help, it may not help, but let’s give it an honest and objective trial.” That would be okay, but you, in my opinion, are a jerk and a quack when you come at people with this fear-based narrative. You do not have anywhere near the requisite evidence necessary to have this strong of a conclusion for this poor guy, Josh, who’s gained a little bit of weight and is now trying to see why.

Interestingly, he mentioned this after the conversation, but I know he won’t have any problem with me sharing this bit, the weight gain started when he moved to Austin. Now that could be lifestyle change. It could be lifestyle change in the sense that other things changed with his diet, with his activity, but it’s also curious that Austin is endemic for mold. I’m careful with the mold piece. It’s me conforming with my own criticism of not being that person who’s dogmatic and hard-driving. I would suggest mold is something to consider if the timeline fits and there’s no other data to point to, meaning, “Well, I moved to Austin and went keto and stopped doing weight training and only started doing cardio because I hurt my knee,” which he did have a knee injury or has a current knee thing.

Sorry if I’m kind of monologuing here in the intro, but all these things are what go into the process that we run individuals through at the clinic. There’s a list of potential hypotheses, but on the one hand, yes, we’re going to be looking to prove a hypothesis, but we’re also going to be looking to disprove the hypothesis. And guess who benefits from that? You do. The individual does. Because if I’m just gung ho about a hypothesis, everyone I work with suffers because I am not weeding out the weak points in the hypothesis. I’m just drinking the Kool-Aid, rinsing, and repeating.

In Josh’s case, there are some clear signs of metabolic sub-optimization. Again, I’m trying to use the most positive framing in my language as possible. I could’ve said metabolic derangement, but I don’t want to say that. Well, I guess I did say it, but you know what I mean. My official way of describing this going forward would be “some suboptimal findings regarding his metabolism, triglycerides, total cholesterol, LDL cholesterol elevated, and body weight creeping up.” So maybe it’s as simple as he went keto, keto doesn’t work well for him and we’re going to change his macros. Or there could be a sleep issue. These sleep issues seem to be more prevalent as you age, as musculature becomes less toned in the throat and palate.

So, there’s a few things that kind of flag. There could also be mold. As Josh onboards into the clinic, because he is going to be seen by one of the doctors at the clinic, all of these things will be taken into account and built into his dashboard of what could be going on, and we’ll responsibly run him through how to improve his health. And the thing that I really want to echo again is we really have to start rethinking this hard-driving narrative on the thyroid. I’m willing to give people the benefit of the doubt for some experimentation for where thyroid hormone may help someone, even though the vast, vast, vast, vast majority of data do not support that. I’m willing to keep a slight crack in the door just because in principle I try to be open-minded and acknowledge that there could be things that I don’t know and things that I don’t see.

But the more that I hear these firsthand case studies, what’s happening in the field is it’s not anywhere near this thoughtful, analytical experimentation with thyroid hormone. It’s almost as if to say there is a irrefutable body of evidence suggesting that people who have TSHs below, and it seems like the goalpost is moving here because in the email he sent me, the provider, it wasn’t even a doctor actually, it was a nutritionist, which I think is also another conversation, but I think this person had remarked that 1.0 to 1.5 is where your TSH should optimally be. It’s to suggest that there’s almost this irrefutable data that this is where the cutoff should be. And there is the opposite of that. There is a large body of data that absolutely refused that hypothesis.

So for patients who are suffering, there are things that can be done. But what we don’t want to do is force upon you the wrong diagnosis, because that doesn’t help you. I guess just a word of caution for individuals that if you’re not feeling well, I get it. I’ve been there. It is terrible, and your mind will play tricks on you and you will go to the worst possible case scenario and grasping for straws. Be careful of the thyroid straw. Obviously, it is something that affects people. Hypothyroidism is a legitimate condition, of course, but it’s incredible how this rampant misdiagnosis is just running away on us. And it is something that we 1000% will be publishing on at the clinic.

We are collecting case studies. This is one of them that will go into some type of case series write-up, hopefully to give people something that will open their eyes. Because again, I think we’re all trying to help people, but boy, some of us have to pull back a little bit and realize that our words carry a lot of weight. If we’re not sure, and if we haven’t done a firsthand fact-checking of an issue, then we should be pretty careful how strongly we’re going to make a diagnosis or a proclamation based upon a weekend seminar, a book, or just one data point of a guru.

So anyway, now that I’ve probably irritated about half of our audience, I mean hopefully not. Hopefully there are not many who are fervently attached to this, and they’re willing to have a debate based on evidence. But now that I’ve had my monologue here, we will go to the episode with Josh where I went on Josh’s show Wellness Force Radio to discuss his disheartening pseudo-diagnosis and how we can steer him out of that. All right, here we go.

➕ Full Podcast Transcript

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.

Thyroid Overdiagnosis

DrMichaelRuscio:

Hey everyone. Today I spoke with Josh Trent about his personal story and journey in being given a totally bogus hypothyroid diagnosis. You’ll hear a little bit more about this when we do the intro. It’s actually me going on his show, but I wanted to share the audio here because it’s just one of what’s now a growing, growing number of examples of this egregious but rampant misdiagnosis that’s occurring in the field and is being called out by people on both sides of the fence. I understand that we’re all trying to help people, but this is one theoretical bit that really needs to be amended.

DrMR:

He was diagnosed as hypothyroid, and he even sent me in writing what his provider interpreted for him, which was flat out, no nuance that he has hypothyroidism. This was based upon a TSH of 4.09 and a free T4 of 5.0. Either I am just missing a whole bunch of research, even though a few other research assistants alongside me and I have scoured the medical journals for evidence, but I’ve been unable to uncover anything that is even remotely convincing that we should be diagnosing people as hypothyroid if their TSH is not at the normal, conventional cutoff of 4.5.

DrMR:

I think we’ve discussed this on the podcast in the past. This comes from a mistaken conflation that when someone’s on thyroid hormone medication, their TSH should be suppressed down to 2.0. Therefore, if normally your endogenous thyroid hormone production is not where it should be, and you see a native or non-medicated TSH above 2.0, Then you’re hypothyroid. We’ve talked in the past ad nauseum about how there’s a pretty strong argument against that, namely via the drove of studies documenting that subclinical hypothyroid individuals who actually have TSHs over 4.5 but have normal T4 don’t have more symptoms and don’t benefit from thyroid hormone medication unless you’re infertile or very young.

DrMR:

But apparently this is still being done. Again, I think it’s being done with the best intentions, but it’s getting harder for me to say that, especially if you listen to the way Josh’s provider really came at this hard and said, “You have a disease. You need this medication. Your body’s starving for ‘XYZ.’” It was a very strong, fear evoking way that it was presented, which really isn’t the way, in my experience, that well-versed clinicians handle anything because there are rarely things that are that black and white. I wouldn’t say never, but in clinical practice, there’s often not any one data point that’s highly definitive. Now sure, if someone had a TSH of 88 and a T4 of 0.1, okay, that’s pretty clearly hypothyroid and there’s not a lot of hand-waving or nuance there. But this is not that. This is a theoretical point that perhaps we could better help patients if we started thyroid hormone treatment at a lower level of TSH.

DrMR:

I’m not sure what’s happening where the contradictory data isn’t being looked at. Well, I do know what’s happening, it’s called bias. So there’s the bias, and then if we combine that with these multimodal interventions where there’s thyroid hormone, there’s changing your diet, there’s going on probiotics, fish oil, stress management and exercise, people say, “Oh, well, I feel better.” This is where we run into trouble, which is why I return to looking at the trials on when we give a group of subclinical hypothyroid patients placebo, half placebo and the other half the drug. And what do we see? Hmm, no benefit. Okay. Does clinical trial after clinical trial all finding this same thing sway anyone? Well, I guess not if you have your mind made up already.

DrMR:

So I’m pontificating here a little bit, but it’s disconcerting when someone like Josh sends me an email, notably concerned in reading his email and being told that he has a disease flat out, point blank, when at best that’s a theoretical diagnosis, and I’m being very generous. The gloves off narrative is that you’re an absolute quack and this is damaging the patient. Now it’s quackery when it’s done that dogmatically, when there’s fear and when there’s an absolutist remark. I could excuse someone who said something along the lines of, “There’s some emerging evidence that suggests if your TSH is below 2.0 that you may benefit from thyroid hormone replacement. Let’s do a short trial and retest your metabolic markers via your cholesterol panel, because you had cholesterol a little bit high, and see if you’re feeling any better. This may help, it may not help, but let’s give it an honest and objective trial.” That would be okay, but you, in my opinion, are a jerk and a quack when you come at people with this fear-based narrative. You do not have anywhere near the requisite evidence necessary to have this strong of a conclusion for this poor guy, Josh, who’s gained a little bit of weight and is now trying to see why.

DrMR:

Interestingly, he mentioned this after the conversation, but I know he won’t have any problem with me sharing this bit, the weight gain started when he moved to Austin. Now that could be lifestyle change. It could be lifestyle change in the sense that other things changed with his diet, with his activity, but it’s also curious that Austin is endemic for mold. I’m careful with the mold piece. It’s me conforming with my own criticism of not being that person who’s dogmatic and hard-driving. I would suggest mold is something to consider if the timeline fits and there’s no other data to point to, meaning, “Well, I moved to Austin and went keto and stopped doing weight training and only started doing cardio because I hurt my knee,” which he did have a knee injury or has a current knee thing.

DrMR:

Sorry if I’m kind of monologuing here in the intro, but all these things are what go into the process that we run individuals through at the clinic. There’s a list of potential hypotheses, but on the one hand, yes, we’re going to be looking to prove a hypothesis, but we’re also going to be looking to disprove the hypothesis. And guess who benefits from that? You do. The individual does. Because if I’m just gung ho about a hypothesis, everyone I work with suffers because I am not weeding out the weak points in the hypothesis. I’m just drinking the Kool-Aid, rinsing, and repeating.

DrMR:

In Josh’s case, there are some clear signs of metabolic sub-optimization. Again, I’m trying to use the most positive framing in my language as possible. I could’ve said metabolic derangement, but I don’t want to say that. Well, I guess I did say it, but you know what I mean. My official way of describing this going forward would be “some suboptimal findings regarding his metabolism, triglycerides, total cholesterol, LDL cholesterol elevated, and body weight creeping up.” So maybe it’s as simple as he went keto, keto doesn’t work well for him and we’re going to change his macros. Or there could be a sleep issue. These sleep issues seem to be more prevalent as you age, as musculature becomes less toned in the throat and palate.

DrMR:

So, there’s a few things that kind of flag. There could also be mold. As Josh onboards into the clinic, because he is going to be seen by one of the doctors at the clinic, all of these things will be taken into account and built into his dashboard of what could be going on, and we’ll responsibly run him through how to improve his health. And the thing that I really want to echo again is we really have to start rethinking this hard-driving narrative on the thyroid. I’m willing to give people the benefit of the doubt for some experimentation for where thyroid hormone may help someone, even though the vast, vast, vast, vast majority of data do not support that. I’m willing to keep a slight crack in the door just because in principle I try to be open-minded and acknowledge that there could be things that I don’t know and things that I don’t see.

DrMR:

But the more that I hear these firsthand case studies, what’s happening in the field is it’s not anywhere near this thoughtful, analytical experimentation with thyroid hormone. It’s almost as if to say there is a irrefutable body of evidence suggesting that people who have TSHs below, and it seems like the goalpost is moving here because in the email he sent me, the provider, it wasn’t even a doctor actually, it was a nutritionist, which I think is also another conversation, but I think this person had remarked that 1.0 to 1.5 is where your TSH should optimally be. It’s to suggest that there’s almost this irrefutable data that this is where the cutoff should be. And there is the opposite of that. There is a large body of data that absolutely refused that hypothesis.

DrMR:

So for patients who are suffering, there are things that can be done. But what we don’t want to do is force upon you the wrong diagnosis, because that doesn’t help you. I guess just a word of caution for individuals that if you’re not feeling well, I get it. I’ve been there. It is terrible, and your mind will play tricks on you and you will go to the worst possible case scenario and grasping for straws. Be careful of the thyroid straw. Obviously, it is something that affects people. Hypothyroidism is a legitimate condition, of course, but it’s incredible how this rampant misdiagnosis is just running away on us. And it is something that we 1000% will be publishing on at the clinic.

DrMR:

We are collecting case studies. This is one of them that will go into some type of case series write-up, hopefully to give people something that will open their eyes. Because again, I think we’re all trying to help people, but boy, some of us have to pull back a little bit and realize that our words carry a lot of weight. If we’re not sure, and if we haven’t done a firsthand fact-checking of an issue, then we should be pretty careful how strongly we’re going to make a diagnosis or a proclamation based upon a weekend seminar, a book, or just one data point of a guru.

DrMR:

So anyway, now that I’ve probably irritated about half of our audience, I mean hopefully not. Hopefully there are not many who are fervently attached to this, and they’re willing to have a debate based on evidence. But now that I’ve had my monologue here, we will go to the episode with Josh where I went on Josh’s show Wellness Force Radio to discuss his disheartening pseudo-diagnosis and how we can steer him out of that. All right, here we go.

JoshTrent:

This is going to be a fascinating one. I personally have been dealing with what seems to be some thyroid issues, but we’re going to get even more clarity today. This is your fourth time on the podcast, man. I think this is the first that we’ve ever had a guest on four times. So thank you for coming on again.

Josh’s Diagnosis

DrMR:

Awesome, brother. It’s great to be on. If you don’t mind me jumping right in, you pinged me with kind of an “Oh boy.” I could feel the fear in your email that you were just diagnosed…

JT:

It was more like concern. It wasn’t like crazy fear, but I was concerned.

DrMR:

Yeah, so there was some concerning stuff in your lab work, and I was thinking “Oh boy, what’s going on?” You sent me your labs, and my comment back to you was that you’re cholesterol might be a little bit better, perhaps we could pull back some metabolic stuff. Nothing there that I was super concerned about, but sure, if we’re trying to tune you to optimal, there are maybe some signs of metabolic excess or slowing. And then you replied, “Well, what about the hypothyroidism?” And I said, “What hypothyroidism?”

DrMR:

This is what had been concerning you, and this is a perfect example of what we had discussed in the podcast in the past. There is this rampant and egregious incorrect and over-diagnosis of hypothyroidism. It doesn’t mean that hypothyroidism does not exist; of course it does. But there have been major outcries, even published in the Journal of Thyroid or in Medscape, that there is this drift to incorrectly diagnosing people. Albeit probably because we’re trying to help them, but it ends up doing way more harm than it does good. And you’re just an example of that.

JT:

Yeah. I wanted to bring you on because this has been your world for so long. How many years have you been involved? If people haven’t heard our other three podcasts, which we’ll link right here below this video, but how many years have you been specializing in autoimmune, gut health, the enteric nervous system, and thyroid function? This has been a long journey for you.

DrMR:

It’s been about eight years from the start, although it’s been about three or four years that I’ve really been honing in on that fact that, holy smokes, there is this division within alternative medicine, again that’s trying to help people, but incorrectly labeling people with a disease when they’re actually in an acceptable normative range. At the clinic, which is now a five doctor clinic, we’re all working together to publish research and try to rectify some of this. We’re about to publish or at least submit for publication a case series exemplifying exactly what you’ve been dealing with, this incorrect diagnosis that ends up harming people. So it’s only been for about three or four years that I’ve really been cueing in on this happening so frequently that I will see a case of this per week, it’s that rampant.

DrMR:

And coming back to that paper that was published in the Journal of Thyroid from 2018 by a researcher named Luvatis, he wanted to assess this also in a controlled research setting. He took a group of people who had an ambiguous hypothyroid diagnosis, had them stop their medication, and then retested six to eight weeks later to see if their thyroid maintained normal function, meaning they actually weren’t ever hypothyroid. And 60% of individuals were able to come off the medication and maintain normal levels. So there is some data to show you how common this actually is.

JT:

All right, so what I’ve been dealing with over the past, I would say 12 months plus because of the COVID and lots of stressors, I’m going to have a baby boy soon, and that comes with its own unique stressors. So I thought it was a beautiful way to just be transparent and just be open and honest so that my journey could be shared with other people, other men specifically, that are dealing with some of the symptomology and also really the erroneous diagnosis of me having hypothyroid. Because as you’ve mentioned, this is something that’s kind of being abused right now on a large scale. So can we set the foundation of how we came together? I was working with a concierge clinic, I’m not going to name their name, but the woman was very serious with me on our consult call. And she said, “We need to put you on all kinds of medications and all kinds of supplements. We need to really get you in this space of understanding that your body is broken.” I remember she actually said that. She said, “Your body is broken, and you need to understand that by you taking the specific drug…” I believe it was, what’s the specific drug?

DrMR:

Levothyroxine.

JT:

Yeah, I think there were a couple of other ones too that were like clinical drugs. And I thought, “I’m going to get a second and even third opinion.” So I talked to my friend, Ari Whitten. He echoed a lot of your sentiments and that led me to you, because I trust you, man. So let’s unpack this step-by-step for people when men or women, but we’ll just speak from a man’s perspective, because I’m a man. When we get diagnosed with hypothyroid, what does that actually mean? What is the truth about that? Maybe let’s just start there.

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Standard Hypothyroid Diagnosis

JT:

When we get diagnosed with hypothyroid, what does that actually mean? What is the truth about that? Maybe let’s just start there.

DrMR:

Firstly, let me just say that I really find it disheartening the way this clinician handled the conversation. When people aren’t feeling well, there’s already a predilection to be a little bit anxious about not feeling well and your mind tends to go to the worst-case possible scenario. I’ve been there. I’ve bumped my shin, didn’t realize I bumped it, felt a lump, and thought I had bone cancer. So these things happen, and if you prey upon that, it’s really the wrong way to handle these conversations because you end up making the person feel worse than they actually are. As clinicians, we should be trying to leverage the placebo in a positive way. You can heal and you can recover; it’s not that bad. These things can be repaired.

DrMR:

So anyway, that aside, the problem comes down to this. There’s this thinking that the conventional ranges for TSH and free T4 are wrong. And if we got you or if we use these narrower criteria, we would be able to diagnose more people as hypothyroid and then get more people the care that they need, like levothyroxine or whatever type of thyroid medication. That’s well-intentioned, but when you look at the evidence, that argument has no good support for it. I’m on the alternative side of the fence here. I’m not constitutionally one who takes the other argument, but this is really where conventional medicine has it right.

DrMR:

Now what’s the evidence for that statement? Let me take a step back since using TSH would be the simplest way to frame this. The cut-off point for TSH to distinguish hypothyroid versus normal thyroid is 4.5 at most labs. The mistake that’s being made in functional medicine is wanting to see people at 2.0 or 2.5. And that’s actually not how one diagnoses. The diagnostic criteria cutoff is 4.5. However, when someone is on medication, the goal is to give enough medication to suppress their TSH to 2.5.

DrMR:

So the mistaken inference is that functional medicine says, “Oh, if that’s the ideal level based upon medication, everyone should be at that level.” It’s a fair posit, but there’s some really compelling evidence that shows us that this is incorrect. That evidence is looking at what’s known as subclinical hypothyroidism. These are people who have elevations of that TSH above 4.5. It’s anywhere from 4.5 to 10. These people will have that elevated TSH, they’ll have normal free T4, but they’ll have this subclinical hypothyroidism. And the data there are clear that there’s no additional symptoms in people who have subclinical hypothyroidism compared to normal, healthy controls, and there’s no improvements in symptoms when giving them thyroid medication as compared to healthy controls, with two exceptions: if you’re infertile or if you’re in your teens. So if you’re very young and infertile, then that subclinical hypothyroidism may benefit. But outside of those exceptions, there’s a fairly robust amount of data showing that as TSH drifts even above that 4.5, there’s no additional symptoms and there’s no benefit from medication. So there’s really ample evidence that using a 2.0 or 2.5 cutoff for TSH is a really bad idea because it doesn’t correlate with symptoms and those people don’t benefit from medication. So your TSH, just to pull it up here…

JT:

We’re going to go deep on this one because I can’t even imagine how many people just do what they’re told blindly with good intentions and then wind up addicted to Metformin and all these other things.

DrMR:

And back to my point, this is why I am seeing one case per week, and I’m assuming the other doctors in the office are seeing about the same. That’s the general consensus when we compare our notes. Again, we are going to publish on this. This is going to be something that we really target with our research because it’s really hurting people. We have seen cases who have been tried on one medication and then a few months later another medication. They go from levothyroxine and add Cytomel, then they go to Armour then WP, then a time-release compounded for years, in some cases. They’ve just been shoehorned into thyroid, never feeling any better. They come to our clinic and we’re like, “Hmm, your sleep is terrible. You have bloating, constipation and abdominal pain. Maybe this is GI driven.” And in two or three months, they have their life back.

DrMR:

So your TSH was 4.09 and your T4 was 5.7. So that T4 is in the lower end of normal, but it’s still normal, and the TSH is also normal. This is not hypothyroidism. If you want I can share this really quickly on my screen, just so people can see this. So here are your results. As you can see, the lab does not flag any of this. There’s the 4.5 cut-off that we discussed, and here’s the normal range. The thinking is, “Well, I know that it’s not abnormal by the labs, but that’s what sick people have.” And perhaps that’s true in some things. Perhaps we can look at a blood glucose of 109 chronically and say, “Okay, that’s a little higher than it should be. You’re not at full-blown diabetes, but there’s something we can optimize there.” But that’s diet and lifestyle. That’s not you having a frank disease that requires lifelong medication, and like we outlined a moment ago, there’s evidence answering this question that this cohort doesn’t have more symptoms and they don’t benefit from the thyroid hormone. So the fact that you were told you were broken really upsets me, because it causes harm to people psychologically, financially and medically. So that’s kind of the long and short of it.

The Lab-Forward Model

JT:

Yeah. And for me, what really matters is that I had this intuition, Michael. I knew that something was off. I didn’t exactly know what it was, which is honestly how I wound up talking to you here. I think the most important thing to point out is that it is always our right to have medical and health freedom where we continually seek out the real truth and the real answers. And so when I look at some of their recommendations, and again I’m not here to slander any company, I’m just here to promote real knowledge that actually applies to people that might find themselves in my shoes, they recommended hCG, Metformin, and NP Thyroid. These are all things that are really just a cog in the Western medical wheel. For some people they’re needed, but for me it was like something didn’t resonate, both with my psyche and also with all the guests including yourself that I’ve had on the show. So from this place, is it really just about smart supplementation? Is it about lifestyle modification? You know, I can go into some of the things that I have been doing. Also, what are the other factors that might contribute to these numbers besides just thyroid-driven parts?

DrMR:

There’s also another concept here of a lab-forward clinical model, which unfortunately, much of natural alternative and functional medicine has drifted into a model that’s lab-forward. That’s really a mistake for many things. Not for all; there are some that are very clear. Actually, ironically, thyroid is very well-steered by labs, but not incorrect interpretation of labs. This is again where I think conventional medicine really has this right. But in much of alternative medicine and functional, natural integrative medicine, it’s labs, labs, labs, labs, labs. What we’re doing at the Center, and this works much better, is a supportive and therapeutic forward. Meaning here’s all the therapies that have clinical trial evidence showing they help people with ‘XYZ’ symptoms. Now let’s organize those therapies in this cascading array of decision trees and navigate you through those until we figure out what works and gets you the result that you’re looking to get.

DrMR:

It’s a much better way because many of these lab-forward clinical models are predicated upon theory. It’s a theory that your TSH shouldn’t be above 2.0 or 2.5. What we’re trying to use is actual proof of when people have these symptoms and they make this diet change, this lifestyle change, use this supplement, whatever it is, there’s clinical outcome data showing it improves their symptoms. And speaking high-level here, a much better model is to put that into a cascade of decision making trees that you can walk the person through until you get the result. Sure, some lab work guides that slightly, but it’s really the person, their symptoms, and their response to therapeutics that drives the model predominantly, rather than the other model, which is just treating labs and treating numbers. That’s really a mistake because much of that is based upon theory, and it’s not treating the person, it’s chasing the number.

Thyroid Treatments

JT:

Yeah, and I do think there are good intentions behind this, but like you said, one thing I noticed with this model and I see with a lot of concierge models is at the end of it all there is a monthly supplement order or a monthly medicine order. These things don’t necessarily hit the root cause. When you look at what I sent you, and maybe for somebody who’s going through what I’m going through, a little bit lower on the testosterone side, I’m at 358 for my total. DHEA is about a hundred, free testosterone is 48. So I’m not necessarily high or even medium, I’m a little bit low on my testosterone. How did these things, these different markers come together? I understand we’re not going to talk about numbers. This is about people, I’m the person sitting across from you. But when you see my testosterone and my hormones combined with some of the numbers for the thyroid, where would you go as that tree you were talking about, the starting tree of how to look at somebody here holistically?

DrMR:

To the other recommendations, I think the Metformin has more merit. There are other ways of starting besides Metformin, but I think something that improves your metabolism makes some sense. Now that could be diet, that could be lifestyle, that could be exercise. How I look at that in the cascading decision tree is looking at your sleep, your diet, and other lifestyle factors first, and then seeing how far we can get the cholesterol profile along and also how that impacts your testosterone. HCG will increase someone’s testosterone. There’s more of a case to be made for something like Metformin or hCG in your case. But where I’d want to start is looking at your sleep to make sure that you’re sleeping and your sleep quality is good. I’m not sure if you’re tracking with Oura Ring and you’re getting consistently at least a B+ score in your sleep, and modifying your macronutrients and looking at your exercise. That would probably be the best few starting points based upon what I’m seeing here.

Diet and Sleep

JT:

My triglycerides and cholesterol, everything’s really high. 355 for triglycerides and also cholesterol at 6.9, triglyceride HDL at 10.14. I went more on the higher protein, ketogenic approach. It made me feel really lethargic and sleepy, but I’m almost wondering about, even in some of the conversations I’ve had with Dan Pardi, the Mediterranean approach for somebody like myself. Obviously, you don’t know my full history, but I’ll just share. I have the APOE3/4 allele. Some people are understanding of that, some people are not. I’m curious how you’d piece this all together.

DrMR:

I’m so glad that you asked that because that was one of the first questions I was going to pose. You could be someone who lower-carb, higher fat metabolically doesn’t work for. There is a cohort of those people out there. It could also be that you need a bit more activity or a certain type of activity change. That’s most likely where we’re going to get the needle to move. It’s a combination of you’re currently doing low-carb, keto-ish, let’s move you to more of a moderate macro composition, and also if you’re doing lots of cardio, let’s get some weights in there. If you’re doing lots of weights, let’s get some cardio in there to kind of balance out the stimuli from an exercise perspective. Glance at the sleep, just to make sure, and lifestyle, macros, and sleep, would be where we would start with this.

DrMR:

These things do have an impact on testosterone, and it’s not to say that the testosterone is problematic. It’s another conversation, but there is this theory at least of saturation point, meaning once you get past a certain level, higher levels of testosterone don’t lead to any improvement in energy or libido. I don’t know enough about that area to really be able to comment. It’s not something we manage in the clinic so I don’t want to speak too far out of my area of specialty, but that’s definitely where I would start.

JT:

It’s a great lens to start because we use an Eight Sleep bed. I don’t know if you’re familiar with that brand. Eight Sleep is really great. It has thermoregulation so it’s tracking me all throughout the night, and we get a sleep score. So I can look at my phone here and I know, like last night, for example, I was a 90 out of 100. So that’s a great sleep score, and that’s specific to me with that thermoregulation. And I really do like that. I like that I get to have some numbers.

JT:

I’m also wearing the CGM right now, and this is from a company called NutriSense, Paul Saladino’s company. For example, yesterday was a holiday and on holidays we sometimes eat foods that maybe aren’t the best. I had a slice of pie yesterday, and I was like, “Okay, let’s just see what happens here.” It took me off the charts. I was way above 140 and it lingered for a super long time. And so I’m thinking, “All right, maybe this Mediterranean path is the way.” And I have been doing a lot of sauna, a lot of Echo bike, not necessarily weight training, and the weight training I do isn’t really intense. So I’m curious to play with some of these things, and honestly, Michael use the data to show me what’s real, otherwise it’s all just anecdotal. What are your thoughts on that?

DrMR:

Yeah, I agree with all of that. The one thing I would add is that there are some fairly big gaps that may occur with something like a mattress that tracks movement and HRV. Oura Ring data will be a little bit better. Something that we’ve just started using at the clinic is what’s known as a home sleep test. So it’s essentially a pulse oximeter with a microphone sensor on your chest to see if you’re snoring. We’re looking at how this correlates with what’s known as attended PSG or polysomnography sleep studies. I want to be careful because it’s too early to really be able to say how much merit this hypothesis carries, but I do have one colleague who was diagnosed with severe and also central sleep apnea. His Oura Ring scores, which are better than mattress scores, were A-. So he had great sleep data from the Oura Ring that was missing his central sleep apnea.

DrMR:

And it’s also important to mention that there are some simple things that can be done to improve sleep quality in a cohort that may have relaxed musculature in their mouth, palate, and throat like singing, didgeridoo, or just meeting with a physical therapist for the mouth known as a myofunctional therapist. That same colleague had central apnea plus obstructive sleep apnea, and he brought his obstructive episodes down to zero after doing a course of myofunctional therapy. I don’t mean to be self-promotional here, but I think a good clinic that’s forward-thinking and not following the dogma of the field isn’t going to pull you into these shoehorned thyroid diagnosis. Because they’re not doing that, it reduces blind spots, and then opens bandwidth for exploring other areas like sleep. So there may be something there, and men are at higher risk for sleep problems than women are.

JT:

Why is that?

DrMR:

It may be due to having a higher degree of musculature and that musculature occludes the airway, so you’re more dependent on having good tone. This is totally theoretical, so I just want to excuse this in advance, and it’s twofold. What could be an increased prevalence of sleep impediment due to lax musculature could be part of the narrowing face that Weston A Price talked about, but it also could be, and this is the main theory, that traditional cultures sang more. At least I think they may have. From what I’ve seen anecdotally, it seems that singing and playing certain types of woodwind instruments like a didgeridoo were more common than they are now. And playing didgeridoo and singing has been shown to reduce other sorts of sleep apnea because of how it improves the tone of the musculature in the palate, the tongue, and the throat.

DrMR:

So the sleep angle is one that we should look at if we’re seeing metabolic insufficiency, so to speak, or sub-optimizations, as well as you may just need to make a macronutrient shift, and not say that you have a disease and you’re going to be on medication for the rest of your life. That a terrible thing to burden someone with. Not to say that hypothyroidism is a tough thing to deal with. It’s actually something that has pretty great outcomes. But we don’t want to label you that out of dogma. And unfortunately, that’s really what it is. If you even look at your provider, the way she handled the conversation reeks of dogma. Usually scientists are cautious, they’re speculative, and they may say, “Well, there’s some emerging evidence that suggests you’re hypothyroid because you’re above 2.5 TSH. We can do an empiric trial on thyroid hormone medication and see how you feel.” That would be what a conservative, cautious scientist would say. It seems like you were given much more of a dogmatic clinician narrative, sadly.

JT:

Yeah, and it felt like there was a system that was in place, and it really didn’t feel too far away from being in a traditional Western medical office. Even when I look at some of the exercise recommendations they made, they were like light walking, yoga, and stretching. Because the analogy that was made to me was, “You don’t want to tax your engine too hard. Look how off your values are. Look at all your biometrics and how off they are. You don’t want to tax yourself.” Again, looking at the sleep, great. I’ll definitely wear the Oura. I’ll maybe even reference it to the data that I get from the Eight Sleep. And then also CGM to monitor foods.

DrMR:

Sorry to cut you off, but I’m happy to send you one of those home sleep tests. It’s essentially a watch device that you wear for one night, and you get that data. So it’s actually pretty easy to do.

Cardiovascular Testing

JT:

You know what’s really great timing? We have a company called Tatch that we’re going to have on the show, and I believe it’s exactly what you’re describing. I need to look more into the literature, but it’s something that you wear, and I’m curious if it’s similar to yours. So yeah, we can definitely link all these resources down below. So from a consultative standpoint, what I heard from you is lifestyle, nutrition, sleep checks, sleep quality checks, not just length, but the quality of the sleep. Anything else that I should be aware of or anyone in my shoes should be aware of?

DrMR:

Well, I’d want to have you do an expanded cardiovascular panel just to get a better quantification of risk. This is something that’s not in my area chiefly. One of the interesting things about having a clinic now that has expanded is that we’re developing a couple of sub-specialties. My area has always been GI and also the gut-thyroid connection, per our prior conversations. But one of the new doctors at our clinic is in internal medicine, and we’re working behind the scenes to use the same analytical processes that I’ve used with GI and thyroid to further develop a cardiovascular risk assessment. We don’t have that fully mapped out yet; we’re still kind of mid-stream in the review of the literature, but I’d want to have you plug in there and just do an updated profile, known as a VAV or an NMR, to get a better sense on what your risk looks like and make some of those modifications. So it wouldn’t really be modifying much in the way of what you said other than some additional lab work to try to clarify your risk. And then we’d go into those same exact experiments that you mentioned.

RuscioResources:

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

The Intake Questionnaire

JT:

Is there a dream panel? With the one that I got here, it seemed like there were many, many markers. I don’t know how many there were total. But when you work with people, is it nice to get a snapshot of literally everything, or is it always symptom specific?

DrMR:

Not everything, no. It’s such a mistake to think that labs are going to clarify everything. Labs are one-third to one-fourth of the information that we look at. I can tell you what’s far more valuable than lab work is having a meticulously-crafted initial intake questionnaire where every question is an index to something that’s going to be on our problems list. Does this person complain of snoring, jaw clenching, dry mouth, or receding gums? Did they have a history of braces and headgear? Do they wake up with drool on the pillow? Do they wake up tired in the morning, even when they get enough sleep? There’s a little section of the paperwork that these are all flags for potential sleep disorder breathing.

DrMR:

If you build all of those things into your paperwork where you’re not just asking BS questions just because some seminar told you to, which unfortunately happens a decent amount in the field, if you throw out the BS and you’re really building all these things into your intake process, when the doctor reviews them, he’s already thrown out a bunch of potential problems and honed in on others. He has rationales behind them and he’s even built them into order of priority. That’s where the magic is. Then the labs clarify that. If we think maybe there’s pancreatic insufficiency and they don’t respond to frontline therapies for their diarrhea, now we can run that test to clarify. But the testing data in absence of all of this other dashboarding of the individual is very much harder to derive meaningful information out of.

Strength Training, Mouth Taping and Singing

JT:

Strength training specifically doesn’t have to be low-rep high-weight. This can be like 15 or 20 reps. What kind of strength training do you see really makes the biggest needle move for testosterone and for general health?

DrMR:

Again, not my area, but from the conversations I’ve had with Mike Nelson who follows this pretty closely, the impact of exercise on hormones is actually fairly minimal. There is an acute perturbation of hormones, but that may be an hour of a spike of growth hormone or testosterone and it pales in comparison to the 24-hour levels. What I have heard, and I haven’t fact checked this yet, not to keep beating on the sleep drum, but one thing that will tank metabolism and testosterone for males is an undiagnosed sleep issue.

JT:

So really getting clear on that data. I’m really excited about this because it gives me new direction. All these different wellness technology pieces exist and they all have their own unique lane, but I think combining the Oura data with honestly also the CGM that I have, that’d be fascinating to see how these sets apply. Also doing mouth taping. That’s the last thing I wanted to round this out with. Mike Mutzel and I have talked about mouth taping quite a bit. I’ve tried it. I don’t notice anything because I haven’t been up to watch myself sleep, but have you yourself experimented with this? Have you worked with anyone that’s had success with mouth taping specifically?

DrMR:

I have experimented with mouth taping. I noticed no change in my Oura Ring scores when I’m mouth taping or when I’m not. What I noticed really moved the needle for me personally was exercising earlier in the day and eating earlier in the day. That was fairly impactful. Now there are a handful of patients at the clinic who have really seen nice improvements from mouth taping. I suspect that mouth taping helps someone who is a nocturnal or nighttime mouth breather. For someone that isn’t really a mouth breather, it probably isn’t going to vector the same amount of benefit.

JT:

I love that you talked about singing too. We just had a blessing here for my son. There were 30 people, we were all singing and I thought this is a lost art form. It’s funny watching people singing, Michael, that aren’t used to singing. They’re so uncomfortable. We’ve lost the ability to sing. It’s so interesting. I know you and I share a mentor and a friend Paul Chek who you’ve podcasted with, and he brought this up to me. He was like, “When did we stop singing? When did we stop dancing? When did we stop telling stories, and when did we stop honoring the mystery of life?” So that is also what I’m plugging into to my healing here.

Finding the Right Clinician

JT:

We covered some great ground in the short time that we had. Is there anything you think we missed for somebody that finds themselves getting some numbers back that produce fear? Irrational, but still fear? What else can we let people know about?

DrMR:

Well, I think it’s important to mention that even the healthiest people, myself included, I think I’m pretty darn healthy and actually perform athletically at a decently high level, even those people have stuff. They have things, there are good days, there are bad days. There are stretches when you feel like you’re riding that wave and you’re just crushing everything, and there’s a moment when you get knocked off that wave and you feel kind of crappy. It’s important to know that because when you’re in that down, knowing that down is somewhat normal prevents you from going to the worst possible case scenario in your mind. And I would add to that, just like people come out of those downs, people come out of those downs every day. With the right clinical advice, things should make sense. You should feel heard. You shouldn’t feel like you’re being shoehorned or as if there’s an excessive amount of fear, and I would for a clinician who really seems to not be too confident or believe too fervently in what they say.

DrMR:

I would almost never use that kind of language with a patient. “You’ve got this, and this is really wrong.” That’s not the way the scientific and clinical process works. It’s very “Sherlock Holmes-ian.” It’s methodical and this is suggested and let’s see how you do. If you do well, that strengthens the rationale, and if you don’t, we’ll pull back and we’ll go to the other problem on that list that I mentioned we dashboard out for individual at the start of their care. So I’d look for those things, because people who know a scientific body of evidence can bamboozle you with factoids. It’s just like when you talk to someone in finance, if you’re not a finance person. You’re like, “It all sounds good to me.”

DrMR:

But what you want to be looking for and how you can cut through is the people who seem like they’re really confident and it has to be this way, and not the person who says something on the lines of, “Well, this has worked in many cases, but there’s also antithetical data that suggests this.” You can tell that they’re really looking at both sides and they’re never too sure because they’re keeping an open mind and looking at the pro and con data to any given point. Those are the sorts of things, those tonality and narrative pieces, that I think can help prevent people from being led astray. And just keep in mind that things can be fixed. Most stuff is not that big of a deal, even though it feels crushing at times. Sure, there are some tough diagnoses, but for the most part, we all get knocked off the horse, and a good clinician will get you back on it without scaring you to death.

Clinic Update

JT:

Well, thanks for your knowledge and wisdom. So obviously we’ve talked about this Healthy Gut, Healthy You, which is a phenomenal resource. It’s almost 400 pages. What is next for you in this functional medicine world? There are really a lot of myths and there’s a lot of truth in your world. So how are you going to rise to the top, what are you guys doing at your clinic, and what’s that like for you now?

DrMR:

Thank you for asking me. It’s been a wild ride in the sense that the work and the philosophy we embody at the clinic has grown so much to the fact now that we have a team of five doctors and three or four adjunctive research staff. Our aim now is to work collectively to publish literature that really answers these questions for the field to give us some data to really rally behind and to try to outline the fallibility in some of these hypotheses and really publish evidence for a better way forward, and also to further legitimize natural and integrative medicine. So it’s a real honor to be in that position where we can hopefully lead the field and try to reform some of these problems. I think it’s a natural growing pain associated with a field that’s expanding. There are going to be some philosophies or some thoughts that weren’t correct, and, we’re hoping to tactfully help weed those out and provide a better way forward which is a win-win for everyone. It’s better for the doctors and it’s better the patients.

Episode Wrap-Ups

JT:

Yeah, and it can be such a confusing world, so thank you for the clarity, because the labs aren’t God. Labs are important, but like you said, they’re a slice of the pie when it comes to a real tactical diagnosis. So where can people learn more? Obviously we’ll link the book, but if they are experiencing this right now in their life, maybe they have numbers that are bringing up fear in them and they’ve been told, “You need to take this medicine, you need to do this.” How can they begin the learning curve with you?

DrMR:

Well, yeah, thank you. It would be an honor to help anyone who is in need of help, and if you go to DrRuscio.com, there’s a link for our clinic there, and also information for our podcast and various articles. You can plug in from there, but again, I would be honored to help anyone not fall into the situation that you did. I’m really glad that we spoke to prevent you from going on medication, because you may have started on thyroid medication and not realized for years that you didn’t need it. So if we can save people from that fate, then it’s a great thing to be part of.

JT:

Yes, man, and I’m excited to share with you some of the different tests and strategies and alterations that I make so that I can bring this greater world of wealth and health that I have. And it was a little scary, I’ll be honest. It was a little scary. The greater world that exists though, is the world of me feeling well. And how great is it that my brand is called Wellness Force and I’m here having a journey of wellness?

JT:

So I appreciate you, man. I appreciate your knowledge. Until Michael and I see you again, we’re both wishing you love and wellness, and I’ll keep everyone abreast of what goes on with my situation so I can share that too. So thanks, Michael.

DrMR:

Awesome, brother. Thanks for having me.

Outro:

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