What Functional Medicine Tests to Avoid - Dr. Michael Ruscio, DNM, DC

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What Functional Medicine Tests to Avoid

Treating People Instead of Lab Results with Dr. Joe and Gavin

There are a lot of incentives in the functional health marketplace to rely on lab testing to make treatment decisions. Unfortunately, this model often serves the bottom lines of lab companies better than it serves patients. 

At the clinic, we use a science-guided framework that is oriented to improving clinical outcomes rather than just focusing on lab results. 

Our patient-centered approach speaks for itself. Listen in as Dr. Joe, Gavin and I discuss.

In This Episode

Episode Intro … 00:00:45
The Problems with Genetic Testing … 00:05:34
Biostat Guidance … 00:12:10
The Four Component Model … 00:19:52
Wasting of the Patient’s Financial Resources … 00:23:23
The Issues of Solely Treating Lab Values … 00:27:59
The Differentials List … 00:32:02
The Science Guided Process of Treating the Person … 00:38:09
​​Episode Wrap Up … 00:44:57

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Hey everyone. Welcome back to Dr. Ruscio Radio. This is Dr. Ruscio here with Dr. Joe Mather and Gavin Guard – all of our team over at the clinic – and we’re doing an in-person pow wow here in Austin. So kind of a special treat – or at least I hope a special treat – and we thought we would keep the topic today somewhat open ended, but with the objective of discussing what testing we’re not using and why we’re not using it just so we can be reissuing this reminder. It does seem something that’s in need of constant reiteration because there are these ongoing market forces where either bloggers or health enthusiasts or doctors or gurus or labs want to tell you how special… effective… novel… a certain test is and that information is pervasive out there. And so to provide perhaps an antidote to that and help people make better decisions with their money and where they put it, we thought we’d go through what tests we’re using, what tests morally we’re not using, and the rationale behind why we’re not using what we’re not using so people can avoid some of those pitfalls. Joe and Gavin – welcome back.

➕ Full Podcast Transcript

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 to Dr. Ruscio Radio. This is Dr. Ruscio here with Dr. Joe Mather and Gavin Guard – all of our team over at the clinic – and we’re doing an in-person pow wow here in Austin. So kind of a special treat – or at least I hope a special treat – and we thought we would keep the topic today somewhat open ended, but with the objective of discussing what testing we’re not using and why we’re not using it just so we can be reissuing this reminder. It does seem something that’s in need of constant reiteration because there are these ongoing market forces where either bloggers or health enthusiasts or doctors or gurus or labs want to tell you how special… effective… novel… a certain test is and that information is pervasive out there. And so to provide perhaps an antidote to that and help people make better decisions with their money and where they put it, we thought we’d go through what tests we’re using, what tests morally we’re not using, and the rationale behind why we’re not using what we’re not using so people can avoid some of those pitfalls. Joe and Gavin – welcome back.

DrJoe Mather/GavinGuard:

Hey Michael!

DrMR:

Well, where should we start? Maybe I’ll kick us off. I’ll put a little grist in the mill here. I saw a patient just the other day, who was operating underneath this hypothesis that his symptoms were coming from thyroid autoimmunity and his thyroid hormone levels were normal. His thyroid peroxidase antibodies (or TPO) were also normal. His thyroid globulin was elevated. So, he was told that he was autoimmune and symptoms are coming from autoimmunity. And I think he was carrying that forward – rightfully so. If you have no other information, that would seem like a potentially reasonable hypothesis. This came from one of the biggest thyroid gurus in the field who is “very well acclaimed,” has written many books, does seminars all over the country.

DrMR:

And this was reinforced by working with another guru – another doctor, a gluten guru, who seems to be diagnosing gluten intolerance based upon HLA DQ genotyping, which we know is very inaccurate. It’s not sufficiently accurate to make a diagnosis. Yet, he starts tying these things together – Well, I’m autoimmune… and I’m also celiac… and celiac and gluten can fuel autoimmunity. “But ironically, Doc (he’s saying to me) I think I actually feel better when I eat gluten. I have more energy. I gain some weight (being underweight is one of the problems he’s trying to contend with). Maybe when I start eating gluten, it’s a problem, but it’s not a problem for a few months. And I also had this observation that maybe I feel better when I eat the gluten because of energy and weight.” So here are two tests we can put on the table – Maybe we start with the gene testing. What’s the place of gene testing? Maybe writ large and just using that patient context as one example of how people come in the door with these hypotheses.

DrJM:

Yeah. And I would back it up one step farther. And for me, the biggest warning flag that a test might be a problem is when a patient starts to self-identify as that test result. And this happens often. So you’ll see patients come in and say my SIBO… my APOE gene… my APOE4… my Hashimoto’s. And that to me is the first warning sign that something unhealthy may have happened. And the test stops giving practical information and starts causing more fear. Genetic testing is one of the pieces I see do a lot of harm because people are coming in and they think because they have one alteration and an MTHFR that their fundamental methylation chemistry is broken. So, absolutely. Let’s start with genetic testing. I think it’s really one of the more unhelpful tools at this stage. And I can’t think of a single patient whose case was different after doing genetic testing. Can you?

The Problems with Genetic Testing

DrMR:

No, I can’t. We go through the quality assurance measures or the fact checking measures where we say – okay, let’s look at some of these tests. MTHFR is one… COMT is another… APOE as another… HLA DQ as another. And let’s see – are these tests able to successfully discriminate healthy from various disease cohorts and/or can they help us personalize an intervention anymore effectively? And when we have fact checked, the answer has come up no. Patients don’t get educated on the fact that a mechanism is one thing, right? People with celiac have a higher incidence of this gene – Okay, that’s true, but it doesn’t mean that that test in and of itself is diagnostic.

DrMR:

I love the example from Dr. Tommy Woods of the obesity gene. We should repeat this like every third podcast, right? The effect size, meaning the magnitude of the impact that the obesity gene has, is less than if you poop or peed before you weighed yourself. So, a consumer could be told if you have the obesity gene, you are at higher risk for weight gain. And that might actually be “true” – meaning it’s a statistically significant effect. It’s not mathematical chance, so it is statistically significant, but if the amount of effect to demonstrate statistical significance was 0.2 pounds, then even though it’s statistically significant, it’s not clinically meaningful. And that’s the filter that we pass the information through. And I don’t think this is done enough in the field. And this is how people can come in with these gene tests and not realize that the effect of the COMT or the MTHFR or the obesity gene… there is something there, but it’s not enough to have clinical meaning. And it’s certainly not enough to personalize the interventions to you.

GG:

When we go through the research papers for anything that we do on the FFMR side, the FFMR Plus, or even the patient education that we put forward, we’re continuing to calibrate on the most pertinent studies that we need to pull out and share. And you’ve hinted at statistically versus clinically significant. Something can be statistically significant. And that just means that the results shown is less likely to be from chance. And we use something called a p-value to discern whether that is or is not. However, something can be statistically significant and not very clinically significant. For example, say a popular supplement leads to weight loss – that’s statistically significant – however, clinically it’s only one pound. Or in your case, that genetic testing. And then furthermore, we have to look at the effect size, right? There are a lot of therapies out there that are perhaps statistically significant, but the effect that they bring about is not that great. I think that’s just something that people have to take in consideration when they’re looking at studies, when they hear a “proven” therapy that some guru is pointing out. Yes, it may be backed by “science,” but it may not be clinically significant.

DrMR:

Not all science is equal.

GG:

For sure. And you have to look at it through your pyramid, if you will, of the veracity of types of studies.

DrMR:

What about when the clinician says, “Well, this test clearly helps my patients.” What is the response to that? People may be listening to this podcast and then they go listen to another podcast that is all about the utility of gene testing. The clinician could say, “Oh, this testing clearly helps our patient.” And maybe even goes into a case study. I mean, I have a response for this, but just to play devil’s advocate – How do we answer that question?

GG:

I would push back on that in the sense that many of those therapies could be done empirically and one could assess the clinical outcomes – or in other words, did your symptoms get better? Did they stay the same or get worse? And just a nod to a project that we’re working on. We’re trying to answer that very question on the evidence-based approach to those two different types of theories. One is very lab-informed and the opposite of that is very outcome-informed. I think the latter allows us to personalize therapies even moreso once others have gotten the diet, lifestyle, and other foundations in place.

DrJM:

Yeah. The underlying idea here should always be only order a test if the result will change your therapy. And if you are going to give a same protocol regardless of the test itself, then it’s not a useful test. Most of the examples I see of clinicians saying, “This lab helps my patient” — they’re generally still doing the same thing afterwards.

DrMR:

They don’t really change care or they have maybe an assortment of therapies. Let’s say there’s an assortment of therapies that have a decent evidence base to them and can help people. And they just reach around for those therapies based upon what the tests are telling them in kind of this clumsy fashion. And they end up seeing results, not because of the tests, but just because they kind of stumbled across one of the therapies that we know can help people — like go low carb… go high carb… cut out gluten… whatever it is. If you’re throwing healthy interventions at someone, some of those are going to stick and help. And if you’re doing that based upon a test result, you could mistakenly associate the test result helping you make that decision when it was just really random chance.

Biostat Guidance

DrMR:

And what we do is we actually set these things up, not based upon this random chance model, because if the tests aren’t accurate, then it really is random chance. Here’s some stuff that can help people — do this based upon this fallacious test marker… oh, you got better? Now I’m confirmation biased and thinking that that helps. But what we do is we set these up in a series of experiments that are guided by biostats. What’s more common to cause someone’s health ailments, right? Let’s say mold or GI – we’re gonna start with GI. And so this allows us to issue the therapies that have the highest likelihood of helping the most people out of the gate. And this is how I think we get better results. Not that it’s a competition, but I do think we need to start painting this contrast for people.

DrMR:

This is how I think we get better results than many people. At every follow-up visit, we’re having a 20% to 30% better outcome than our competition. Then you go out six months and that leads to a vastly different aggregate outcome. And we’re working on this paper and also a video series where we put side by side the result percentage you get when you do testing guided care… here’s the result percentage you get when you do person guided care. It’s usually 20% or higher better in favor of the person guided care. There are still results that you may see on the other side, but we’re going to have better results because we’re using a more accurate barometer, which is the person’s symptoms and how they’re feeling and not just treating a lab value.

DrJM:

And just to put this in context – the average patient that comes in to see us have failed a handful of physicians (both conventional and alternative) before seeing us. And it took us a long time to figure this out and we didn’t always have this degree of clarity

DrMR:

10 years in the making.

DrJM:

So, this is multiple practitioners working for 10 years and really putting our heads together to sort this out. And that’s why we can say these things with confidence. Michael – I know you and I both spent some time in the wilderness doing adrenal four point cortisol testing and came to the conclusion that it really was somewhat like reading tea leaves. That’s the sort of thing that sounds good. There’s a great explanation for why someone may be fatigued and perhaps you can find a pattern on a test, but when you examine it a bit more critically, those conclusions on the tests seem to fall apart and are not held. There have been studies where people will send in the same sample a couple different days apart and get completely different results. One case series of adrenal tests – they had sent their tests in every morning for a week and they saw huge shifts from one day to the next. And if this is a reliable test and you’re examining a physiological pattern of the body that you’re going to treat, it’s not going to be going up and down and up and down and up and down.

DrMR:

You had SIBO… you didn’t have SIBO… You had SIBO… you didn’t have SIBO…You had SIBO… you didn’t have SIBO… That would not be a very valid SIBO test if those are the results that are produced.

DrJM:

We’re just going to keep dunking on adrenal testing here. If you do think someone needs some adrenal support, it could not be easier to give them a blend of adrenal adaptogens.

DrMR:

Which is an important point. We’re not saying the therapies are unhelpful. We’re just saying you don’t need the tests to guide the therapy.

GG:

And to date, there are only two (to our knowledge) studies supporting this tested, guided adrenal support. In other words, let’s look at your cortisol, DHEA, etc. levels before we give you such and such therapy (in this case, adrenal support) and then retest – “oh my gosh, your cortisol, your DHEA ratio got a whole lot better. This is why you’re feeling 50% better with your fatigue.” And contrary to that, a person is coming to us with chronic fatigue burnout symptoms. Let’s give them rhodiola or ginseng… they got better. No testing was needed in that case. And there’s even some studies suggesting that once energy levels can improve who are baseline healthy, who don’t have any of those symptoms. The evidence is on the side and the majority of cases (and especially in this case with adrenal fatigue) of using it with 1. What does a patient look like coming in? You don’t need testing.

DrMR:

And that’s important to underscore. We’re not in any way short changing the individual because some patients will come in and say, “I’m willing to do whatever it takes to get better… I’ll do whatever testing…” Almost as if to intonate the tests are essential in order to get you better. And I think it’s important that we start really flipping that upside down. We will get you better, faster if we understand you – who you are, what your symptoms are, what your history is – all that information about you. And that’s what we treat. And as a quick parallel, Rob published a case study (and we’ve talked about this on the podcast in the past) of a gentleman who came in. The tests were treated by his prior provider.

DrMR:

He did not have fatigue. He did not have insomnia. He was just trying to better recover from his travel to Asia and the circadian disruption that ensued as a byproduct of that. But when treating the tests, this guy who had no problems to energy and no hallmark symptoms of adrenal fatigue, was told no more coffee (which he loved)… given handfuls of supplements… told to reduce his exercise… this ridiculous array of changes that were treating the tests and made the patient worse. It’s a shining example of how specious tests are. On the surface, they sound appealing because they pull your heart strings and make this promise that’s appealing. But in actuality, when you treat the test, you more often than not get worse results.

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The Four Component Model

GG:

And I want to back up and give us some context that we had talked about this before. We just want to have the audience remember this point – the lab results are only 10%, maybe 20%, of the information we need to make educated decisions moving forward. The other 70% to 80% is done on not just that first appointment, but the good deal of effort that we’re putting in looking at characteristics of symptoms, past health history, responsiveness to treatments. I don’t think a lot of patients understand when they come in, how much work has been done on the backend before we even see them. We come in into that appointment already having a really good grasp on the patient’s story and what needs to be done moving forward.

DrMR:

I like describing this as a four component model. One – your history; Two – your symptoms. To your point, we are laboring over their history and their symptoms before we even see them for the first time. It’s a lot of work. Equally as important (maybe the most important) is their treatment response, and we’re looking at their historic treatment response and then we’re obsessing over their treatment response from visit to visit. So, history, symptoms, treatment response, and lab work. It’s really a fourth. And then you factor in that many of the labs are absolute BS. The labs are used very sparingly. So, we’re only using validated labs that have an impact, not all the malarkey in the field, but it’s that four component model that patients and providers need to continuously be reminded about because right now it seems testing is the primary focal point of the model.

DrMR:

It’s such a problem and at best 20(ish)% and it really has to be interpreted in the context of the patient. Especially in GI, there are gray area findings. So, how do we know how to interpret a gray area finding? Do you go down the heretical path where every finding has to be squelshed down to zero or normal? No, because as any provider who was listening to this has 1000% experienced, you will see a perfectly healthy patient with stuff flagged on their labs. You will see a really sick patient with nothing flagged on their labs. And that’s because labs are not the end all be all. You have to look at the labs in juxtaposition to the individual and that’s our four component model – their history, their symptoms, their treatment response, and their lab work. Just like you’re saying. A lot of the work that we’re doing is really obsessing over those details so that we don’t overweight the value of the labs. It’s a great point.

GG:

And for example, what do you do when a patient feels 80% to 90% better and they do a repeat stool test? And it shows a little flagged high H. pylori… maybe some dysbiosis… let’s call it good there. Do you treat that? Do you try to do more? That may send someone over the edge if you prematurely go to a triple antibiotic therapy when we don’t have good evidence that quantitative PCR is a good indicator of who does/does not need treatment. All that to say – it could be distracting to get too much information.

DrMR:

Distracting is a great way of describing it.

Wasting of the Patient’s Financial Resources

DrJM:

Can I pivot the conversation slightly? The thing that’s been bothering me lately, and I’ve been getting upset, is the harm that’s being done to patients with the current amount of over-testing in functional medicine. People are being financially harmed. They are having their money wasted on non-validated tests, on sometimes fraudulent tests, and oftentimes on tests that aren’t going to change the treatment. What this is looking like it is not uncommon. This happens several times a week with new patients coming in. They’ve already spent $2,000 or more on unnecessary testing that does not help them get better. And that needs to stop. That is harming patients. We are into medicine to get them better. And when you waste and squander a patient’s resources, you make it harder for them to get better. If you only have $3,000 to get well, and you’ve spent 2/3rd of that on BS testing, you don’t have the resources to follow up with a doctor who might actually get you better… or to buy the validated, helpful supplements or treatments to get you better… or to spend a little bit of money on making sure that you have an Oura Ring… or you can lift weights or go to a gym… the things that really shift the needle. That to me just has to stop. In the last month, I had a patient come in and say, “I just spent $10,000 before I got into another functional medicine practitioner. I think the things you told me, Dr. Joe, are really going to get me better, but I’m out of money.” It’s infuriating,

GG:

That’s egregious.

DrJM:

t’s horrible. And it happens all the time. And I think it’s happening more.

GG:

So, you’re saying we could get patients better without testing, perhaps.

DrMR:

We know that we can because there are patients we see where we don’t do any testing. There are some patients that say, “I’m really in a strapped financial position. Do we have to do X, Y, Z?” And unless you’re suspecting something that truly needs to be quantified, then yes. I think hypothyroidism would be one example of that if you are suspecting frank hypothyroidism. Unfortunately, more often than not, people are being fictitiously diagnosed with hypothyroidism. There are so many, many, many, many cases wherein you don’t need them coming back to our four component model. If you have those four components, then you can use the other three components -that 75%. Is 75% good? Yeah. 75% is great when you’re in the testing centric models. “Well, we need the labs. We need to know the mechanism and what’s going on.” Then you’re put in this pigeon hole position as a provider – “I really want to help you, but until we know what’s going on in your gut or until we know what’s going on with your genes…” You’re right. It’s so bothersome because these patients come in harmed, not only financially, but also psychologically. This is why we recommend that patients do not look at any of the lab work that we order until we speak with them. A patient will invariably go on the internet and look up… let’s say E. nana or a dysbiosis marker like Prevotella. And they’ll read all about how that could be a problem and they’ll come in thinking – Is it going to be antibiotics? Where is that even coming from? It’s like – no, there’s nothing even to worry about on this test. But for three weeks they’ve been ruminating about that.

GG:

I think we were talking about this earlier – where the genesis of this of this problem started. I think it comes down to a lot of the mechanisms that “gurus” propose really propel into a simple story and simple stories stick, right? We were joking fat makes you fat and blueberries make you blue. I think that is a big driver as to why this has stuck. And why the clinical outcome model needs some more push behind it to really get the functional medicine field up to par with the latest evidence and be more mindful.

DrJM:

So, in other words, it’s really easy to say you have fatigue because of Hashimoto’s.

The Issues of Solely Treating Lab Values

DrMR:

It’s also much easier for providers to treat lab values because it’s much more simplified and concrete and it doesn’t require all the analysis to your earlier point, Gavin that we go through. We’re going through their history and their symptoms and their prior treatments and environmental factors. We have our differential problems list that’s organized by the biostats for most common through least common. Every piece of information that we see, we’re either supporting one of the items in that list or we’re moving it up if it’s gaining importance based upon the supporting data or we’re crossing it off the list. It’s grinding and analyzing information… or adrenal fatigue… high morning cortisol. Oh, easy. It’s easier in a lot of cases to treat lab values because it’s just this direct – “here’s a value, here’s a support for the value, we’re done.” And it’s not this – here are seven different things that could be causing your ailment. How do we prioritize which one based upon who you are as a living, breathing human with symptoms that evolve over time? That’s much harder to do. This is compounded by who has a large financial incentive for educating what we’re advocating for in a weekend seminar. It’s much easier to say, “We’re ‘adren-o test’ and here’s the four point cortisol – here’s why it’s important – here’s the protocol for how to treat it. It’s much easier. And then there’s a financial incentive for them to fund a seminar and to find a speaker who presents eloquently. It runs away into this model and this is how you get where we are.

GG:

So, what does a patient experience look like in this new clinically focused model?

DrMR:

Well, we send them a picture of Dr. Joe.

DrJM:

That’s all it takes.

DrJM:

They run away screaming.

DrMR:

A poster. It’s him washing a car on a hot day. Sorry. It’s a bad joke. But that’s a great question, Gavin.

GG:

I think a lot of people come in – “So now what are you doing? Why did you spend 40 minutes beforehand?

DrJM:

We are going to listen. And I think that’s the secret power here is that we listen very, very closely and we read every word that patients write on their application and most physicians don’t do that. That’s a sad truth, but we really listen and we can therefore start on second or third base, right at the first sentence when we’re talking to a patient. We already have most of the puzzle put together and the first visits are really just kind of solidifying and making sure that certain sections are fleshed out and we have all the information. So, just listening. The field of functional medicine has gone through so much growth, and there’s so many new ideas that weren’t out there a few years ago, but the key to this is simply good medicine. It’s good listening. It’s listening really closely to your patient. That is what the key is. And there’s too many distractions out there.

DrMR:

On the theme of distractions, it’s also important for clinicians to focus what information they’re getting from their patients because sometimes patients want to go into a long narrative about their breastfeeding history (let’s say) and that’s not directly applicable.

DrJM:

Yeah. “My mom had antibiotics when I was in utero.”

DrMR:

And some providers will (I don’t want to say) let patients go on. They may mistakenly feel there’s a lot of valuable information there. I would argue there’s not. And so another art or science of this – just like we’re honing in on the testing that works – we’re honing in on the historical and subjective snippets that also are important.

The Differentials List

GG:

And with that information, we build that problem list. Or in other words, what’s called the differential, the possibility of issues that could be causing your health concerns. And with that comes the corresponding treatment plan. I liken it to a roadmap that we’re going to help and guide the patient through. Step one – here’s our foundational diet and lifestyle practices that if we don’t get in place, none of these other therapies are going to have the most effect. And then we’ll start walking through the least invasive and most likely to help therapies before moving onto the most esoteric and exotic therapies.

DrMR:

Take a tree, flip the tree upside down. We start with the core therapies and those core or trunk therapies produce improvements. And it’s the treatment response that we see as someone’s working down the core of the diet, lifestyle, and gut health foundation’s model that we use that then tells us the signature of the symptoms that remain indicate low HCL… or mold… or apnea… or female hormone imbalances. And this is really how we focus the information that they’re sharing with us, which we’re listening to intently (to your point, Joe) to then dictate how we further propel care and pursue whatever branch has the most evidence as we’re trying to either rule something in or rule it out in our mind. And this is way more effective than testing guided care.

GG:

Absolutely.

DrJM:

I was just working on a list of some of the unnecessary testing and I thought it might be fun to just have a quick lightning round.

DrMR:

I thought you were playing Snoot. I was a little little offended that you were on your phone during the podcast.

DrJM:

Alright. So, the unnecessary tests that we see in the clinic that we just roll our eyes and flip to the next test. That’s what we’re presenting. Adrenal testing? Are we all in agreement?

DrMR/GG:

Agree.

DrJM:

How about salivary hormonal testing?

DrMR:

Agreed.

DrJM:

Dutch testing?

DrMR:

We’re not doing that.

DrJM:

Candida antibodies? This one drives me nuts.

GG:

Rob had a really good review on that with the FFMR not too long ago.

DrJM:

Can you remind me what the conclusion is if you remember it?

DrMR:

Maybe. Candida antibodies, maybe not great evidence, some minimal preliminary signal, maybe also ASCA antibodies, and one of the things that we have on our list. I should clarify for our audience. This is what’s exciting as the clinic is growing. There are these different teams where Rob, Gavin, and I are working on research and Joe and myself are working on clinical training/clinical systems. And both of these teams are chugging away and then periodically they have to reintegrate. We haven’t had a reintegration since we’ve done this deep dive into the candida assessment. There’s not great evidence. So, I think part of your suspicion is totally dead on that the candida antibodies do seem to have limited utility for diagnosing intestinal candida or a correlation (more importantly) to something like an IBS presentation. The ASCA antibodies may also have some utility. What we want to do at some point is look for agreement between a quality of life measure, a digestive symptom measure, in parallel to a stool test for candida, probably PCR-based.

DrJM:

That’s going to be awesome because my perspective on the candida antibodies is… there’s a practitioner who I often see order these and the patients end up in our care. And I think every single one has been positive. Is every single one of these patients overgrown with candida? Candida is a normal constituent of the microbiome at some degree. When is it a problem? When does it have to be treated? I’d be really interested to see.

DrMR:

I can’t say there’s disproof. There’s different types of evidence. There’s evidence disproving a test. I don’t think that’s been established. Is there adequate evidence showing that this test predicts or correlates with symptoms? I don’t think so. There’s a little flicker of a signal and that’s what we want to try to explore. I do see it being minimally impactful in terms of how does it change clinical care. I think we’re on the same page there. We have our clinical model. Would we deviate wildly from that tree model because of one candida positive antibody? No.

GG:

And here’s an example of how this could lead to worse outcomes. And this is what we’re working on in that paper. Let’s say someone gets the ASCA antibodies and they have inflammatory bowel disease. Some practitioners may say, “You know what Mary Sue – you have these antibodies to this fungus. I really want you to avoid a probiotic like Saccharomyces boulardii, which is a cousin to this Saccharomyces cerevisiae.

DrMR:

Stealing my thunder, Gavin.

GG:

I’m stealing it.

DrJM:

Take a coffee break, Michael – we’ve got this.

GG:

We have how many clinical trials showing that Saccharomyces boulardii is very effective for inflammatory bowel disease. So, in this case, someone has these antibodies, they…

DrJM:

…get sidetracked on a less important treatment. They get blasted with Diflucan and oregano. It might be unnecessary.

GG:

These probiotics have very powerful anti-fungal properties. That might not just lead to missing a therapy, but actually worse outcomes.

DrMR:

And this is a really important point. I think we should just try to frame this as it’s less scientific in the majority of cases if you treat a lab value. As a patient, it may seem like, “Ooh, we have the labs…”

DrJM:

Because clinical trials are set up to evaluate treatments, not lab tests.

The Science Guided Process of Treating the Person

DrMR:

Exactly. Most clinical trials are looking at people with syndromes or symptoms or conditions. Does a person like you who is suffering with this benefit from this treatment as compared to placebo? There are some cases where lab values are treated, but it’s the minority. And I think that’s because the medical system – one of the things it has done well is figured out that treating lab values only gets you so far. In defense of conventional medicine, even though we criticize it for being overly reductionistic, treating lab values is uber reductionistic. It assumes the outcome you’re seeing in this multi-system, complex organism of a human being… that one value tells you exactly how to account for the infinite complexity of a human system. It’s so hubristic.

GG:

It ignores the complexity of physiology…

DrJM:

Which brings us to the next…

DrMR:

Just to reiterate one more time. For patients & providers — Treating lab results is far less scientific than treating presentations or treating people. And I think it’s really important that we plant that flag pole and people understand that if you want to be scientific and have a science guided process, the provider who listens to you and treats you is actually being more scientific given you don’t think that they’re some sort of kook. There are kooks out there who just do weird assessments that don’t use testing, but within the confines of you having confidence in the provider being science-based. Treating the labs is far less scientific than treating the people.

GG:

That’s our main takeaway point here.

DrJM:

I’ve got micronutrient testing, in most cases. I have hormone ratios.

DrMR:

We do not do most micronutrient tests. I think ferritin is one of our most favorite lab tests…

GG:

Vitamin D occasionally, right?

DrJM:

Yep. But we’re not looking at levels of serum zinc, copper, magnesium, potassium…

DrMR:

Let’s make a quick point on ferritin. Some of the papers by Sapi, et al, were suggesting a ferritin below 100 would indicate iron deficiency anemia. And there were at least two papers that found this, and even one paper that found that in the setting of women on thyroid medication who had non-responsive fatigue, supplementing with iron, their ferritin to above 100 led to resolution of the fatigue. So we’ve been experimenting with this in the clinic for well over a year now. And the clinical signal that we’ve seen is 100 seems to be too loose of a cutoff where it’s too high. And in my estimation, I think 30ish is a better cutoff, but here’s how I think we also reconcile this. If someone has gone through the core of our model and they’re still experiencing fatigue and they maybe have a ferritin of 70, that’s when iron makes more sense. If their initial phase in working through our model and they have a ferritin of 70, and they have fatigue, the likelihood that the diet, lifestyle, and gut health foundations model is going to resolve their fatigue, is extremely high. The gut causing fatigue – very high, perhaps female hormones, perhaps a sleep issue causing fatigue. That’s much more likely, but if we work through all of that and the ferritin is still 70, and one of the only remaining symptoms is fatigue, that’s when I think it makes more sense. So, just maybe to speak to how we’re even critical of some of the things that we’ve discussed. And we’re always reevaluating some of these positions.

GG:

And there was a recent study that was published that suggested probiotics could improve many, many micronutrient levels – including zinc, magnesium, folate, B12.

DrMR:

Where’d you read that? Was that the FFMR Plus?

GG:

I don’t know. Maybe. A little plug for the FFMR Plus?

GG:

In other words, you could not take any micronutrient supplementation and just get after improving your GI ecosystem, and you can improve many of those levels.

DrMR:

Which is exactly why we have these things codified in the order that we do.

GG:

Exactly.

Dr Ruscio Resources:

Hi, everyone. If you are in need of help, we have a number of resources for you. Healthy Gut, Healthy You – my book and your complete self-help guide to healing your gut. If you’re not a do-it-yourselfer, there is the clinic – The Ruscio Institute for Functional Medicine, and our growing clinical and supporting research team will be happy to help you. We do offer monthly support calls for our patients where I answer questions and help them along their path. Health coaching support calls every other week. And also we offer health coaching independent of the clinic, for those perhaps reading the book and/or looking for guidance with diet, supplementation, et cetera. There’s also the store that has our elemental diet line, our probiotics, and other gut health and health supportive supplements. And for clinicians, there is our FFMR – The Future of Functional Medicine Review database, which contains case studies from our clinic, research reviews, and practice guidelines. Visit drruscio.com/resources to learn more.

GG:

What’s next, Joe?

DrJM:

Next is hormone ratios, particularly thinking thyroid hormone ratios. We do not do those. Not helpful. Including reverse T3 – I don’t think reverse T3 is important at all. And genetics. That’s my list. Did I leave off any tests that you guys see on a regular basis?

DrMR:

We should say Dutch testing because I think sometimes Dutch tries to dodge the bullet of some of the more traditional adrenal testing criticism. I think it’s important that we disclose that we’re not finding that testing… not to say that I’ve done a lot with it… Firstly, it’s been heavily questioned if that’s even accurate. Secondly, it’s so variant from day to day.

DrJM:

That’s the problem I have with it.

DrMR:

And thirdly, I think it’s more an intermediary, so it’s not really telling you what’s causal. If you’re doing too much and you’re tired, fix the doing too much. If your gut’s a mess and you’re tired, fix the gut. If you’re feeling great, keep doing what you’re doing. It’s a midlevel intervention. It’s midstream and we want to intervene upstream.

GG:

And even if it was validated, it may not be clinically useful because it doesn’t really change the order of operations for us as we guide the patient through the roadmap.

DrMR:

It’s midstream. It’s not the upstream, most causal, level of analysis and intervention.

Episode Wrap-Up

DrJM:

To conclude, listen to the patient, choose the treatments most likely to help the patient, put testing later after you’ve seen the response, and don’t waste your patient’s money.

DrMR:

I think there are some select studies that can be done earlier phase – not to get to in the nuance.

DrJM:

The clinicians who are most evidence-based are those who are using all of the meta-analyses and the studies to help guide choices of treatments rather than labs.

DrMR:

Treating the patient rather than treating the labs. That’s the most science-guided perspective.

DrJM:

Absolutely.

DrMR:

I think that’s a good run through. Anything else before we close? We’ll probably do one more podcast because this is fun, but I think this is a good spot to pin this topic and maybe just a few closing remarks for our audience. I think everyone in our audience gets it. Of course, the audience is thankfully growing month over month so I think just resurfacing these conversations… it’s helpful for those who are new to our audience. And also for those who are long time listeners, resurfacing this discussion helps.

DrJM:

And for people who are thinking about becoming a patient, we’re trying to help understand what makes us a bit different. And the amount of work that goes in the back end to getting good outcomes in patients who failed otherwise. So, if you’re looking for help, please consider us. We’ll do everything we can to help you. And if you’re a clinician who is having trouble with patients or have a few cases that are hard, we’d be more than happy to work together and help take on patients. We’re here to help and that’s where we’re coming from — trying to get great medicine to as many people as we can.

DrMR:

And don’t feel like you’re crazy for lack of a better term, if you feel like a lot of what you’re reading is not reinforcing this – and is reinforcing a testing heavy model.

DrJM:

There are a lot of marketing dollars against us.

DrMR:

Unfortunately, a lot of the incentives are aligned in the direction of a testing heavy model.

DrJM:

The companies have a big incentive to show their product first and foremost, their test first and foremost. And that influences how people think, unfortunately.

DrMR:

And if some of these incorrect arguments are appealing, then people will read more of them. And then the Google algorithm will reward those by pushing those search results higher up in the search feed. That’s one of the ultimate travesties. It’s like the YouTube algorithm. If you watch cat videos, you’re going to start seeing more cat videos. And if people find mold and thyroid to be a more appealing potential cause of their fatigue (let’s say) and more and more people read about that, Google says, “Oh, people really like it when they say – why am I fatigued?” And we show them stuff about thyroid or about mold. And so those go higher and higher in the search feed.

DrJM:

They get a distorted view of what might actually be causing it. So, that’s why it’s so important to work with a clinician who is thinking through these things critically.

GG:

And I would say that if patients have got these labs that they shouldn’t feel bad. We are obsessing over a model that is really trying to get us clinical outcomes, not just improving labs. There is so much information out there that really what you are paying for when you see a doctor in the clinic here is guidance. We’re obsessing over this and performing a lot of work to develop this model. If you floundered in other care, it is maybe time to take a different approach.

DrMR:

Good thoughts to close on. Thank you everyone for listening. Please share this podcast with a friend or family member or a loved one. I think the more we can get this word and message out there, the better. Also, to additionally help us in that aim, please give the podcast a review if you haven’t. That also helps us climb higher in the various search feeds. So anyway, that’s just a few thoughts with Joe, Gavin, and myself. Hope this helps and we will talk to everyone next time.

Outro:

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