In the past several decades, the incidence of autoimmune conditions, including autoimmune thyroiditis (Hashimoto’s), has skyrocketed — and the use of thyroid pharmaceuticals has gone up accordingly.
What’s often overlooked in conventional medical practices, however, is the strong connection between the gut and the thyroid, and how improving gut health can ease symptoms and reduce the need for thyroid medication. Functional medicine practitioner, Dr. Michael Ruscio, DC, specializes in the gut-thyroid connection.
In this podcast, he talks with Dr. Kara Fitzgerald about the gut-thyroid axis and how even some of the prevailing functional medicine wisdom gets it wrong (when it comes to optimal range numbers for thyroid antibodies and treating adrenal issues, for example).
He also touches on the dangers of over-testing and over-treating — and the health benefits of releasing our collective obsession with optimal wellness. This discussion is chock full of clinical pearls.
In this podcast you’ll hear:
- How improving gut health can reduce the need for thyroid medication
- The (surprise) strongest predictor that someone has SIBO
- How pseudo-selenium deficiency could open the door for autoimmunity
- Why more lab tests don’t always translate into better clinical outcomes
- The pitfalls of iodine dosing for autoimmunity (and the benefits of iodine dosing for fibrocystic breasts)
- The optimal range for TPO antibodies, which differs from conventional functional medicine wisdom
- The best functional lab panels for assessing thyroid health, including which T4 assay is the most accurate (many direct-to-consumer tests use the less accurate assay)
- Why, in many cases, the cause of symptoms is not the thyroid
- Why highly prescriptive dosing might not be necessary for the adrenals when using herbals and how adaptogenic herbs’ biggest impact might be on the microbiome
- The importance of using anti-biofilm agents in treating SIBO
- The potential dangers of too many interventions at once
Dr. Michael Ruscio is a functional medicine practitioner, researcher, and author. His specialties include autoimmune, thyroid, and digestive disorders. He consults clients locally in the Bay Area and remotely across the country. His clinical research is focused on digestive disorders.
Dr. Ruscio has been a featured speaker at numerous conferences including the SIBO Symposium, PaleoFX, Ancestral Health Symposium, and an international symposium in London. He’s also spoken for several online health summits, including Sean Croxton’s Digestion Sessions.
Dr. Ruscio has collaborated with many authorities in the health and wellness industry, including Robb Wolf and Melissa Hartwig. He has been interviewed on several popular podcasts such as Sean Croxton, Robb Wolf, Ben Greenfield, and Jimmie Moore, and he’s provided clinical training for Designs for Health and the SIBO Symposium.
Dr. Ruscio also conducts a very highly rated functional medicine podcast. You can visit his website and podcast at www.drruscio.com
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Dr. Kara Fitzgerald: Hey everybody. Welcome to New Frontiers in Functional Medicine. I’m delighted to be with Dr. Michael Ruscio today. We’re going to be talking about all things gut and thyroid, or specifically SIBO and the gut-thyroid connection. I know that you’re going to love it. He’s got just a lot of really good stuff to teach us. I actually had the honor of being on his podcast recently and I’ve got to know him in the process and he’s a kindred spirit, for sure.
A little bit about Dr. Ruscio. He’s a functional medicine practitioner, researcher and author. His specialties include autoimmune, thyroid and digestive disorders. He consults with clients locally in the Bay area and remotely across the country. His clinical research is focused on digestive disorders, and as a sidebar, he just completed a pretty cool SIBO study looking at a biofilm intervention, and we’ll talk about that at the end of the podcast.
Dr. Ruscio has been a featured speaker at loads of conferences, including the SIBO Symposium, Paleo f(x) and the Ancestral Health Symposium. He’s also been an international speaker, as well. He’s done a whole lot of health summits, he’s collaborated with lots of authorities in our industry, including Robb Wolf and Melissa Hartwig. He’s been on loads of podcasts also, including Robb Wolf, Ben Greenfield, Jimmy Moore, and he’s provided training for Designs for Health, as well as the SIBO Symposium attendees. Dr. Ruscio also conducts a highly rated podcast, himself. As I said, I was just on it. It was a lot of fun. And you can visit his website, podcast, and access him and his clinic over at DrRuscio.com. That’s D-R-R-U-S-C-I-O.com, and of course we’ll have all of that information in the show notes.
Welcome to New Frontiers. Michael, it’s great to have you here.
Dr. Michael Ruscio: Hi. Thanks for having me.
Dr. Kara Fitzgerald: All right. Well, listen, let’s jump right in. This is a pretty hot topic, and there’s just lots of … I know there’s lots of clinical pearls you’ll impart. You’re really a clinical pearl-centric individual, and just the more user stuff we can give away to clinicians the better. You talk a lot about the gut-thyroid connection. Can you walk us through that?
Dr. Michael Ruscio: Sure. I mean, there’s, I guess, a lot. When you unpack it, there’s a lot there, but there’s a few broad takeaways that are really important, which is your gut health does affect your immune status, and optimizing one’s gut health can improve different immune, including auto-immune conditions. This is probably why we see a number of people who go on a gluten-free, or at least a gluten-reduced diet who have Hashimoto’s, for example, feel better. We have one study to date that’s really documented in non-celiac subjects that a carbohydrate reduced or restricted diet can actually cause a 40 to 44% improvement in thyroid autoimmunity. So it’s not just an airy-fairy natural medicine concept. We’re actually seeing some contemporary science really start to back this up. There’s one showing that the treatment the H. pylori can cause a significant improvement in Hashimoto’s. There’s a gut-immune connection.
There’s also something I think that’s overlooked quite often, which is when you improve someone’s gut health, they need less thyroid hormone medication, and it’s probably not because of an immediate impact on the thyroid autoimmunity, although it’s often attributed to that. It’s probably because the person is absorbing their medication better, and so now they need less of a dose.
And then, there’s also this connection between thyroid autoimmunity or hypothyroidism causing gut problems. This is probably why one recent study that surveyed over 1800 people found the two strongest predictors for if someone would have SIBO was either being hypothyroid or being on thyroid medication.
Dr. Kara Fitzgerald: Wow.
Dr. Michael Ruscio: Yeah. There’s this complex web between the gut and the thyroid, and I really don’t think you can have optimum thyroid health without optimum gut health, or optimum gut health without optimum thyroid health. And so, there are definitely things that have a lot of interplay between one another, and if you can sort this out you can do your patients a great service.
Dr. Kara Fitzgerald: Yeah. Right. Right. Well, first of all, let me just say that if you can shoot me any of these citations for the show notes, that would be fabulous. I’ll just give you a list to jog your memory, but you’ve just mentioned four in pretty rapid succession, and I have a feeling people will want to see them. But so there’s this interrelationship between SIBO and hypothyroidism, so thyroid meds can actually induce SIBO, and likewise SIBO can induce hypothyroidism? Am I hearing you correctly?
Dr. Michael Ruscio: Well, we don’t know if it’s the thyroid meds themselves.
Dr. Kara Fitzgerald: Okay.
Dr. Michael Ruscio: Because in this one study they showed that people had risk if they were undiagnosed hypothyroid, meaning they were hypothyroid, but they were not yet being treated. But then they were at even more risk if they were on thyroid hormone medication. And so, sometimes people may attribute, “Well, if they’re hypothyroid, they have slow motility and that’s why they have SIBO.” But that doesn’t account for why the people were actually on thyroid medication.
Dr. Kara Fitzgerald: Yeah. Exactly. Right.
Dr. Michael Ruscio: So it may be something unique to thyroid disease itself, and perhaps it’s something to do with the bacterial overgrowth, utilizing selenium, that causing a pseudo-selenium deficiency, and that opening the door for thyroid autoimmunity. That’s one mechanism I’ve speculated, but certainly those who are hypothyroid, or even more so those who are on medication for hypothyroid, have a higher instance of SIBO. I do not think that means people should stop taking their medication. That’s not the answer. It’s probably a non-thyroid hormone dependent mechanism that drives this.
Dr. Kara Fitzgerald: Yeah, right. Interesting. So if you’re doing full functional medicine, you’re casting a wide net and you’re thinking about selenium and iodine and some of the amino acids involved, you might address it. Is that what you’re suggesting?
Dr. Michael Ruscio: Mm-hmm (affirmative). Well, I guess the way to wade into this would … and maybe I should take a big step back. There’s just one preface that I think is important to mention, and I don’t want to get overly political here, but I think it’s good for us in the field just to maybe be aware of some areas that really need improvement. I do think that old practitioners and patients alike have been sold a little bit of a bill of goods where the more lab testing you do the better results you will get, and somehow if you could just get better lab work, you could get better results. I think that’s a very virtuous and well-intentioned assumption, but I really think that’s severely flawed and that may actually inhibit a lot of patients and a lot of providers from getting healthy because they’re chasing down lab markers that aren’t super relevant.
When we start looking into digestive health and into thyroid health, if we can focus on the markers that are the most salient, then we can really use those as a North star to guide our treatment rather than getting pulled into frivolous exceptions. And I’m happy to elaborate on that, but I’ll pause there for a second.
Dr. Kara Fitzgerald: Yeah, yeah, yeah. Well, we talked about some common nutrients used, and I can’t imagine you would argue with making sure they’re either replete in the diet or you’re giving them extra if you suspect, whether you test or not. Any comments on that? Do you want to say anything?
Dr. Michael Ruscio: Yeah, sure. For thyroid autoimmunity, for example, I don’t typically run testing for the nutrients.
Dr. Kara Fitzgerald: No, no. Oh, yeah. Go ahead. Sorry.
Dr. Michael Ruscio: But I agree with you. Something like selenium … there’s been studies documenting selenium, vitamin D, CoQ10 and magnesium can all benefit thyroid autoimmunity. What’s interesting is, and where we have the best data is probably for selenium, if you read some of the systematic reviews with meta-analyses, some of the highest level of scientific evidence, you will see them concluding that selenium does not have an appreciable impact on thyroid autoimmunity. It’s probably because these reviews are lumping together studies of three, six, nine and 12 months or longer duration.
If you look at the research carefully, you see that selenium has most of its benefit between three to six months, which probably means that people don’t really take selenium every day in perpetuity, but rather they may have a deficiency, or maybe even a pseudo-deficiency, a real sub-clinical deficiency, that just benefits from a small amount of selenium. Similar results have been shown with vitamin D. In non-vitamin D insufficient populations, vitamin D supplementation has been able to reduce thyroid autoimmunity. So I think testing to make sure you’re not overdosing, perhaps for vitamin D if you’re going to use it in the long-term, makes sense. But really, a lot of this can be well remedied with just a simple cocktail of selenium, vitamin D, magnesium and CoQ10.
Dr. Kara Fitzgerald: Okay. And you would actually do that short-term, at least for some of them?
Dr. Michael Ruscio: I would. I would probably have someone on a regime of that for about six months. The nice thing about vitamin D, for example, is that you don’t have to use whoppingly high doses to have the effect that’s been seen in some of these studies. If you’re not using these aggressive doses, you don’t have to be as concerned with very, very tight serial retesting to prevent overdosing.
Dr. Kara Fitzgerald: Yup. Yup.
Dr. Michael Ruscio: Also, when you look at … And there’s so many directions we can go, but … when you look at thyroid autoimmunity, I think we can start making the case that antibodies between 100 and 300 for TPO are really considered a clinical win, and that we don’t have to get below 35 or 30…
Dr. Kara Fitzgerald: All right. Listen. Let me back you up, because I was going to go there. I was going to go there. We just need to color in some of what you’ve thrown out there because people are going to want these details. All right. What are you dosing vitamin D at? Selenium? CoQ10? Are you using iodine? How are you dosing that? So let’s just get those fundamentals out of the way, and then we’ll talk more about the labs.
Dr. Michael Ruscio: For selenium, the dosing is usually about 200 micrograms per day. That’s been used in most of the studies. With vitamin D, some of the studies use a once a week bolus of something maybe around 10,000 or 20,000 IUs. But if you break them down, often times a vitamin D dose averages, if you wanted to give a daily dose, around 2,000 IUs, so nothing there is incredibly exotic. Off the top of my head, I don’t recall what the dose of CoQ10 is. I’m assuming it’s probably somewhere between 60 and 150 milligrams, just kind of standard dosings.
Dr. Kara Fitzgerald: The typical.
Dr. Michael Ruscio: Yeah.
Dr. Kara Fitzgerald: Yeah. And it’s not Ubiquinol. I’m sure there wasn’t any Ubiquinol used in these studies, it was just…
Dr. Michael Ruscio: No. Right, just the cheaper form. Exactly. So yeah, no dosing that would be considered overly high or exotic, which is nice from a cost-effective standpoint because it doesn’t mean you’re having people take, especially the CoQ10, it can get quite expensive if you’re using very high doses.
Dr. Kara Fitzgerald: Yeah, that’s right. And selenium, I’m assuming [selenomethalunate 00:11:21] is what you’re using most commonly.
Dr. Michael Ruscio: That’s what I use. Not all the studies have used that, but that’s what I use. Yes.
Dr. Kara Fitzgerald: Okay. All right. And are you going with iodine? Are you testing and then treating with iodine? What is your approach there?
Dr. Michael Ruscio: I usually don’t use iodine. For most cases I don’t really use iodine. Maybe if someone is sub-clinical hypothyroid and they don’t have thyroid autoimmunity, then I would use or do a trial with iodine. But if you look at most … And this is observational data … but we have an overwhelming number of observational studies showing that when we add iodine to the food supply either in the milk or the bread or what have you or the salt, that the instance of thyroid autoimmunity goes up. There are a few clinical trials that have put patients on iodine, seen an induction of thyroid autoimmunity or hypothyroidism, and then taken them off the iodine and seen that reverse.
I speculate that perhaps one of the reasons why a diet like an autoimmune Paleo diet works well is because that is, in effect, a lower iodine diet because you cut out many of the iodine-rich or iodine-fortified foods. I’m open to iodine, but when we look at how it’s really been show to provocate thyroid autoimmunity, and thyroid autoimmunity is the main driver of hypothyroidism in Westernized countries, I really reserve that as a secondary or tertiary intervention just due to some of the stats.
Dr. Kara Fitzgerald: Well, yeah. But conversely, it’s also dropped the incidence of goiter to nil. I mean, I would say that it’s U-curve distribution and even … I personally, in my practice, I do use a smidge of iodine when I think it’s indicated, even in my autoimmune patients. But you’re right, I pay attention and I have on occasion seen it go up, even very modest dosing. Yeah. I would absolutely concur that if you’re going to walk in that direction with iodine that you need to be responsible with how you dose it and track it more carefully with labs. It’s interesting though. It’s interesting what you say.
Dr. Michael Ruscio: And just what you said, if you’re using a smidge, I’m assuming maybe that’s …
Dr. Kara Fitzgerald: Like 150 micrograms or 200 or …
Dr. Michael Ruscio: Right. That’s actually very reasonable. I mean, even I believe the upper dietary intake limit is 1100 or 1200 micrograms, and some of the research has shown that 450 micrograms per day may be the ideal dietary intake to shoot for. So if someone’s got a fairly iodine-deficient diet and you’re giving them a couple hundred micrograms, I think that’s totally doable. It’s when you get into the camp of really aggressive iodine dosing where you’re at one, two, three milligrams that I think you have the highest incidence for potentially having a problem. You make a really good point.
Dr. Kara Fitzgerald: Yes. That’s right. That’s right. And there was a very strong camp where they were going into milligram amounts. I actually think that, again, with careful observation and things like fibrocystic breasts, there may be a period of time where we use that.
Dr. Michael Ruscio: Completely agree. Yup, and that’s where I think the best research is, is with fibrocystic breasts and higher doses of iodine.
Dr. Kara Fitzgerald: But again, it’s short term and you’re paying attention, and if the person has thyroid disease, you’re paying attention. But you’re right. You’re right. Folks going into five, ten and higher milligram amounts of iodine, I agree that’s worth challenging.
Okay, so let’s talk about labs. You threw out a real teaser with regard to the antibodies and what your expectation is of seeing them drop. We definitely have patients coming into practice after a lot of these summits, and certain speakers, I’m sure not all speakers, but wanting to see antibodies zero out. We absolutely do see them zero out in some of our patients, but not all. So just talk about what you’re thinking about with regards to antibodies, how often you’re testing them and what your expectation is for people with autoimmune, thyroid dis-
Dr. Michael Ruscio: Sure. I’d love to. If people wanted to get a really deep dive on this with many references, I do have an article coming out in October. It’ll publish on our website on October 1st, and it’ll be in our clinicians newsletter, which is the Future of Functional Medicine Review clinical newsletter. If people wanted to get a fuller expansion on this with all the supporting references, that will be available there.
Essentially, when you look at many of the studies, while we don’t have the best data in the world where we can completely, complicitly answer this question, you do see a trend start to emerge where essentially when people have antibodies in the 900, 1100, 1200, 1300 type range, that does seem to correlate with a higher risk of progression of hypothyroidism. However, when you see patients that have a lower level of antibodies in the low hundreds, that’s been associated with a minimal risk. There was one study that did track longer-term follow-up and did definitively show this, and there are some other semi-complete data sets that had been published that suggest this.
Now, people may say, “Well, I read a study or two that had concluded that if you have thyroid antibodies above 100, then that correlates with poor psychological well-being,” which is true. But when you actually read these studies, you see that the researchers were just defining Hashimoto’s as TPO antibodies of 100 or above. When you actually look at the average level of antibodies in this group, they averaged out at 1,122. So, the researchers concluded those with TPO antibodies above 100, what they were meaning to say was Hashimoto’s had a poorer psychological well-beings. However, the average level in this study group was 1,122.
The reason why this is really relevant is just because you want to prevent a patient from thinking that they have to get down to 30 or 35, especially if you’ve gone through all of the fundamental interventions that we can go through and if they’re presenting fairly healthy, then I think it’s, from a psychological standpoint, it’s very assuring for people not to think that there’s something wrong with them. I think it’s just good to make that clarification for people.
Dr. Kara Fitzgerald: Perfect.
Dr. Michael Ruscio: The TPO antibodies, if you can get them … And I’m sure clinicians probably see this. Someone comes in and they’re not eating a good diet, they’re not taking any vitamin D or they’re vitamin D deficient and they’re inflamed. They maybe have some insomnia and some depression and some bloating. You change their diet, you go through some of your fundamental interventions, and then their antibodies may go from 1100. And then, months later when their symptoms are all pretty much gone and they’re feeling a lot better, their antibodies are now at 284. I always say that’s a clinical win.
Dr. Kara Fitzgerald: Yeah, that’s great. I think that’s really great, Michael. That’s a very good point. And then, sometimes you do. You see them level out. And sometimes you might see them trend up during a stressful time, or if they’ve fallen off plan and you’re doing a recheck and it’s a barometer for them to dial back a little bit, engage in some self-care.
Dr. Michael Ruscio: Sure. And you know, we use the concept of a graded-risk categorization in many things, for example, blood sugar. We don’t look at a blood sugar of 103 the same as we do a blood sugar of 183, right? So we probably shouldn’t be doing the same with thyroid antibodies where 283 shouldn’t be looked at the same as 1,183. I think it’s common sense that sometimes we got so wrapped into the fear of autoimmunity that we don’t take a moment to pause and just kind of think through it.
Dr. Kara Fitzgerald: Yeah. That’s right. That’s right. Well, especially in this age of loads of emphasis on predictive auto-antibody testing. I think there’s a strong and extremely important place for that, but it can make us hyper-aware of what our antibody status is, and a periodic trend off in ANA or whatever can just lead to great anxiety. It is, it’s just a careful dance between good self-care and good life habits and releasing the obsession of optimal wellness, I think.
Dr. Michael Ruscio: Yeah.
Dr. Kara Fitzgerald: Just sort of trusting. All right. Well, anything to say about thyroglobulin antibodies? My experience clinically is those tend to be a little bit harder to drop, but I want to hear what you have to say about them.
Dr. Michael Ruscio: Yeah. I would agree with you. The thyroglobulin tends to be a little bit less responsive, and we don’t seem to have as much data. Part of it may be because the thyroglobulin antibodies aren’t tested as often as the TPO antibodies, so we just have less research in this regard. But some studies have shown that if the TG antibodies are below ten times the reference range, then that can be considered a clinical win.
Dr. Kara Fitzgerald: Interesting.
Dr. Michael Ruscio: Many labs may use .9, for example. That may be something for people to shoot for, and I would just try to apply the same logic where you look at their antibodies, see where they come in initially, and if they come in only mildly elevated, then there may not be a lot of thyroid autoimmunity. I guess this brings another point into question, which is if someone has thyroid autoimmunity and has symptoms, it doesn’t always mean your thyroid autoimmunity is the cause of the symptoms. That’s important to keep in mind.
Dr. Kara Fitzgerald: Yeah, that’s right. And because most … well, we have both consumers and a lot of clinicians who listen to this. If you’re really practicing systems or functional medicine, you’ll be capturing the full scope of potential causes and you’re totally correct. I’ve never seen a case of what appears like a classic hypothyroid patient have only thyroid disease as an issue. So we’ll circle back to the gut again, which was our original touchpoint with the thyroid. We’re going to talk about adrenals, so we’re casting a wider net. And actually, anything else you want to throw in there that you see in your gut-thyroid patients, if you see mitochondrial involvement, whatever you feel like talking about you can. But before we do, I’ve got a couple more questions for you. One, I’m super curious to hear what you have to say about this epidemic with benign nodules we’re seeing in our thyroid patients and what you might be doing about it if anything, and if you’re tracking them and what are your thoughts?
Dr. Michael Ruscio: That’s a great question. I can’t say I’ve done as deep of a dive into nodules as I have gut health, thyroid health and kind of the interplay between gut health and thyroid autoimmunity, but there are some theories in terms of what causes nodules. I’m sure people have probably heard part of it could be due to accrued DNA damage from oxidation or toxins or stress or what have you. Part of it may be from damage accrued by the autoimmune process, which is why … and there’s been disagreement in the data, but there’s finally been, I believe it was a systematic review with meta-analysis that did conclude that those with thyroid autoimmunity are at a higher risk for thyroid cancers. And so, of course, one of the things that can predispose to thyroid cancer is nodules that can go from benign to malignant. Thyroid autoimmunity may be one factor that underlies the cause of nodules.
Dr. Kara Fitzgerald: The nodules.
Dr. Michael Ruscio: Some have said that a TSH-suppressive dose of thyroid hormone may help with either nodules or with goiter, and I think you can make a case for iodine also in potentially the prevention, but the data there doesn’t seem to be consistent. There’s some studies showing benefits, some studies not showing benefit. I think we have a lot more there to learn. I’d be curious to hear your thoughts if you have anything there that you think is noteworthy.
Dr. Kara Fitzgerald: Well, the whole oxidative damage piece is absolutely reasonable for hypothyroidism, for toxin exposures, for the progression towards cancer if it’s not adequately treated. At the molecular level, it’s just basically different flavors of oxidative damage leading to DNA damage and so forth. I think it argues for getting in early. Because of that U-curve with iodine, I haven’t with my nodule patients … I mean, I’ll absolutely use it with the caveats that I just talked about. I’m very conservative in my autoimmune patients, and maybe less conservative in nodule patients who don’t have any clear autoimmune hypothyroidism, but I’m still going to be mindful of it.
We’re addressing it more intentionally in practice to see what’s working for us to turn them around. We have seen successful reversion. We’ve seen questionably malignant become unequivocally benign. So we’ve seen some good outcome there and I was just positing this to my … the reason I’m pinging you with it right now is because I was positing it to my colleague here at the clinic, Dr. Kenlo, that we really need to be shining some light around what we’re doing. I just had gotten an ultrasound back the other day where a nodule was no longer visible in a follow-up ultrasound, which was really pretty cool. And, of course, the patient was really, really excited about that. It felt really empowering to her.
She’s on a good full-functional protocol. Nothing in her approach is super special or different, it’s just a full-functional intake and she’s committed to living a clean lifestyle. The only piece that was unique in her case beyond anybody else was that she wanted to do topical glutathione, so we did to topical glutathione with her. I don’t know if that’s it at all. The fact that I’m pointing that out is … actually the only reason I’m pointing that out to you is because she came back to me and said, “It must be the topical glutathione.” And I was like, “Yeah, maybe.” I’m not sure because we really used a full-functional approach. It’s nice to see that we’re seeing some good turn around. We’re not turning around all the nodules, but I did just recently bring it up for us to start paying attention to it as a clinic. I’ll blog about it or I’ll keep you posted on it.
Dr. Michael Ruscio: We went through a fairly comprehensive review of the literature. I just took a moment to pull this up, because this was about two years ago now. We went through a pretty comprehensive review of the literature on goiter and nodules. If you go to our homepage search box and just type in nodules you should find it. It’s a podcast episode. There’s a number of links cited there, and there’s one study from the Journal of Endocrinology and Metabolism which showed that the addition of thyroid hormone plus iodine had the greatest impact on decreasing nodule volume compared to thyroid hormone being secondarily less effective to that, iodine alone being third most effective to that, and placebo being least effective.
Dr. Kara Fitzgerald: Well, how were they …
Dr. Michael Ruscio: So most effective-
Dr. Kara Fitzgerald: It was a combination of thyroid and iodine. That’s cool. Good … and this, actually, this most recent lab work is a Hashimoto patient who I was giving her very modest iodine because her labs indicated a need for it. I do like to test for that one, and so that was a piece of her protocol, as you said there was evidence for need there. In that study, I’m sure you don’t remember because that was two years ago, but what the dose was of iodine they were using?
Dr. Michael Ruscio: I don’t, but it was a good sample size, 10,024 subjects.
Dr. Kara Fitzgerald: That’s great.
Dr. Michael Ruscio: Click through our notes see if I can find it, but I’m assuming it was a somewhat reasonable dose that they used.
Dr. Kara Fitzgerald: Okay, well you know what, I’ll just ping you on it if you can give me the citation. Or, folks, as Dr. Ruscio pointed out, you can go over to his site and just search nodule and pull it up. All right. Let’s see. Now let’s talk about the labs. What are you testing for? What’s your thyroid workup, laboratory only? We’ll talk about physical exam after that.
Dr. Michael Ruscio: Sure. I recently actually changed the methodology that I’ve been using in the clinic for our T4, and this is actually, I think, important for clinicians to be aware of. I did write about this in our clinician newsletter for the month of September, and I’m going to … I’m just pulling it up here because I want to give people the specifics. Essentially, I always do a TSH and a free T4 and TPO antibodies and thyroglobulin antibodies. I’ve been doing much less of T3, reverse T3 uptake, because, to be honest with you, I don’t think it has a ton of clinical relevance. I’m open to it should the right evidence be presented, and just for people … I caught this in a recent review, there’s a more accurate form of free T4 which is by liquid como …
Dr. Kara Fitzgerald: Liquid chromatography.
Dr. Michael Ruscio: Yeah, chromatography. Thank you. Jeez, sometimes these get me.
Dr. Kara Fitzgerald: That’s fine.
Dr. Michael Ruscio: Tandem mass spectrometry, so its LCMS/MS. Essentially, when I looked into this, there has been some internal discussion in the endocrinology community about some of the T4 assays, specifically free T4, as being inaccurate and not being valid as matching the gold standard. When I looked at LabCorp, it’s actually one of the T4 that LabCorp offers. So if you’re using LabCorp or if you’re using a click through lab that maybe is right to consumer but ultimately uses LabCorp, it’s important to be cognizant of that and not to use the inaccurate form.
Dr. Kara Fitzgerald: That’s great. All right. That’s a super duper pearl. And LC tandem mass spec is … it’s the better analytical tool for a lot of things.
Dr. Michael Ruscio: Yeah. The analog immuno assay is the other one that’s often used, and that’s been shown to be fairly inaccurate. Why this is important is if you’re especially for using these tight ranges … which I don’t really agree with, the tight functional medicine free T4 ranges … If you’re using a form of free T4 that’s not highly accurate, then you have a very high probability that you have no clue where in the range that T4 actually is.
Dr. Kara Fitzgerald: That’s pretty interesting.
Dr. Michael Ruscio: If that makes sense.
Dr. Kara Fitzgerald: Well, they are using immuno assay at Quest. But you know what, they have … I’m looking it up right now … they do have LC tandem mass spec for free T4 at Quest.
Dr. Michael Ruscio: Yeah, they do. Both LabCorp and Quest offer the inaccurate and the accurate form, so just important to make sure you’re using as part of your routine assessment the accurate form and not using the analog immuno assay. Yeah.
Dr. Kara Fitzgerald: All right. It’s really funny that you said you’re not doing free T3 because that was the integrative/functional medicine community breakthrough assay. We all thought we were doing so much more than the conventional world and helping our thyroid patients so much more, and you’re basically saying, “Nah, not necessary,” which I think is very funny. That’s quite iconoclastic of you. Why?
Dr. Michael Ruscio: Well, I always try to ask myself is this test allow me to do a treatment I could not otherwise do? Or is it giving me some information that I would not otherwise have? Really, to put it simply, people’s thyroid hormone levels are not paint by numbers. If it was just as easy as trying to force someone’s thyroid levels into the range that you thought was adequate and they would magically start feeling a lot better, thyroid care would be a lot easier than it is. But, unfortunately, what happens for a lot patients, is even when their thyroid hormone levels are in the tight normal range that we want, they’re still exhibiting symptoms. I think it comes back to the fact that often times the cause of the symptoms is not the thyroid, but the thyroid, if we’re being honest, is so heavily marketed that practitioner and patient alike are blaming it for more symptoms than it’s actually causing.
And so, I like to start with a very practical approach, but I have to say it works fantastically well, which is on day one, we typically screen for both digestive ailments like SIBO, H. pylori, candida, what have you, and we screen for thyroid autoimmunity and frank hypothyroidism. Now, if someone has frank hypothyroidism, which would mean conventional-range elevated TSH and low T4, then they’re going to need to be on thyroid hormone at least in the short term. When using the thyroid hormone dose, we typically will start someone with just the T4. If they don’t feel better on that, then we’ll consider a switch to a T4/T3 and allow for one or two dose adjustments.
But after that, if that’s not fixing the problem, the problem is most likely not the thyroid, and it’s most likely … because what you’ll see is people will be pretty much in the normal range for their thyroid hormones, but many of their symptoms will be non-responsive, which means that their symptoms are probably being driven by something else. This is often where we’ll see someone who’s a little bit constipated and also has some bloating, and they’re hypothyroid. When we fixed their … Let’s say they have SIBO and H. Pylori … when we treat those, they finally see all their symptoms improve. And then, in some cases, they actually need even less thyroid medication. So I thinking missing the gut is one the big pieces that force a lot of people from getting their results with the thyroid that they’d like to.
I got an email from … It was for some fix your thyroid on your own kind of do-it-yourself protocol, and the gut, I think, was the eighth step out of nine steps. I’m certainly open. Maybe someone has a different way that they’re approaching this, but in my practice, if I wasn’t addressing the gut very early on in the process, we would probably be chasing down things like Lyme, metals, mold, what have you, all the while because we’ve missed a fundamental problem of an issue in the gut. I don’t think it necessarily needs to be that complicated. Figure out if somebody is frankly hypothyroid. If they are, get them on a medication. One study show that about 45% of patients prefer T4 with T3, 18% prefer T4 alone, so certainly I’m open to getting someone on a T4/T3 combination if they don’t respond. But if, after that, if they’re still not responding, it’s probably a problem in the gut.
Not to be too long-winded here, but this is also partially further evidenced by the fact that some studies with non-responsive thyroid patients who also have things like ulcers or gastritis have found that the administration of a liquid thyroid hormone that’s more easily absorbed, known as tyrosine, has been able to cause a better outcome in symptoms and the stabilization of the thyroid dose. I think there’s a big gut piece here that’s being overlooked at the expense of these very expanded thyroid assays, which are leading us on this witch hunt for thyroid, and in some cases, maybe in many cases, it’s actually not.
Dr. Kara Fitzgerald: Right. Okay. I do agree with you. I think that for a lot of folks thyroid disease is over-diagnosed, as is probably mold toxicity and a handful of other things that some of us have really leaned on. I do agree with you. Also, my experience with tyrosine has been really nice, as well, for people who are very sensitive.
I just think it’s kind of funny that you’re starting with levothyroxine alone. I don’t. I use T3 and T4 and I do think, just as that study pointed out, people respond to it a lot better. They feel better sooner with it. But I absolutely agree with you that you have to address the gut or, in my world, casting the functional medicine that whatever pops up as a fundamental piece of the puzzle for that given individual we want to look at and address, even if it appears at a glance not related. But I completely agree with you. You absolutely have to look at the gut. Nary is there a perfect gut person that walks through our door. I mean, I don’t know that they would come to us otherwise, right? Once in a while you have somebody’s who’s got no obvious gut complaints. Even in those cases, often there’s some disregulation. There may be some malabsorption, maldigestion, even if it’s not causing symptoms.
Dr. Michael Ruscio: To your point, one of the reasons why I … Typically, people come to see me, they’re already on thyroid hormone. Seems like one of the typical patient groups we see is someone who’s seen their endo, been diagnosed, they’re on levo, for example, and then what I’ve noticed is oftentimes people need less medication once we start doing our gut work. If I convert them over to T4 and T3 at the same time as we enhance their absorption, we risk overdose. That’s why I like to wait a little while and say, “Let’s leave the thyroid piece constant for a couple months, optimize your gut, and then if you’re still not fully improved, then we can discuss the switch to T4 and T3.”
Dr. Kara Fitzgerald: Got it. Yeah, that makes total sense. You’re right. A lot of folks come to us already on a protocol, and they don’t feel good. Let me see. All right. Where do I want to go? Why don’t talk a little bit about adrenal function? I mean, we know that adrenal function certainly interacts pretty closely with thyroid and a full HPAT access needs to be reasonably harmonious for all systems to be go and for somebody to feel good. What are you thinking about there?
Dr. Michael Ruscio: Oh gosh. I’m going to sound like the ultimate contrarian here.
Dr. Kara Fitzgerald: That’s really funny. Yeah. I’m looking forward to the comments that we get.
Dr. Michael Ruscio: Well, the term adrenal fatigue has been incredibly highly criticized, and the four-point salivary cortisol test has also been extremely heavily criticized. The cortisol awakening test is probably more representative of dysfunction in the stress-handling system, which is your HPA access. I think we really need a cultural shift. I’ll be sitting at a conference and people will be saying, “Oh, my adrenals are going to be so burnt out after this weekend. Better take some extra adrenal support.” It’s almost this mystical unicorn that everyone’s chasing down their adrenals. Really, I think we’re chasing down another empty promise and I think it’s much more simple.
The adrenals always malfunction with the exception of Addison’s, Cushing’s, rare, rare diseases, they dysfunction secondary to something else, usually a source of stress in the body. And so, certainly I think some of the traditional adrenal adaptogenic herbs can be very helpful, rhodiola, ginseng, for example. But we don’t need testing to tell us how to do that. I did the four-point cortisol testing on people for two years, and I never really felt like they were super healthy because I don’t need a four-point cortisol test to put someone on some adrenal support. If you look at a pretty much every study with only one exception that has used adrenal herbal treatments, they have never predicted based upon lab testing who would respond better to what dose. They simply put people on ashwaganda and they noticed the majority of people had better mood, sleep and energy. There was no need for this testing to steer the dose.
And so, again, coming back to a more fundamental approach, if you can get someone on the right diet for them, a good lifestyle plan, manage or treat any thyroid autoimmunity, get them on a reasonable dose of thyroid hormone, and fix problems in their gut, you can do a tremendous service for those people and you will see their adrenal-like symptoms go away. But having some magical dose based upon the four-point cortisol rhythm thinking that you’re going to truly heal someone with that, I think, it was a well-intentioned promise that many of us bought into. But I think as we’re learning more about it, that’s something that can be assigned to the history books of functional medicine and we can move forward in a bit more of a constructive direction.
Dr. Kara Fitzgerald: Fair enough. Yeah, I think that’s fair enough. I agree. I guess I’ve been using a panel looking at metabolites and there can be an accumulation associated with problem thyroid metabolism, and actually this lab, it’s Dutch Lab, actually. I think they’re a great lab. They’ve just released cortisol awakening response and yeah, I mean I think that there’s … unequivocally, it’s time for us to move forward in that conversation.
Dr. Michael Ruscio: I am open to Dutch, certainly. Because that’s newer and they’re using a different technology, so I’m certainly open. I just try not to lose sight of simple patient symptom changes and rely more heavily on lab work.
Dr. Kara Fitzgerald: Yeah. No, fair enough. I think if you back up and do all the foundational interventions, you know …
Dr. Michael Ruscio: And you can still support the adrenals. I use adrenal support on many patients. I’m just using the argument that I don’t think we need highly prescriptive dosing, especially if we’re using herbal adaptogens for the adrenals.
Dr. Kara Fitzgerald: Well, and what you’re describing as being adrenal support have the mechanisms are far … arguably, the adrenal impact is secondary. So the mechanisms of rhodiola, there’s many and they’re pretty far-reaching, and being adaptogen they’re really pretty remarkable. Okay.
Dr. Michael Ruscio: Sorry, not to chime in. Tell me if I’m too nerdy here. But even one study showed that ginseng was able to improve the gut microbiota, so these things may be having impacts on many systems outside of just the adrenals.
Dr. Kara Fitzgerald: Mm-hmm (affirmative). Yeah. I would imagine that if we looked in that direction with other botanicals we would see that routinely, because the microbiome is metabolizing the botanical and releasing the secondary products that are often times the ones that are the most effective, so they’re acting as prebiotics in a way. I would imagine that we would find that with a lot of botanicals because they are, after all, plants, foods. Yeah, that’s really interesting. All right. Actually, why don’t we talk a little bit about the interesting research study that you did. We’re going a little bit sideways here. We are talking about the gut, though. You were looking at biofilm eradication in SIBO.
Dr. Michael Ruscio: Yes. We took a group of patients and essentially either randomly assigned them to receive standard herbal antimicrobials for SIBO, or standard herbal antimicrobials plus anti-biofilm agents. We essentially tracked their SIBO lactulose hydrogen-methane breath test scores pre and post. We were able to show that with the co-administration of the anti-biofilm agents we saw a significantly improved reduction in hydrogen gas SIBO. So that was something that was pretty interesting, and to my knowledge it was the first time that’s been documented. Our sample was somewhat small. It was 12 treatment and nine control, but it was enough for us to show significance and it’s definitely something that I think that is something that can be utilized. I wouldn’t recommend it as a frontline therapy, but if someone has only partially responded to a round of herbals and you think you need a stronger protocol, as a secondary treatment, I think it’s definitely something to consider as adjunct.
We did use different types of anti-biofilm agents, and that does weaken our data a little bit. But I did that on purpose because I did not think that there was going to be some one formula that was super duper strong and impactful compared to others. I had the feeling that different cocktails of anti-biofilm agents would all have a benefit. And so, we used either N-acetylcysteine, that was prominent. The prominent two were either N-acetylcysteine or InterFase Plus, and in some patients we also used Samento. It was really based upon a clinical presentation. If someone had SIBO plus H. pylori, we would almost certainly used N-acetylcysteine. If someone just had SIBO, we would use InterFase. And if someone had SIBO but a history of Lyme or some other funky stuff that made me suspicious of potential a Lyme co-infection, we would use the Samento. They all seemed to vector benefit.
Dr. Kara Fitzgerald: That’s pretty interesting.
Dr. Michael Ruscio: But not on the methanogens. And even though methanogens have been to shown form biofilms, we did not show a significant reduction in the methane archaea or the methane gas [inaudible 00:45:58].
Dr. Kara Fitzgerald: All right. Does Samento actually have anti-biofilm …
Dr. Michael Ruscio: You know, I don’t know if it has anti-biofilm …
Dr. Kara Fitzgerald: … research behind it?
Dr. Michael Ruscio: … but it has been shown to help with the … There’s different forms that Lyme can take to hide, or to evade infection. There was one paper published regarding this in the Townsend Letter. I want to say their round bodies in … They can change form to a cyst-like form. That’s why we used Samento, just to see if that may be able to be helpful. I don’t know of Samento having traditional anti-biofilm characteristics. I know that the cocktail in InterFase has been shown, and also N-acetylcysteine has been shown.
Dr. Kara Fitzgerald: Yeah. Right. And why N-acetylcysteine specifically when H. pylori is present? What prompted that decision?
Dr. Michael Ruscio: There was one study in particular that showed, I believe it was a jump from around 20% … I’m just giving rough numbers here … but 20% clearance rate to about 60% clearance rate of H. pylori when you add it to an antibiotic N-acetylcysteine. So antibiotic alone, 20% clearance rate of H. pylori. You add N-acetylcysteine, now you get a 60% clearance rate.
Dr. Kara Fitzgerald: And how did you dose the N-acetylcysteine in your study?
Dr. Michael Ruscio: Just a standard dose. I apologize for not knowing the dose off hand. I believe many N-acetylcysteines may use around 500 milligrams. I’m just approximating there, but what would typically be one to two capsules of your standard dose of N-acetylcysteine.
Dr. Kara Fitzgerald: Yup. That’s it. Like 1000 to 1200 a day.
Dr. Michael Ruscio: Right. Okay.
Dr. Kara Fitzgerald: Okay. All right. And then, so the Samento, which is Cat’s Claw. Samento is a type of Cat’s Claw. Did you use Samento specifically, or did you just use a general Cat’s Claw?
Dr. Michael Ruscio: We used Samento. I believe it’s through Wise Woman’s Herbal that has a liquid tincture Samento that we used. To be truthful, I haven’t been actually using Samento a ton, very often. I was doing some experimentation with Lyme protocols in my office for a while, and I was not seeing many patients that fit that description. The more patients that tended to come in were patients with predominant IBS and SIBO-like presentation and thyroid involvement, and not many from Lyme. My population of patients doesn’t seem to need it, so it’s not something that I’ve used now probably in about a year.
Dr. Kara Fitzgerald: Yeah. Right. InterFase is from Klaire, and that’s got a handful of different things in it including some proteolytic enzymes, I think, and some EDTI, right?
Dr. Michael Ruscio: Mm-hmm (affirmative). Exactly.
Dr. Kara Fitzgerald: Okay. Well, that’s interesting. I would say, again, N-acetylcysteine, what a really basic thing to do. For me, as well, it’s a secondary intervention or even tertiary sometimes that I’m thinking about “biofilm busting”. But, you know, it’s great keeping it simple with the N-acetylcysteine. I know your study was small, but can you say fairly conclusively that you saw Cat’s Claw working, the Samento?
Dr. Michael Ruscio: I believe it did.
Dr. Kara Fitzgerald: That’s so interesting to me. That’s pretty cool. I mean, it is a potent antimicrobial, so you might have just [crosstalk 00:49:27].
Dr. Michael Ruscio: Right.
Dr. Kara Fitzgerald: I mean …
Dr. Michael Ruscio: Exactly.
Dr. Kara Fitzgerald: It’s hard to actually …
Dr. Michael Ruscio: It may not have been an anti-biofilm mechanism. It may have just been because it’s an antimicrobial, also. Yeah. Good point.
Dr. Kara Fitzgerald: What did you use for your SIBO intervention? Did you have a standard intervention?
Dr. Michael Ruscio: Yeah. We typically use a protocol, it’s similar to the protocol that Gerry Mullin used in his study where he compared Rifaximin to two different herbal blends, except for we used different herbal blends. We used GI Microb-X from Designs for Health, along with oil of oregano for the first month. And then, in the second month, we switched to Para Biotic, which is by BioGenesis and OrthoFlora Yeast Support, which I think is by Protocol, which is the practitioner level version of Now.
I think that’s important to mention because, this is something I oftentimes write about in the clinical newsletter that we publish, which is people are looking for the magic protocol and I really don’t think there’s a magic protocol out there. I don’t say that to make practitioner’s lives more difficult, because I know sometimes when you’re starting, you’re just looking for a protocol to do. But the problem with relying on protocols and not understanding the process is you’re dependent upon protocol. And so, you’ll just go from guru to guru to guru looking for protocol, protocol, protocol, not understanding that here’s what I’m actually using and when I understand what I’m using, I can select my own protocol because I just understand this is a cocktail of antimicrobials like Mullin used. We use a similar but different cocktail of antimicrobials and saw a similar effect.
So, I just think sometimes we get too reliant on a protocol and we don’t just think what is the mechanism of this protocol? What are other similar things that we can do? And then, more importantly, if this doesn’t work maybe it’s not that I need to do another similar protocol, but maybe I need to change my treatment method completely.
Dr. Kara Fitzgerald: Mm-hmm (affirmative). Well, and, I’ve seen some of the protocols that are being released and they’re entirely onerous. Not every SIBO patient needs every possible SIBO intervention at the get-go.
Dr. Michael Ruscio: Oh, I couldn’t agree more. Couldn’t agree more.
Dr. Kara Fitzgerald: Many of our folks we can turn around really pretty straightforwardly. I also go with a primary, secondary and tertiary approach, and I do tweak it based on my history and how they’re presenting.
Dr. Michael Ruscio: You know, it’s funny you say that because we just wrote up, I think this went out … this I think will go out in a month or two in our newsletter, but we write up as part of a case study every month. One gal came in who had been treated for SIBO and was still having diarrhea and insomnia, and so she kind of got fed up with her other clinician, even though I think if you’re working with a clinician you should give that clinician a chance to really see through their process, because if you clinician hop it’s difficult to get traction. Sometimes to get through what works you have to work through what does not work. If you’re confident in your clinician, give them time. But I think she just got to the point where she wanted a different perspective.
She came in to see me and we very easily could have done a lot more with this gal. We could have tested for small intestinal fungal overgrowth or tried to. We could have tried to assess hydrogen-sulfide SIBO, advanced mast cell activation syndrome, or histamine intolerance, what have you. She was having reactions to bile. She was having bile acid diarrhea. Once we figured that out, which we did in about a month, and got her off the bile, her diarrhea went away, her insomnia went away and she was fine.
Dr. Kara Fitzgerald: Was she taking isogenous bile? Was she using bile acids?
Dr. Michael Ruscio: Yeah, she was taking a digestive enzyme-bile acid cocktail. It wasn’t a very high amount, but it was enough to be causing bile acid diarrhea in her case. And so, I’m agreeing with your point in a very long-winded way, which is when you do too much, you have a fairly high probability of something that you’re doing causing a reaction. You may think that that reaction is the condition not responding, but all the while it’s just a reaction that’s confounding your ability to listen to the clinical response. Which is why one of the things I’ve been doing and the clinic lately is staggering the start of my interventions. We start with a dietary change, give that two weeks before we add in any kind of supplement protocol. This way, you get a layering effect that tells you what works one intervention compared to the other, but also helps you pinpoint any reactions. And that sometimes can be the difference.
Dr. Kara Fitzgerald: Yes. Thank you. That reminds me, I was going to ask you in your research study, well, A, are you guys publishing it? If, and when, where? B, did you prescribe a diet, as well?
Dr. Michael Ruscio: Good question. I’m thinking back on this now because we finished collecting this data about a year ago. And then, some of the back story is we also were trying to move forward on a study looking at the administration of natural prokinetic agents and their ability to prolong time in SIBO remission. This was going to be a full-on double-blinded controlled trial that need IRB approval. We jumped through all the hoops and filled out all the paperwork, and went through all the rigors of that. We were going to be using Iberogast as the compound.
Dr. Kara Fitzgerald: Oh, hey. I remember you were telling me about this.
Dr. Michael Ruscio: Yeah. And then Iberogast got taken off the US market, and that was just like a punch in the stomach after all of that work. And so, now we’re trying to do this with a different compound, but we’ve been really struggling with getting … ironically, the hardest thing is getting placebos. Everything else is ready to go, but no company wants to stop the machinery just to make some placebos for us. That’s actually been the most challenging aspect. Between that and finishing up my book, we haven’t actually finished drawing up the study and submitting it for publication. My plan is early 2018 is to get that published. I’m not sure where it will be published, but we are definitely going to submit that for publication. It’s just a few of these other things really kind of ate up a lot of my bandwidth in the mean time.
Dr. Kara Fitzgerald: Right. I get it. Listen, we’re going to wrap up. It’s just been a great time talking to you, but you were talking about all this SIBO research you’re doing and you’re paying attention to those patients really pretty carefully. I was wondering, are these folks just SIBO or what incidence of thyroid disease do you see? What percentage of your SIBO patients have accompanying thyroid disease? I’m just kind of curious.
Dr. Michael Ruscio: That’s a great question, and I’d have to give a rough estimation. I haven’t ever actually crunched that number, but I would say maybe 30%.
Dr. Kara Fitzgerald: You should data mine that number, because you’re talking about gut-thyroid connection a lot these days. I’m going to challenge you to data mine it. It wouldn’t be too difficult.
Dr. Michael Ruscio: You’re right. And there’s a lot interplay there, and so that would be …
Dr. Kara Fitzgerald: Of course, I could do it too, but …
Dr. Michael Ruscio: One of the things I want to do soon is kind of update the software that we’re using at our office so that doing some of this would just be a simple few keystrokes.
Dr. Kara Fitzgerald: Yeah. I hear you.
Dr. Michael Ruscio: But it’s time to get that set up, too. With enough time we could really do anything.
Dr. Kara Fitzgerald: I know.
Dr. Michael Ruscio: But to your other question, no, it’s not just SIBO. I’m so glad you asked that question because I’m not meaning to be critical against overly expanded thyroid assays or adrenal assays, but the reason why is because these things sometimes overtesting prevents us from thinking and just doing the art of medicine, which is looking at a patient, listening to what’s wrong with them, and then treating what you think is wrong with them rather than always needing some piece of paper to tell you what is wrong with them.
The same thing, I think, applies to SIBO where there’s definitely a SIBO-centric way of treating patients that’s emerging, and I really try not to get pulled into that. Even though I publish, or collecting and intending to publish research in SIBO, sometimes it’s not SIBO. Something that pops up sometimes that’s, I think, important for clinicians to be aware of is histamine intolerance. It’s just something where people will be sometimes eating foods that they think are healthy, especially probiotic rich foods, like fermented foods, and if they have a degree of histamine intolerance along with that, that can actually thwart that response and they think that they have SIBO because some of the signs of histamine intolerance are bloating, diarrhea, loose stools, abdominal pain, fatigue, brain fog. Those can look very much like SIBO, and sometimes the solution is not more SIBO testing. It’s actually making some simple modifications to one’s diet. There have been a number of cases where we’ve sniffed that out. We could have done a …
Dr. Kara Fitzgerald: Oops.
Dr. Michael Ruscio: … a lot more testing and not been overly excited about testing and just made some simple dietary changes. So it’s definitely something for people to be aware of and treating histamine intolerance, I think frontline, just try a low histamine diet.
Dr. Kara Fitzgerald: Mm-hmm (affirmative). Yeah. Easy.
Dr. Michael Ruscio: Sometimes that’s all you really need to do, in short.
Dr. Kara Fitzgerald: That’s right.
Dr. Michael Ruscio: Yeah.
Dr. Kara Fitzgerald: Absolutely. That’s a really easy diagnostic, a diagnostic diet. And you don’t have to do it for a month either. It’s not like a typical elimination. You can bang it out, and if somebody’s truly histamine intolerant, they’re going to know post haste.
Dr. Michael Ruscio: Yeah, I’d say a couple days they would notice.
Dr. Kara Fitzgerald: Exactly. Yup. Another thing that we do here at the clinic is we’ll start with a couple of days of an elemental, and then we’ll start reintroducing foods after just a day or two of the elemental, which in most patients, but not all … and that’s telling in and of itself … but in most patients, they’ll have really complete relief and they’ll be so grateful even though an elemental diet really kind of sucks. But then we’ll start layering in safe foods, and from there we can get an idea of what their diet-
Dr. Michael Ruscio: Exactly. And there’s a lot that can be done. I mean, a low FODMAP diet in one study showed an eightfold reduction in histamine levels.
Dr. Kara Fitzgerald: Yes.
Dr. Michael Ruscio: I know one of the things you wanted to talk about was low FODMAP, but I just want to quickly chime this in because I think this is really important for clinicians. Low FODMAP is criticized as being bad for microbiota. I think that’s a very erroneous assumption because there have been studies that have shown, for example, a decrease of histamine on low FODMAP, like we just mentioned, an eightfold decrease. So there is a decreased immune activation with a low FODMAP diet. One study showed a reduction of leaky gut on low FODMAP, and a few studies have shown a normalization of enteroendocrine cells in the endocrine cells in your intestines, most mainly a normalization of the cells that create serotonin, which is very important for pain signaling and for motility. And so, on a low FODMAP diet, IBS subjects the density of their serotonin cells in their gut look more like that of healthy controls.
Dr. Kara Fitzgerald: That’s so interesting.
Dr. Michael Ruscio: And so, we get this microbiota way of thinking blinding us to the fact that there’s a lot of other healthy things happening in the gut on a low FODMAP diet. If you’re using it with patients and it’s working well, don’t be pushed off of it. Use it for a month or maybe two months, and then try to re-introduce, yes, to the broadest diet possible. But if people have limited FODMAP tolerance in the longer term, don’t be afraid because there are other healthy changes that are occurring in the gut that should be mentioned.
Dr. Kara Fitzgerald: Absolutely. Yeah. What is the idea of fasting the microbiome anyway? I mean, anything that you consume is going to be a prebiotic for some of the critters down there. I mean, it’s only fasting would fast the microbiota completely. I know there’s been a lot of talking around that. I know when Pimentel posited the idea that outcomes would be improved if you treat through their standard diet rather than using the FODMAP, and I do think that there’s a place for the FODMAP. Again, when you do all of the underlying work that you’re talking about, we can rebuild them.
Often times, you know, after you do a careful re-introduction, we find that it’s only one or two foods that really seem to be the problem players. But when people are really feeling lousy, in the beginning maybe all of them, but then there’s really maybe one or two lasting.
Dr. Michael Ruscio: And there is a small subset that seem to be really sensitive, and I think the cause of this really sensitive patient population can be multi-factorial. But I did have Lawrence Afrin on the podcast, and he’s a mast cell activation syndrome researcher and clinician. He, I thought, gave some phenomenal clinical pearls and tidbits. That will go out probably sometime in the next three to four weeks, but really, really impressed with the conversation with him and just some simple over-the-counter interventions that can really help sort out mast cell activation syndrome. I use the term syndrome and not disorder because one of the things I took away from the interview with him was that disorder is more so reserved for diseases that are much more severe, much more rare. It’s actually more appropriate to say mast cell activation syndrome.
Dr. Kara Fitzgerald: That’s great. I’ll look forward to listening to that podcast. All right. Well, listen, we could go on and on and on and on. Just jump and jump and keep talking. We’ll have to circle back and do another podcast together at some point. Just let me know when you feel like it. Again, Michael, Dr. Ruscio, thank you so much for joining me. And folks, we’ll get as many tidbits and pearls outlined in the show notes as possible. Of course, you’ll see access to his link to his site and other details. Thank you again.
Dr. Michael Ruscio: My pleasure. Thank you for having me.
Dr. Kara Fitzgerald: Absolutely.