In this episode, I am speaking with Dr. Michael Ruscio – who is a Doctor of Chiropractic, clinical researcher, expert on the gut and author of the bestseller, “Healthy Gut, Healthy You.” – about the gut-thyroid link and how to treat hypothyroidism naturally and heal your gut.
In this podcast, Dr. Ruscio will cover:
- The latest research on SIBO (And is the breath test a valuable method for diagnosis?)
- What it means if you are diagnosed with subclinical hypothyroidism
- How does gut health affect thyroid health?
- The surprising link between thyroid antibodies and hypothyroidism (It’s not what you think!)
- Is there a link between gluten consumption, autoimmunity, and hypothyroidism?
- Should you be concerned about lectins in your diet?
- The top tips for people dealing with a thyroid condition
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The Gut-Thyroid Link: How To Treat Hypothyroidism Naturally And Heal Your Gut -Transcript
Ari Whitten: Everyone, welcome back to the Energy Blueprint Podcast. I am your host, Ari Whitten and today I have with me for the second time the esteemed Dr. Michael Ruscio, who is a Doctor of Chiropractic, clinical researcher, expert on the gut and author of the bestseller, “Healthy Gut, Healthy You.” So welcome back Dr. Ruscio. Such a pleasure to have you on again.
Michael Ruscio: Good to be here. Thanks for having me.
The latest scientific developments around SIBO
Ari Whitten: Yeah. So, I was hoping to kind of start off by getting into, kind of wrapping up some of the things that we talked about a bit on the last one around SIBO which we talked a little bit about that and like how it is somewhat of a controversial sort of diagnosis. And I am just curious sort of how the literature has evolved since our last conversation or how the thinking for you and maybe other people have evolved or not evolved over the last, whatever it has been, eight months since we last talked.
Michael Ruscio: Yeah. How time flies, right? I wouldn’t say that much has really changed for me clinically, but that is because I typically don’t fall into a dogmatic way of thinking about almost anything. And if you follow kind of the moniker or the dictum that I have recommended people follow which is look at lab testing as maybe one third or one-fourth of all the information you need to make decisions clinically. Then, whether or not the SIBO [inaudible] are there or you know, the nuances become less relevant if you have a well-constructed clinical model that you are working through. But, you know, that there is controversy regarding SIBO, I certainly don’t think that it is tenable by any stretch to say that SIBO is not a real thing or a fictitious diagnosis. That is a total misread of the data.
But there are also camps on the Internet that would have you believe that you have SIBO until you have a breath test normal. And anytime you get a breath test and the printout says you have SIBO, that means that you have SIBO, and, you know, this whole kind of, I would call it the more dogmatic SIBO centric camp that loses the nuance in the other direction. There’s a couple of things I think might be helpful in terms of how do you contextualize all this noise regarding SIBO? Because there are some people on one side saying it is not a real thing.
There are other people saying it is THE thing. And like most things, the truth lies somewhere in the middle. And the reason why it lies in the middle is because we have these data points that are at the extremes where you could find one study that do set up or the patient’s selection on no correlation between let’s say SIBO breath testing and symptoms. So that would be a strong study anti-SIBO. There could be another that shows [inaudible]. But the challenge, like many things, is when you get the people who want to believe Y or Z and they find all the data supporting Y or Z and then that is what they reference missing this nuanced body of data in the middle that show, you know, more of a middle ground sort of approach.
The way that I think about SIBO, and I think this is the most justifiable read of the data, is that a SIBO breath test, albeit imperfect, you have your lactulose test and your glucose test. There are pros and cons for each. Leaving those aside, they can be helpful but not perfect for [inaudible]. A SIBO test can help you identify if you have dysbiosis of the small intestine. It can mean you have SIBO, maybe not. And we recently had, just as an example here, I’m sorry for kind of a long prelude.
But we had Richard McCallum on our podcast who is a gastroenterologist and he did a study, a very elegant study in which they correlated SIBO breath test findings to actual digital sampling. So, sampling directly from the small intestine. And what they found was it wasn’t actually the… So, in the SIBO positive people, the people that had SIBO, the bacteria that were overgrown weren’t actually what we sometimes think.
And one of the theories from SIBO is that bacteria from farther down in the large intestine reflux upward into the small intestine. They actually found that the bacteria that were overgrowing were more similar to and identifiable to be found in the oral cavity, the throat, and the stomach. So, it may have been that it is bacteria from the top coming down. So that kind of shoots this hole in the theory that SIBO is this refluxing upward of bacteria from the small intestine to the large intestine.
But all this is just kind of academic noise, right? At the end of the day, that is something for researchers to kind of fine-tune so that we have a better understanding of the academics and the mechanisms. When you cross a line into clinical practice you need to know how can you use a breath test to help you get over your symptoms and get healthy. And then that comes back to a breath test is suggestive that you have an imbalance in the small intestine. It’s not a 100% corollary but certainly, it’s justifiable after that test to go to work to remedy that. And to be honest you don’t really need a breath test to do much of the work. You can try a little FODMAP. You can try probiotics. You can try herbal microbials. All that treats SIBO without needing a breath test. But it may give you some clues in terms of the territory that you are in. So that kind of, you know, sums it up there.
Ari Whitten: Yeah. Nice summary. So, just a real quick question. You mentioned the study where they were trying to correlate the sampling of the microbiome with the breath test and then you said something to the effect of how well it matched up with the people who were, who actually had SIBO. Well, how were they given the diagnosis? Was it based on the breath test or was it based on something else?
Michael Ruscio: I believe the details of the setup here… I didn’t read this full paper. I interviewed Dr. McCallum who was kind of expounding upon this. So, you get some pieces that were published in the paper and some that are more as commentary and, you know, what was in that study compared to what were his thoughts? That line, it’s a little bit blurred. So, my general understanding is they were using the SIBO breath test to find the positives and then they were looking to correlate the SIBO breath test positive with, “Okay, what is actually found in the intestine when we go in there and sample.” And in that group, the one they sampled, they didn’t find the large intestinal bacteria. They found more upper intestinal bacteria that seems to have crept their way down.
Ari Whitten: Got you. Yeah. Interesting. So, one of the other things you said is that you don’t necessarily need a diagnosis for SIBO for… And for people, let me quickly step back for people who are lost and don’t know what we’re talking about. Small intestinal bacterial overgrowth, SIBO, is a common diagnosis now within especially the functional medicine community. And it is somewhat of a controversial diagnosis. There are lots of people who believe in it. There are some people who are skeptical of it. And Dr. Ruscio gave a nice summary of all that just now. One quick question though. You said you don’t necessarily need a breath test to diagnose this. What other things would help you diagnose this and how would it differ symptomatically from just someone who has dysbiosis?
Michael Ruscio: Right. Well, it’s not that you don’t need a breath test to diagnose this. And if you want to diagnose SIBO probably the best way to diagnose it would be a breath test. But you don’t need a breath test to use the therapies that are often employed for SIBO. And that is where I think the pro-SIBO camp could relax their recommendations a little bit because I can have this translate into, okay, Joe Smith is trying to get healthy. And if you have someone with the right approach compared to the wrong approach, he could be doing a breath test at baseline, another one, six weeks later, another one another six weeks later. And that gets exhausting. It’s daunting, it gets expensive. And in my opinion, you don’t really need a breath test to say, “Hey, we’re going to give you six pearls of oil of oregano per day.
Right? And if you wanted to be the most persnickety, I mean, I guess you could. But the only time I would really want to see a breath test, and even this I think you could criticize if you’re considering administering dual antibiotic therapy, something like Xifaxan paired with Neomycin. But even then, Rifaximin or Xifaxan is FDA approved for diarrheal IBS. No lab test is required, just a symptomatic presentation. And so, this is where I think the critics of SIBO are correct. For if you fall into this camp of being so anal about your testing, oftentimes I think that does more disservice to the patient both psychologically and financially than it does assist them in getting to the endpoint of clearing all their symptoms.
Ari Whitten: Right. Yeah. So one other layer to this is just given that the breath tests are not necessarily differentiating that well between people with SIBO and not, in the scenario of sort of relying more on symptomatic presentation instead of the test, how do you like, are there clear differences in terms of symptomatic presentation of people who you are treating for SIBO or people who have Crohn’s or IBS or maybe just dysbiosis?
Michael Ruscio: Great question. And this is both a gift and the curse of the gut. Symptoms or I’m sorry, imbalances in the gut can manifest as a wide litany of symptoms even outside of the gut. And so, what is great about that is you could have someone come in with rheumatoid arthritis who has no gut symptoms and you do some therapies to improve their gut health and their RA vastly improves. That’s great. The challenge with that is you don’t always have gut symptoms to signify that it is the gut as the root of the problem.
So, to your question, I mean, if someone has gut symptoms, yeah, that is kind of like a red flag or bullseye. But there is definitely a subset of people, and there’s a number of papers that have supported this, that can have for lack of a better term, inflammation or dysfunction in the gut that is only manifesting in the brain, in the skin, in the joints, what have you. So no, there’s not a great, “If you fit these symptoms then you have SIBO.” Which is why I come back to more of a hierarchical way of working through things or, you know, we can work through a process of elimination. And I think that oftentimes gets left out of clinical practice we are so testing heavy. And when you look at a testing heavy approach that is built with tests that have questionable validity at the expense of a well-vetted clinical hierarchy, this is how you end up in the precarious situation of much of functional medicine where you see a few functional medicine doctors, you spend thousands of dollars and you are not much better off for it. And I don’t mean to be overly critical of functional medicine, but this is definitely an area that we need to improve.
Ari Whitten: Yeah, very well stated. I share the same exact criticism and I really appreciate this about your approach that you point out where tests have questionable validity and you move towards the hierarchy of the foundational habits. Now, one more follow up to this. It sounds like, well, you know, let me just add one layer to this. There is this issue of how gut problems can manifest as all kinds of non-gut related symptoms. We know there is a gut-brain axis. We know there is, you know, there are papers on the gut-mitochondrial crosstalk and so we know that there is a direct impact between what is going on in the gut and, you know, mitochondria. We know specifically another layer there is within chronic fatigue syndrome. We know that there is potential, there’s been some studies that have found like elevated LPS antibodies and things like that suggestive of leaky gut is a factor in chronic fatigue syndrome.
And it can manifest as all sorts of different things that are non-gut related symptoms. We are also going to talk about autoimmunity and thyroid in this Podcast. Given that and given that the tests themselves are sometimes not that great and have questionable validity, it sounds like to a large extent almost everybody who walks into your practice and almost anybody who walks into any practice should be potentially thought to have gut problems unless like proven otherwise. You know, whether they have gut symptoms or not it seems to almost make sense to do something to treat the gut. Is that a fairly accurate statement?
Michael Ruscio: Yeah, I think that’s a really reasonable hypothesis. And we are going to be releasing on our website a case study of someone who, she is a firefighter and very healthy her entire life. And then all of a sudden, this acute drop in terms of how she was feeling. Fatigue and this fuzzy thinking or brain fog. It’s all [inaudible]. And she went through [inaudible] medical centers [inaudible] and good diagnosis. She was diagnosed with hypothyroidism, which is great, and she went on medication. And that is important that that was identified, and it is important that she started on medication. But she went on medication and she didn’t feel any better. Fortunately right around the same time she came across my book, she went through the book protocol and within two or three months all of her symptoms and the symptoms that did not respond to thyroid medication finally went away because of a gut problem even though, I don’t believe she had, you know, much in the way of gut symptoms. She had some, but she was thinking, “Well, it must be my thyroid because the thyroid can cause a slowing down in your motility and hypothyroidism can cause a lack of secretion of digestive acids.” And all those are correct. But the bigger question is, as you alluded to, you know, what do we have to tackle first to try and have the best kind of order of operations? And so, in this case, and this is such a great, I think, segue into our thyroid aspect of the conversation, you will see people who go on thyroid medication and that is not the only layer to what is causing their symptoms. So, they don’t respond. And here is the travesty or there is a fork in the road here. You go deeper down the rabbit hole of thyroid.
Now we’re going to test reverse T3 and T3 and we are going to change the ratios of T4 to T3 or this whole line of thinking, which does have validity, but it is more so for a minority of patients. They go down that fork and they miss the gut fork. And I mean there have literally been doctors who have now written case studies for our clinician’s newsletter where they went through this exact process with a patient. Only after eight months or so, “Hmm,” they said, “We should go back, check the gut.” And they checked the gut and that was what finally got the resolution of the symptoms. So, it is not to say thyroid has no place, but we start with basic thyroid hormone replacement therapy and then we optimize the gut. That will take care of most of these situations. If it doesn’t, then you consider fine-tuning of the thyroid hormones.
Ari Whitten: Yeah. Interesting. You just reminded me of a study that I saw maybe a month or two ago that I wish I had looked up the study prior to this podcast so I could present the name of it. But basically, they were looking at treatment for subclinical hypothyroidism. And, if I remember correctly, they basically determined that a huge percentage of people who were given thyroid hormones to treat their subclinical hypothyroidism didn’t actually have any symptomatic improvement.
Michael Ruscio: Correct.
Ari Whitten: So, like they, to your point, these people are getting the thyroid hormones to bring them back up into the normal range. But the symptoms or whatever they were claiming were being caused or whatever was thought to be caused by the hypothyroidism, those symptoms didn’t really improve. So, it suggests potentially another layer of underlying causes there.
Michael Ruscio: Yes. And what you are saying regarding subclinical hypothyroidism and just for the audience, that is when you have high TSH paired with normal T4. And so, there is debate as to whether or not these patients require treatment. There are some nuance guidelines to determine who does and who does not. But for brevity sake, most people do not require treatment of subclinical hypothyroidism. And it varies from what study you look at, but you can essentially say that more than half of those cases will spontaneously go back to normal all on their own. And in the studies that have looked at, “Do these patients benefit from supplementation with thyroid hormone?” They really don’t, other than women who are trying to get pregnant and/or have a history of infertility. So that is a very important caveat that I should mention out of some of the nuance. So, if a woman has been, you know, unfortunate to have a miscarriage in the past or she is having a hard time getting pregnant and she has that subclinical hypothyroidism, high TSH, normal T4, that population does clearly benefit from using thyroid hormone. But most other people will not experience any benefit.
Ari Whitten: Very interesting. I have one more layer on the gut and then I want to transition into the thyroid. So just to follow up on that last question of, you know, to the extent that we might almost be treating anyone with most types of symptoms, be potentially looking at treating their gut. What I mean, I would say the only potential caveat to that approach is if there is harm if you have to worry about like let’s say a healthy person who actually doesn’t have any problems with their gut health doing a gut protocol and actually causing themselves harm from it. Do you feel there is any concern with that possibility? And maybe also like differentiating between maybe a more natural approach using some of the herbal antimicrobials versus antibiotics. Is that a factor as well?
Michael Ruscio: Yup, yup. So, I mean it is a great point and you are absolutely right. We want to, if we are going to use this kind of hierarchical process of elimination type approach, that is really only tenable if we have minimally to non-invasive therapies. And so that is what is beautiful about natural medicine. We don’t have to make a strong case to try an elimination diet, great gut intervention, a low FODMAP diet, another great gut intervention, a well-rounded probiotic protocol or even herbal antimicrobials. When you get into herbal antimicrobials those are a scotch more invasive, but I still say they are very safe. If we are going to be using things like pro-kinetic medications or antibiotics or anti-fungal drugs, those aren’t as bad as they are often depicted on the Internet, which is important to countervail the narrative with. But, you know, then we are getting into a territory where I think we want to at least have built someone up to this. And oftentimes this is far more common sense driven than I think patients appreciate.
Let’s say you saw some improvement from a low FODMAP diet, another bit of improvement from a probiotic protocol. That tells you something is amiss in the gut and these certain modulations are getting you flickers of improvement, but they didn’t have quite the punch to fully get you back to aerobiosis. So, you could use those clues to say, “Okay, this increases the probability that you may respond to antimicrobial therapy, pharmaceutical or antibiotic therapy.” So, you know, in the hands of a good clinician, you know, a lot of these concerns become allayed, but you do make very relevant criticism which we shouldn’t be jumping to… Let’s say someone who read an article on Rifaximin and they, are like, “This has got to be my issue.” Well, I would not jump there before you went through those earlier steps of diet because you may notice all the improvements that you would have seen from Rifaximin from four to six weeks low FODMAP followed by a reintroduction. So yes, the order of operations is very important.
Ari Whitten: Yeah. I was just thinking; would you do chemotherapy in a preventative fashion? Like, “Whoa, you might have cancer so let’s do chemotherapy.” Like with an intervention like that that carries a lot of potential for harm you obviously have a lot more to be concerned about. But, as you said, doing an elimination diet or, you know, doing some probiotics or a FODMAP diet or something like that, a low FODMAP diet, there is a lot less to be concerned about when it comes to harming yourself.
Michael Ruscio: Exactly.
How gut issues can impact thyroid health
Ari Whitten: So, I want to transition to the thyroid now which you have already talked a bit about, but let’s talk about this relationship. So how is it that gut problems can impact thyroid health? What’s going on there?
Michael Ruscio:There are a few mechanisms through which the gut impacts the thyroid. The one that I think doesn’t get the attention that it deserves is malabsorption of thyroid medication. So, for people who are on thyroid hormone, when they start to improve their gut health, they will oftentimes see an improvement in their symptoms and a reduced need for the medication at the same time. Why is that? Well, one, the gut might be causing some of those symptoms. But two, an unhealthy gut leads to malabsorption of the medication. So as their gut gets healthier, they absorb the medication better and they need less of a dose. And this ties in with a big part of my philosophy, which is the small intestine is very important. This is where things like SIBO do have relevance because the thyroid hormone is absorbed entirely in your small intestine. So, when we see people have improvements in the amount of thyroid medication that they need, a lot of that is like underlined by the fact that their small intestine is getting healthier and better absorbing the medication.
So that’s one path where I think people would benefit from understanding better. And there have been published trials. For example, H. pylori is the best model that we have here showing that after patients treat an H. pylori infection, they will see a reduced need for thyroid medication. Not because functional medicine is so great and repaired their thyroid. That would be nice if that were the case. But when you see, you know, a four-week change in how much medication someone needs, that is almost for certain not that the thyroid gland has vastly regenerated itself in four weeks. Again, that would be great if that were the case. But I don’t want to paint it as such just because that is what patients want to hear. We want to be, you know, as representative of the actual mechanisms here. So, when you see that sharp change in need it is more likely the small intestine was inflamed, wasn’t absorbing well, you improve the health, they are absorbing the medication better, their thyroid hormone levels in their blood spike and then you have to drop their dose down.
Ari Whitten: Interesting. What about sort of backing up and, you know, outside of the context of someone who already has known hypothyroidism. Do you feel that poor gut health is playing a causal role in the generation of the hypothyroidism in the first place or the autoimmunity?
Michael Ruscio:There are probably three main ways that these interfaces. So, one we just covered, the absorption of medication. Two is through the impact on thyroid autoimmunity. And then three is the most elusive like we alluded to earlier which is the symptoms might not even be thyroid, to begin with. They might be the gut. And we have the data published showing improvements in fatigue, in brain fog, in mood, you know, in joint pain from improving the gut which is oftentimes things people are associating to thyroid. So those are the three: absorption of medication, the ability to modulate the immune system and autoimmunity, and then the symptoms, thirdly, might not be thyroid at all. It might be caused by the gut. But on point two here, this is also an exciting area of research and we are somewhat in our infancy. The best data we have here is for H. pylori because that is the thing that conventional medicine has been focused on for the longest.
So, we have the best data here. There’s only really been one study that tracked autoimmunity after treating small intestinal bacterial overgrowth. And they didn’t report, we even reached out to the researchers. They didn’t, they saw other autoimmune markers improve after treating SIBO, which is great, but they didn’t track thyroid antibodies and that killed me cause they said, “Oh, it would be such great data to have.” They did a baseline assessment of the TPO antibodies, but they didn’t do serial repeats. So, we don’t have any data yet that has shown that treating SIBO can improve thyroid autoimmunity. We do have some data showing that for H. pylori. But we also have data associating small intestinal bacterial overgrowth to thyroid autoimmunity. And one Polish study looked at three groups – healthy controls, those with diarrheal SIBO, those with constipative SIBO. And the TPO antibodies, one of the measures of thyroid autoimmunity, was normal in the controls, was slightly elevated in the diarrheal group, and even more elevated in the constipation group.
And one other trial looking at about 1800 patients and assessing a litany of factors to try to figure out what of these factors was most tightly associated with hypothyroidism, I’m sorry, with small intestinal bacterial overgrowth. They found that the primary factor associated with SIBO was being hyperthyroid. More associated than being on acid-suppressing medication or immunosuppressant medication or even prior intestinal surgery. So, there is this fairly tight, impressive association between SIBO and hypothyroid. We have some data showing that the treatment of the gut can improve the medication absorption we talked about. And then a little bit of preliminary data, although it definitely is in its infancy, showing that treating the gut can improve thyroid autoimmunity.
Ari Whitten: Got you. You know, there are some people there who talk a lot about gluten and grains and sort of that aspect of the reaction in the gut and causing gut permeability and that being a key factor in the generation of autoimmunity in the first place. What do you think of that hypothesis?
Michael Ruscio: The best research on this has been done in the University of Bologna by a researcher, Volta. And they did find an association between non-celiac gluten sensitivity and thyroid autoimmunity. Non-celiac gluten sensitivity is really the most relevant measure. The reason for that is we know that if you are celiac, a whole bunch of stuff is going to improve when you go off gluten. So, you are not really making a case that for the rest of us going gluten-free is helpful when you say, “Look at all the people who were celiac and all this improved when they went gluten-free.” That shouldn’t be the argument. Unfortunately, some gluten gurus make that argument and I think if that argument isn’t juxtaposed with other data then that is a very weak argument in my opinion, at least this kind of overzealous propagation of the notion that everyone has to avoid gluten.
Now in the Volta paper, they did find an association, I want to say it was about 9% of the cases that had documented autoimmunity. And I believe that the percentage of people, I may be slightly off in some of the numbers here, I haven’t quoted this paper in a while. But they looked at 12,225 patients and they assessed them for non-celiac gluten sensitivity. And of the people who had non-celiac gluten sensitivity, I believe it was only 14% total that had autoimmunity. So, of all the people who had non-celiac gluten sensitivity, 14% were autoimmune and nine of that 14 were thyroid. So, there is an association, yes, but we have to be careful to contextualize it…
Ari Whitten: Real quick. Do you have numbers on what those percentages would be in sort of the general population that doesn’t have gluten sensitivity?
Michael Ruscio: So, you are asking how many people in the general population have thyroid autoimmunity?
Ari Whitten: Yeah, thyroid or any kind of autoimmunity. So, let’s say if it’s 14% of people with non-celiac gluten sensitivity who have autoimmune conditions, what is the comparison percentage of people in the general population who don’t have gluten sensitivity who have autoimmune conditions?
Michael Ruscio: Yeah, I want to say that it is around 1 to 2% and then the incidence of hypothyroidism is actually slightly less than that. And this begs another interesting note which is… And again, the exact numbers, you know, and I can get you these afterward if you want to put these, you know, the specifics in the show notes. But I…
Ari Whitten: I’m just curious like I wanted to… I guess I feel like that other comparison percentages, just a good other data point to compare this with is, is the gluten sensitivity explaining 90% of autoimmunity or is explaining 3% of autoimmunity? Do you know what I mean?
Michael Ruscio: Well, so in the general population estimates for the prevalence of non-celiac gluten sensitivity range from 0.6 to 6% of the population and this Volta paper found 3% of the population. So maybe the most accurate measure is to say around 3% of the population suffer from non-celiac gluten sensitivity. And I believe the number of people that have thyroid autoimmunity is about 1 to 2% of the population. That number I might be off on, though, so you know, I would want to double-check that. But, I mean, the conclusion we can draw is a small subset of people. And when you look at that in juxtaposition to the claims that everyone needs to be avoiding gluten, it is hard to connect those dots. And there is one other thing a little bit tangential, but I think important to mention.
If you look at the prevalence of thyroid autoimmunity only roughly half of the people who have thyroid autoimmunity actually ever become hypothyroid. And this is really important to mention because when people find out they have Hashimoto’s; they freak out like they have this terminal path to hypothyroidism. And one prospective study in Tehran followed patients and they found that only 9 to 19% of the population who had thyroid autoimmunity ever actually became hypothyroid.
Ari Whitten: That is fascinating.
Michael Ruscio: And I don’t say that to diminish the impact that hypothyroidism can have. I say to empower people to understand that if you have Hashimoto’s, don’t freak out like you have this 90% probability that you are going to become hypothyroidism and let whatever you are reading or whatever guru you are working with coercing you into thinking you have to live like a nun because the odds are stacked in your favor. And yes, we want to go through all the same stuff. Sunlight, vitamin D, healthy diet, elimination, reintroduction, tune-up your gut, all those things for anybody makes sense including those with thyroid problems. But you shouldn’t be extra compliant or fearful because you have positive TPO antibodies.
Ari Whitten: This is fascinating. I’ve never heard this before. So I’m really curious to know what like, do you know or does anyone know, what are the factors that determine or impact or influence whether somebody goes down a path of having the thyroid antibodies and then it manifesting in very serious destruction of the thyroid gland and hypothyroidism versus not, versus maintaining normal thyroid levels for let’s say decades?
Michael Ruscio: Yeah, there’s a couple of factors. We know that the degree of elevation of the antibodies does seem to be predictive. There is not a ton of data here but in the studies that have looked at it, one of probably the best studies found that there was this transitional point of about 500 for the TPO antibodies. Again, that’s a blood test that your doctor can run to assess if you have thyroid autoimmunity. And unfortunately, many in functional medicine look at every positivity of TPO antibodies the same. And I think we talked about this in the past where that is like saying, “If your blood sugar is 101 you have same risk as if it were 191.” That is a ridiculous conflation and that hurts people psychologically. Same thing seems to be happening with hypothyroidism where if someone, you know, it shouldn’t be above 35. If someone has, let’s say 125 they are given the same prognosis as someone who has 1,125 and that is a mistake.
And again, we don’t have meticulous data here. But from the data that we do have, it seems that 500 is the cutoff point. When you are above 500 the researchers conclude you have a moderate risk. So even when you are in the high-risk category, the risk is only moderate which makes sense if we look at the prevalence data, we talked about a moment ago, right? It’s only the minority of the population anyway. The other thing that can be helpful is if someone also has elevated TSH. So, there is that subclinical hypothyroid. So, if they have high antibodies and/or they have a very elevated TSH that tells you that the gland is getting a decent amount of damage and those can be predictive of, you know, your chances of becoming full-blown hypothyroid. So again, this is where some of the nuance matters, where not every positive TPO test is the same.
If you have a level above 500 and I’d say definitely above a thousand, that increases your probability. And if you have had high TSH in the past, that also increases the probability. But if you have had normal TSH, if your TPO antibodies are 100, 225, 312, 411, I wouldn’t really be overly concerned. Sure. Consider some noninvasive interventions, vitamin D, selenium, magnesium, CoQ10 have shown to be helpful. But don’t go into this way of thinking where you have to be constantly fearful. You eat out and you are asking the waiter, “Is there any gluten in the sauce?” Because you read an article about, you know, how every thyroid autoimmune condition should avoid gluten exquisitely. You know, that might be going too far. And my contention is you are oftentimes operating so fearfully when you are doing that, you are actually making your stress pathway to stimulate autoimmunity worse than the actual food insult would have been and you are ending up in a net negative.
Ari Whitten: Yeah, I definitely think there is a lot of validity to that argument. I do want to say, so you mentioned a lot of biomarkers that are predictive of this decline or overt, you know, the progression to overt hypothyroidism. But does anyone know what factors like on a nutrition or lifestyle level or environmental level influence, or genetic level, whatever, influence whether somebody progresses let’s say from slightly elevated TPO antibodies at let’s say 200 or 300 up to 1,000? So, do we know any of the factors that influence that?
Michael Ruscio: Some. We know that selenium can help to decrease thyroid antibodies. Although the data here are not airtight and there are some studies showing selenium does not help. There seems to be equivalent or something more data showing that selenium can help. The length of time is important. Usually, three to six months is long enough to see a benefit generally speaking and people don’t have to be on selenium lifelong which is important to understand. Magnesium and CoQ10 have both been shown to also, and vitamin D, have all been shown to decrease thyroid antibodies which can ostensibly decrease risk. It is a bit of an inference because we don’t have any data because this would be a fantastic study tracking patients who have thyroid antibodies, putting them on nutritional intervention and then, you know, watching those compared to a placebo group and seeing did the vitamin D plus magnesium plus CoQ10 group have a lower incidence of conversion into hypothyroidism than the placebo group?
That would be great data to have. We don’t have that. But what we do have is we know that higher antibodies are more associated with risk of hypothyroidism. And some trials have found that you know, at day one we test your antibodies and then we then test them again 30 days later and people on Vitamin D or selenium or CoQ10 tend to have lower levels of antibodies. So, it is an inference that that will carry over to decreasing the prevalence, but I think it is a reasonable inference to make. There has also been one Paleo diet study and one, loosely call it kind of a Paleo/low FODMAP diet study showing that you can decrease thyroid antibodies with diet. So that’s great. All right? But you know, again, I think it’s a mistake to say that people have to go to autoimmune Paleo, 100% gluten-free. You can probably get 80% of the benefit with 20% of the changes meaning just going to that general kind of Paleo, clean template.
There was also one study looking at the Autoimmune Paleo Diet, and this is published by one of my friends and colleagues Dr. Robert Abbott. He tried patients who were coming from a fairly healthy cohort because many of these people… If you’re going to go on the Autoimmune Paleo Diet you are not going from Slurpees and soda, right? You likely have been reading about diet. Many of these patients seem to have already been on some type of gluten-free diet and/or elimination. And they put them on the Autoimmune Paleo Protocol, and they didn’t show any appreciable change in their thyroid antibodies after doing that. So again, just to support my point that a little bit will get you that initial benefit. But there is this law of diminishing returns where, you know, the more you do doesn’t mean the better you get. In fact, you could counter-argue that if you get overly restrictive with your diet the pressures of that may actually lead to a decrease in how you are feeling. So…
Ari Whitten: That is interesting that your perspective has shifted more from like focusing on trying to get people to do every possible intervention to relax, don’t stress and become super neurotic and obsessive-compulsive on this to the point where the stress itself is now a factor in the progression of this condition.
Michael Ruscio: Well it helps being a clinician, right? So, I’ve been in practice now just under 10 years and I’ve been questioning, “Do we need to be this excessive?” Because these things never felt fully right to me. It just seemed, some of these detailed lab analyses and these restrictive diets, they seemed too confining. And as I started testing some of those waters and boundaries I started noticing, “Man, we have a lot of wiggle room.” And, I also, unfortunately, have seen a number of patients who have come in scared of food and really contracting their life into this very unpleasant scenario because they kept reading about how all these things were bad for you and they had this kind of, you know, Internet induced hypochondria orthorexia and that is definitely damaging.
So, it’s finding the right balance of intervention. But then also not running over the edge of the cliff, going off the deep end and making people afraid of everything.
Ari Whitten: Yeah, absolutely, 100%. I know we only have a few minutes left. I was hoping, I have like three more questions on my list that maybe we can do rapid-fire. I would love your thoughts on lectins, kind of to address that line of thinking in terms of the role of lectins in gut health and Steven Gundry’s stuff around how lectins are causing so many diseases. And then the biome tests. And then I would like you to give like maybe your top two or three practical tips or strategies for people who are dealing with a thyroid condition.
Michael Ruscio: Sure. So, regarding lectins, I appreciate that Dr. Gundry is trying to look into the diet as a healing tool. And I should lead with that comment because anyone who is trying to find a way to use natural therapies that get people healthy, I think is a step in the right direction. And he has been on my podcast maybe three years ago. This was before I reviewed the evidence of his argument. And after doing that I was really disappointed that there is not any good data to support that lectins are an issue. And when I say good data, there is levels of evidence and the highest level of evidence are clinical trials or at least are interventional trials. And they don’t really have any of that data. They have one retrospective analysis, but these patients weren’t having lectin changes in the diet as their only variable change. They were essentially, loosely terming it, going from an unhealthy diet to kind of a Paleoish, low lectin diet.
So, they were removing a lot of unhealthy foods. And it is very unscientific and unsound to claim, “Well, because of one of the eight things you changed was lectins, this supports the hypothesis.” And, you know, again, and I don’t mean to be overly critical of Gundry, but he certainly has the time and practice and the resources to have done at least an open-labeled trial. Meaning he has patients isolate the dietary variable of lectins, tracks them over time and then reassesses whatever the measure is. And that hasn’t been done. So that makes me a little bit wary. I will be the first to change my mind if any quality evidence is produced. But unfortunately, I would, at this point in time, I would advise against following the low lectin diet. Some of the principles or the foods to avoid in the low lectin diet are good principles.
You know, reducing your grain consumption and getting off of processed foods seems to be one of his comments and that can help people. But we shouldn’t confuse the fact that someone improved when doing that, that the lectins were the reason for that improvement.
Ari Whitten: Yeah, 100%. So, and I completely agree with everything you said, by the way. That is exactly my thoughts. And so, biome [crosstalk].
Michael Ruscio: So, one of the sister companies to Viome does that same type of testing and you probably heard about this was recently raided by the FDA. Now, to be fair they weren’t raided because they were inaccurate in terms of the testing. They were raided for fraudulent insurance billing practices. But it is still a hint at some of this nefarious, sketchy business that I’ve been warning about regarding all of these micro, I shouldn’t say all, against microbiome mapping.
Now some of these companies are just trying to collect data and amass data in order to help scientists better establish cause and effect and trends and connectivity. But when you start telling people that we can map your microbiome as the underlying cause, to find the underlying cause of your symptoms, that is not accurate. That is inaccurate, that is dishonest, and I really take issue with that. I take issue with that because I’ve seen a number of patients who have done these tests because they have fallen prey to marketing buzzwords to come in only to realize that there is no clinical information there. We haven’t gotten to that point. And that’s, those aren’t my words. Those come from some of the preeminent researchers specifically in this niche who literally pioneered some of the technology. They have quite openly said a number of times, “Do not use these tests clinically. They are not there yet clinically.” Some of the tests are getting close. But there is a big chasm of ground to cover between initial research and clinical viability. And unfortunately, many people are getting caught in this lurch of, you know, no man’s land where you haven’t proven it, but it might be good. And so, we are going to just tell you all the reasons why it might be good, leave out the fact that this hasn’t been clinically validated. Someone sees a high or a low or a red or green on a test and they assume, “Ooh, that must mean something.” There are tests where that high or that low or that green or that red mean nothing. And that is really important to understand because if you spend your money on that nothing-burger of a test, then, unfortunately, you have just wasted the resources that you may have put into something that was more beneficial.
So, and again I don’t mean to be, you know, hating on certain tests. But you know, certain companies have kept their recommendations within the lines of, you know, “Be a citizen scientist. Help us amass data so that we can figure out, you know, better treatments for XYZ.” Great. But the people who say, “What if weight loss was, you know, so easy and what if the disease didn’t have to be a reality?” Those are really nefarious, misleading marketing claims…
Ari Whitten: And, “Learn, you know, the best diet for you based on analyzing your microbiome.” And, you know, “We have done this test. Here is your microbiome and based on this you should eat this way and this way and this way.” I’ve seen many of those tests and some of the recommendations that they are giving people just seem totally wacky and really out of harmony with the overall body of evidence on nutrition.
Michael Ruscio: Yeah, and I want that to be true. I want there to be a diet that can tell me, I’m sorry, a test that can tell me what diet to go to. But thankfully it is not that hard to figure out the best diet for your gut. And I expand upon this in “Healthy Gut, Healthy You.” It’s not that difficult. And yeah, I wish there was a test that would tell us that, but unfortunately, we are not there yet.
Ari Whitten: Yeah. So, wrapping up, I know we got to cut off here, but if you want to give maybe your top two or three quick recommendations for people who do have, who are listening to this who actually have hypothyroidism or suspect they might have hypothyroidism.
Michael Ruscio: Well, one thing I definitely want to make sure that we mention is there was a paper done by Livadas in Athens, Greece. And they were tracking a number of patients to assess if patients came in with this kind of ambiguous hypothyroid diagnosis, maybe some of them didn’t actually have hypothyroidism. And they essentially tested this group of 299 people, took them off thyroid hormone for six to eight weeks and then retested. Sixty percent were not hypothyroid and did not need the medication that they are on. So, there are definitely people watching this who have been given an incorrect diagnosis of hypothyroid and I would consider double-checking. Do not stop taking the medication if you are on one. Check. A way that you can check this is go to the lab that diagnosed you before you went on the thyroid hormone. If you don’t have flagged high by the lab TSH high and T4 low, then that is pretty much guaranteed that you are not hypothyroid. Again, check this with your doctor. I don’t want you to misinterpret what I’m saying and then do something to harm yourself. But incorrect and overzealous diagnosis of hypothyroidism is a legitimate issue both in conventional and in alternative medicine and there is an outcry to remedy this.
Now symptoms, patients are pursuing this because they have symptoms that are, that they don’t have answers for. I get that. If you want the thyroid to be the cause of your problem, it doesn’t mean that you can will that into being. So, don’t forget that the gut can be a very powerful source of the symptoms that you could be attributing falsely to the thyroid. So, you know, I will leave people I guess with that. And then also we have put together a “Quickstart Guide” to help people navigate, you know, thyroid support, gut support, both. If they go to drruscio.com/gutquiz, I made a quiz that helps steer them down one of three kinds of Quickstart pathways with some initial dietary changes and a few supplement recommendations that can help them kind of sort some of this out. So if they heard, “Oh, low FODMAP and probiotics” and they are not sure how to sequence or how to do that, then the “Quickstart Guide” would, you know, take some of their symptoms into account and then point them down a pathway to get the ball rolling in the right direction.
And then the other thing I would leave you with is when you are not feeling well your body becomes hyperaware. And that is because it is trying to figure out what is making you not feel well. That is a good survival instinct. But unfortunately, when you combine that with the Internet where there is all this information, some of which is not really well-vetted, then you can very quickly get yourself into a situation where you think things are worse than they are. And please understand that oftentimes the picture you get from the Internet is far worse than it actually is. People are very much so able to overcome chronic illness or even short-term symptoms that are making them not feel well if they have the right approach. So have hope. Find someone who you think is competent and you should be able to get through whatever you are dealing with without too much rigmarole. But, yeah, remember that every day people who have not been feeling well for a while get over that feeling and oftentimes things are not as bad as you may think.
Ari Whitten: Yeah, excellent. Well, Dr. Ruscio, this has been an absolute pleasure. I’ve really enjoyed this conversation, having you on a second time. I continue to be very impressed with the way your brain works and approaches to these problems. And I really appreciate you sharing your wisdom with us. Is there anywhere other than drruscio.com/gutquiz that you want to direct people to? Do you want to send them to get your book or send them to your website? Or should they focus on doing the gut quiz? Is that the best place to start following you and get practical strategies from you?
Michael Ruscio: Yeah, I mean the gut quiz is kind of the easy starting point. So, I’d say if you are someone who is a bit overwhelmed and a bit maxed out, the gut quiz will give you the simple shortcut to start. If for someone who is saying, “I want to go full-on in,” then buy, “Healthy Gut, Healthy You.” Buy the book and then you can go through the really comprehensive gut healing protocol and also the narrative that kind of undoes some of the fear. We talk about gluten and we help kind of give you that nuanced view where, “Yes, it’s a problem” or, “No, it is not a problem for everyone.” So, the good news is you can do some experimentation and you can figure out if you have to be really avoidant or if you have some leeway or not a problem at all. So, yeah, depending on where you are in terms of your bandwidth you have those two options. And, of course, my website is always just the general hub for pretty much everything.
Ari Whitten: Awesome. Well, thank you so much again, Dr. Ruscio. And for everybody listening, I highly recommend you go grabbing his book, “Healthy Gut, Healthy You” on Amazon. It’s excellent. I enjoyed it myself. I learned a lot from it. And again, really, really enjoyed this conversation. Thank you so much for coming on the show again and have a wonderful rest of your day.
Michael Ruscio: Same here. Thank you.
The Gut-Thyroid Link: How To Treat Hypothyroidism Naturally And Heal Your Gut -Show Notes
The latest scientific developments around SIBO (00:29)
How gut issues can show up as other non-gut related issues (11:22)
How gut issues can impact thyroid health (21:09)