Dr. Michael Ruscio on Gut Health, Autoimmunity, Thyroid, and Sleep


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Katie: Hello, and welcome to the Wellness Mama podcast. I’m Katie from wellnessmama.com and wellnesse.com. That’s Wellnesse with an e on the end. And this episode goes deep on gut health, autoimmunity, thyroid, sleep, energy, and how they are all connected. I’m here with Dr. Michael Ruscio, who is a clinical researcher and doctor, and an author working to reform and improve the fields of functional and integrative medicine. With his clinical and research teams, he scours existing studies to inform ongoing clinical research, patient care, and guidance for health seekers and clinicians around the world.

His primary focus is digestive health and its impact on other facets of health, including, as I mentioned, energy, sleep, mood, thyroid function, and more. His research has been published in peer-reviewed medical journals, and he speaks at many conferences and on media outlets around the world.

In this episode, we start off by talking about why he does a cold plunge every single day and then go into the reason gut issues are so prevalent, even more so than thyroid problems, by quite a bit, how non-digestive symptoms can often still start in the gut, or signal a digestive issue, why we’re seeing a rise in these problems, the symptoms that indicate gut problems, but that you might not consider gut-related, why testing is only about a fourth of the data you need to understand what’s going on in the gut, other things that are important to look at, and why gut microbiota mapping isn’t clinically effective yet, when things like prebiotics and fiber can actually be counterproductive, how the gut can relate to the thyroid, and when you might actually not need thyroid medication at all, even if you’ve been told that you do, SIBO, and so much more. Very wide-ranging episode, and I know I learned a lot. I think you will as well. So, without further ado, let’s join Dr. Michael.

Katie: Dr. Ruscio, thanks for being here.

Dr. Ruscio: Thank you. It’s great to be here. Always fun talking to you.

Katie: Oh, likewise, and I’m excited to get to go deep on a couple of different topics today. But before we jump into that, I have a note in the show notes that you do a cold plunge in 35-degree water every day for 3 to 7 minutes. And this is something I also do personally, but I find that a lot of women have a pretty severe resistance to the idea of getting in cold water. So I’d love to hear a little bit about your personal experience and also why you find it so helpful. Maybe encourage some people to get in a cold bathtub.

Dr. Ruscio: Sure. Well, you’re right, women tend to not like jumping in that cold water. So that’s a pretty prevalent observation. And I like to go into the sauna. I have a sauna that I go up to about 220 and you get pretty hot from that. And two reasons I like going into cold afterward. One, if you don’t, you end up sweating for about 30 minutes or so afterward because you’re just so hot. But the other is there’s a number of health benefits that are at least tacitly being associated to cold plunging, obviously recovery, muscle and joint recovery, athletes using this to recover from workouts and such. And with the popularization of Wim Hof’s work, there’s been more study. And Wim Hof is more than just cold exposure. It’s also a breathing technique, as I’m sure people know. But it may have this, kind of, broader anti-autoimmune, anti-inflammatory benefit. It certainly helps with circulation. And I think if nothing else, it helps people feel a bit more empowered, that they can actually do this thing and they have the machinery to jump in cold water or to walk when it’s 20 degrees outside with just a t-shirt and shorts on. And it’s like, yeah, you can go out there. Sure, you can’t go out there and maybe for five hours but, you know, we’re strong enough and we have bodies that can really do some pretty amazing circulatory adaptations to allow us to be okay in a variety of environments. So there’s a few reasons that people may want to literally take the plunge.

Katie: Yeah, It took me years to actually want to, and then at first it was like 10 seconds and it was like, “Oh, no, I’m out.” But I learned that it’s very much mental as much as physical or more so. And the mental benefits are amazing after. As a tip for anybody who’s afraid to try it. I’ve learned from scuba diving, the feet are the part that gets the most cold. And there’s not really a ton of benefit from getting your feet cold for a long amount of time. They don’t have as much body fat. So, a good baby step for people is to get neoprene socks that help the feet be a little more comfortable, it actually lets your whole body stay in longer. I found that really helpful when I was learning.

But we’re actually here to talk about the gut, which also is truly talking about every aspect of physical health because the gut relates to everything else, we’re finding more and more and more. But I hear from an increasing number of people who have different specific gut problems and then also what I would consider, kind of, like crossover conditions that are probably largely starting in the gut but aren’t necessarily considered that in conventional medicine. So I think there’s a lot of different directions we will go in this in this conversation. But to start with, let’s talk about why start with the gut and why this is such an important area to really hone in on.

Dr. Ruscio: Yeah, well, this is the key question, and sort of the order of operations I’d recommend people proceed through is get your diet and lifestyle in generally good working order first. You know, whatever dietary template you go to, I think as long as you’re focusing on food quality, you can make an argument, you know, that’s probably the most important point to start, whether you go paleo, Mediterranean, low FODMAP, what have you. Just get your…your diet quality work should be sleeping, exercising, stress managing. Have those major boxes checked. And this is the key. If you’re doing that and you’re still having lingering symptoms, it’s not an absolute rule but the potential highest probability of what’s driving your symptoms is your gut. And just, you know, some stats, IBS affects 15% of the population. Gastrointestinal conditions broadly affect 40% of the population, whereas something like hypothyroidism affects 1% of the population. So it’s really important to keep these things in mind because the symptoms can be very overlapping. Many of the symptoms of hypothyroidism and, let’s say, IBS or some other non-diagnosed inflammatory issue in the gut can be very similar.

So what we need is to have this list, this order of operations, what is most likely to cause the symptoms in the highest number of people in the population? And that’s where starting with the gut is really quite important because you can have all these different symptoms as an offshoot. And something I learned myself where many, many years ago had brain fog, fatigue, and insomnia, no digestive symptoms, all extra-intestinal. And I overlooked the fact that these non-digestive symptoms can be caused by problems in the got. So, I want people to know that it is possible that pimples, or joint pain, or moodiness, or brain fog, or insomnia can ultimately emanate from the gut. And important to have that, kind of, order of operations so that you don’t go chasing whatever.

It’s, kind of, the hot topic of the moment, right? Because those things will get the most clicks by Google. They’ll raise the highest in your search feed but it doesn’t mean those are the most accurate. You know, it’s how the algorithms work. The more you click, the more it floats up in your search results. And also, it’ll be more in favor in terms of what’s in vogue to discuss in the blogosphere in the podcast-sphere. And it’s all fine but we wanna have the order of operations to make sure we’re not starting at the end and needlessly, kind of, spinning our wheels.

Katie: That’s a great point. And I realized that problems were really prevalent, and thanks to you, even more prevalent than thyroid problems. So I would guess a lot of people listening suspect they have thyroid problems or have been diagnosed with thyroid problems and not necessarily are really considering the gut issues, and I wanna go deep on that. But before we do, why do you think we’re seeing an increase in all of these gut-related issues right now?

Dr. Ruscio: Yeah, great question. That’s likely multifactorial. Our environment has changed a lot. I’m sure people have probably heard that we came and involved in this, kind of, hunter-gatherer environment where there was lots of contact with dirt, and soil, and animals, and think about a hunter-gatherer, right, in the dirt all day, not washing their hands, handling food, handling, you know, family members. And there was just so much exposure to different microbes in the environment. And those microbes help tune and train your immune system. So that’s one very important facet. You know, now we’re in these more hygienic, sterile bubbles, so to speak, when compared to hunter-gatherers. And then things like early antibiotic use, poor diet quality, changes in the diet, in general, in terms of less fiber, less probiotic foods.

And then you compound that with stress and lack of activity, both these have negative inputs on your gut. And it really creates this, kind of, perfect storm where the environment seems to be skewed in the direction of being antithetical to the development of a healthy gut and also immune system because the gut formation, the gut bacteria community, helps to establish a healthy immune system. Yeah, and so all these things are really, you know, kind of, skewed against us. There’s a lot that can be done. It’s not necessarily cause for alarm, but important that we understand these things so we can make the changes to have the healthiest gut that we possibly can and all the side benefits from that, like mental clarity, and clear skin, and what have you.

Katie: So you mentioned, even for yourself symptoms that didn’t appear at first glance to be gut-related but that were stemming from the gut. So, let’s talk about maybe some of…like, kind of, give us an overview of these and maybe some that are more often an indication of something going on in the gut that might get missed in conventional medicine if someone’s not having a digestive disturbance, specifically.

Dr. Ruscio: Sure. Sure. But the more we study this, the more that we’re seeing there…There was just a paper that found an association between heart disease and small intestinal bacterial overgrowth. Now, this was just an association, that’s important to clarify, association does not mean causality. So we’d have to then demonstrate that some sort of treatment for SIBO improved cardiovascular outcomes. And so I wanna be careful not to overstate that case. But nonetheless, there is still this notable observation that those who had SIBO had more cardiovascular episodes than those who did not. But, you know, of course, there’s some hallmark digestive symptoms, gas, bloating, constipation, diarrhea, reflux, abdominal pain, distension, which acknowledge those really quick.

But then what I think is less so understood, to your point, people can have brain fog, fatigue. Insomnia, ironically, has been shown to be caused by problems in the gut. In fact, there has been a number of papers now that have found that probiotics just, you know, showing that if we can intervene in the gut and show a benefit, that means it’s causal. It’s really important that we don’t just talk about all this academic interesting conjecture but actually say, “Hey, when a group of people took this and a companion group took a placebo, they saw this result.” It’s crucially important. And this has been documented with probiotics for anxiety and depression and also some early evidence showing that probiotic administration can improve sleep quality, just to mention two of these, kinds of, you know, gut-brain connections and that there’s actual treatment data that we can go on to inform decision-making. And, you know, in addition to that, joints, as people may have heard that certain dietary changes, like nightshades for some people due to how they probably trigger the gut and the gut immune system, can lead to things like joint pain.

And then outside of that, skin issues have been linked to the gut, and benefit has been shown for both dietary and, you know, probiotics is another proxy. I’ll mention probiotics a lot. This is one treatment proxy showing that, yes, we do have evidence that a gut treatment can lead to a non-gut positive outcome.

There’s some association between thyroid disorders and gut health. The treatment data there is still a little bit lagging. There’s only been a couple of studies. I believe one showed a reduction in antibodies, one showed no reduction. So, some of this may be a little bit multifactorial. But certainly, as more and more evidence is being published, we’re seeing that you can have a cast of non-digestive symptoms that are caused by a problem in the gut and progressively more emerging data showing that, yes, if we give a treatment of some sort for the gut, whether it be gut-directed antibiotics, or herbal antimicrobials, or probiotics, or elemental diets, we can see improvements in XYZ outcomes. And that’s why I say that it’s more important to have the order of operations, rather than saying, “Well, if I have this one symptom but not that one, then I should proceed with the gut,” because, you know, that heuristic will help you align your decisions in a way that’s gonna be the most efficient.

Katie: Yeah, and it seems like gut health has crossover into seemingly almost every area of health. Like, I know most people have probably heard about the gut-brain connection, for instance, and how many of our neurotransmitters, from my understanding, actually originate in the gut and, like, some form of gut dysbiosis can actually very much affect how you feel, your mental health. I’ve seen some studies on that connection. But what are some other direct ways we know that the gut directly impacts other parts of the body?

Dr. Ruscio: Well, the immune system, that’s probably the most predominant. And this is because the interface between all the food in the lumen of your digestive tract, and then getting into the bloodstream, and therefore getting assimilated into the various organs of your body where the nutrients are gonna have their effect, that gatekeeper is the lining of the gut. And if you’re to picture that as a true gate, the immune system are the soldiers that intervene if anyone steps over the gate or attempts to step through the gate that shouldn’t. And the immune system, if we’re picturing, again, in keeping with the soldier analogy, if they’re armed with a weapon, that weapon is inflammation. That’s the instrument through which they, you know, shoot and prevent the people from coming over the line or whatever. And that inflammation can become systemic.

And so this is why you’ll see in some cases when there’s an inflammatory issue in the gut, some of those inflammatory proteins also get to the brain, or even some of the bacteria they get through that shouldn’t also get into the brain and cause an inflammatory response there. And then you have the symptoms associated with that, or it might be the joints, or it might be the skin. So there’s a few other mechanisms, but I think the inflammatory one probably satisfies the majority of the mechanisms.

Katie: Okay, that makes sense. So, how might someone know…especially if they’re not experiencing digestive symptoms, how might they know for sure that something might be originating in the gut? Is there effective testing for this now or what do you recommend when someone comes to you with nondigestive symptoms but potentially originating in the gut?

Dr. Ruscio: This is a great question. The testing is about one-fourth of the data that you need to really inform and make a decision. And I just wanna, kind of, underscore that because we’ve drifted into this territory where as much as the scientist in me appreciates tests and test results, there hasn’t been appropriate bridling from the clinical and scientific community to say, “This is an experimental test. We should not be telling patients that these results truly mean XYZ.” And as one example, UBiome, really powerful, or popular rather, stool testing company was shut down, mainly for litigation brought against it for billing practices, but that investigation produce evidence that they were using dog feces, in part, to establish what the normative ranges of bacteria should be in the gut for humans. So I don’t think consumers adequately understand that many of the tests used in functional integrative medicine do not have the requisite evidentiary basis to be called accurate. And I think people really need to be bridled and help to understand that just because you see something in red or with a high or a low, it doesn’t mean that that actually has scientific merit to it. And so, if we can identify that, that takes probably more than half of the tests on the market off the table.

But not only that, even with a test that has more validity, like elastase, which is a marker that can help diagnose pancreatic insufficiency, you won’t always see a high clinical response to the treatment for that, which is pancreatic enzymes. In fact, me and one of the other doctors in the clinic were discussing this the other day, kind of comparing notes, and we estimated about a 30% response rate when someone has that validated lab marker positive to the corresponding treatment of enzymes. So if there’s one alarm bell we’re, kind of, trying to sound over at the clinic, it’s we have to stop treating numbers and we have to start treating people.

And so, one-fourth of the data would be a lab test. And we should also look at someone’s history, their family history, their symptoms, how their symptoms have responded to treatment, and their labs. So all those things together help you inform what decisions to make with an individual. Now, regarding your questions, sorry for the long, kind of, lead-up to this, but there are some tests that are validated. SIBO breath testing has been validated. And there’s been enough trials now and even acknowledgment from major bodies in gastroenterology like the North American Consensus and the Rome Consensus but yes, this is a legitimate test. It can effectively discriminate from people who have a condition from those who don’t. And correlations between treatment and lab results occur in, kind of, a prospective fashion.

There’s also stool testing. Stool testing is where it’s a little bit more challenging to answer that question because not all stool companies are testing the same stuff. So a UBiome that’s gonna map the microbiota and perhaps make all these promises that we’re gonna be able to tell you exactly how to eat and what you should and shouldn’t do, the science just is not there yet. And, you know, I think most tenured scientists and experienced clinicians are echoing that sentiment. And I think the UBiome lab was a good example of a company that was probably well-intentioned and trying to, kind of, get there through citizen sciencery to figure out and clinically validate their measure. But what was so disheartening is all these people came into the clinic saying, “Hey, Doc, here’s my UBiome, what do I do?” It’s like, ugh, I wish you didn’t spend that money. Because if you’re doing that to say, okay, I wanna contribute to the database so that we can learn, that’s one thing. But that’s not how these tests are often being marketed. It’s you have depression and brain fog, let’s figure out what bacteria are skewed. Let’s do this test. And that’s really hoodwinking someone and that should not be done.

So with stool testing, anything that claims to map your microbiota, we are not at the level of clinical significance yet. You will hear some claiming…some clinicians saying, “Well, I’ve been treating those tests and we’re getting results,” but just because you’re caring for a patient and they’re improving and a test is involved somewhere does not mean that the test actually allowed you to do the things that helped the patient, right? And oftentimes, what happens is, these tests can do harm because oftentimes, these tests will show low good bacteria scores and then prebiotics and fiber are given. And the clinical interventional data is pretty clear that the more symptomatic you are digestively, the higher the likelihood that prebiotics, not probiotics, prebiotics and fiber can actually flare you and cause adverse events. So another example of treating the test rather than treating the individual can lead you astray.

So stool testing is an option, not the ones that claim to map the microbiota, the ones that look to identify certain inflammatory markers like lactoferrin and calprotectin, which haven been validated, elastase, which is a marker of pancreatic insufficiency has been validated, but remember, it doesn’t have a super high translation to the majority of patients will experience benefit from the corresponding treatment. And then things that assess for infection, and this is getting a little bit murky because some people will call a non-infectious organism a parasite, like Blastocystis hominis is one that comes up as an infection. And it’s not to say that Blastocystis homins is purely a commensal, meaning part of the normal residency, but the signal there is very weak in terms of it seems to be a weak player. And the evidence that treatment is demonstrably helpful is also fairly weak. There is a signal and that’s important to acknowledge that.

So we have to be careful with what we call infections, right, because that category seems to keep expanding and becoming progressively capacious, when actually the scientific literature is showing less and less of these organisms are being proven true pathogens. And be careful with the sections that are called dysbiosis. And sorry if I’m going too deep here. Feel free to pull the leash and pull me back on this a little bit if I’m going too deep. But then you have the section of dysbiosis, which really requires a clinician to interpret. And remember I said it was, kind of, like one-fourth of the data because how exactly we define dysbiosis is still being mapped out. And I can say as someone who for years was doing two stool tests on every patient, now we do just one. You almost never see that dysbiosis section of a stool test normal. And so, what that tells us is dysbiosis may not be highly effective at discriminating between a healthy population and that who has some kind of problem in the gut.

So sorry, if that’s a little bit long-winded, but the one thing I hope people would take away is you’re much better off not doing a stool test or a SIBO breath test on your own and working with the clinician because, unfortunately, that leads you down this road of treating the numbers. And that more often than not ends up with people either flaring themselves, or spinning their wheels, or thinking they have a parasite when they don’t. And again, sorry if I’ve been going too long on this, but we just see such a mess. You know, people come in talking about their entire psyche framed around, “Well, you know, I have joint pain. It’s my Blasto flaring again.” Well, you know, who told you a Blasto is a pathogen? Why are you hinging your identity to this one organism from one stool test three years ago? Why are you avoiding certain foods that feel good to you just because of this one lab finding? So, you know, it really does do a lot of damage and that’s why I’m just trying to, kind of, highlight the fact that we should be much more discerning with the labs that we’re ordering.

Katie: I love that quote that you said that we have to stop treating numbers and start treating people. And I think a lot of people, to your point, will get a test and then assume that that’s a black and white, set in stone diagnosis and then alter their behavior quite a bit because of that. And you also brought up normative ranges, which I think is really important and also crosses back over into the thyroid conversation, which I wanna go a little deeper on. Because even within different labs, I know I see different considered ranges of normal. And I’ve heard, at least from some sources, that those ranges of normal are often determined by the people who go in and get testing, people who go in and get testing often think they have a problem, that there can be issues with even the levels we consider normative ranges. But I guess within that topic, how do we know then…Is there a difference between normative and optimal? How do we know what those are? And then from there, maybe let’s go back into the thyroid crossover conversation.

Dr. Ruscio: Sure. Sure. Well, as it pertains to the gut, you know, this is something that’s currently being debated. And this is as it pertains to really infectious organisms in the gut. There is this ongoing conversation that, okay, the classical ranges for how much of a, let’s just say parasite to keep it…let’s say Entamoeba histolytica, right? E histo, this amoeba is highly pathogenic. It can kill people in third-world countries because they can have so much diarrhea, they will have this enteric death, meaning they will dehydrate to death, essentially. So this is squarely a pathogen, no debate on where we classify this organism. But with some of these organisms, there is a debate on how much of it do you have to see in the stool to consider it an infection? Because there is this background noise of sometimes these things are just passing through me from the environment and not necessarily colonizing the individual.

An example could be a radio signal. If your radio is so sensitive, it picks up everything, you’d never be able to hear the station that you wanted to hear. It’d be all this background noise, all these other stations, kind of, getting, you know, a confounding signal. So we do like to be able to set, kind of, this cut-off for this is, kind of, normal background noise, not gonna worry about it. This is where we trigger the threshold to infection. And so we have these classical definitions of, you know, someone who reports to a gastroenterology office with acute diarrhea, kind of, you know, the classical parasite symptoms, all of a sudden had food poisoning, throwing up, having diarrhea, and that’s where the traditional levels have been established. Some of the newer functional medicine labs, what they’ll do is they’ll flag a parasite as positive but they’ll also say, “Okay, it’s not positive for this window of range. It’s detected, but not positive.”

Now, you know, where this is simpler to read is if it’s an amoeba. You may say, “Okay, if it’s an amoeba, a highly pathogenic organism, and you’re having some symptoms,” this could be this, kind of, subclinical infection. And I think there’s probably some merit to that argument. But where the argument really breaks down is these other organisms like Blasto, or Emanna which is another amoeba that’s not pathogenic. And just because those are registering on the test, people will say, “Well, it’s time to go in there guns a-blazing with antimicrobials,” again, treating the numbers and not treating the patients.

And just a bit one quick juxtaposition, and we’re working on a video that really helped lay this out for people, we have way more data on how to treat people with therapies than we do how to treat the numbers on labs. Meaning if you look at probiotics, and how probiotics have been studied for people with gut problems, only one or two studies in the world have actually said, “Do a baseline test. From that test, we’re gonna give this probiotic.” Almost 99% of the tests that have administered probiotics have looked at symptoms and based upon those clustering of symptoms administered a probiotic. So if your doctor is gonna go to an evidence base and say, “How can I learn how to best use probiotics,” or what have you, the overwhelming majority of that data is people who have clusters of symptoms, and learning the individual, you know, who are you, what are you suffering with? Okay. There’s been 17 studies with that cluster of symptoms, someone just like you, we can use the probiotics.

People, I think, assume it’s the inverse. It’s all about the research treating the numbers. And that’s not the case. So I think we should start inverting our expectations. Because again, the overwhelming majority, adrenal support, another example, a wealth of studies showing adrenal herbs can help with vigor, vitality, energy. I believe only one study in existence that tests people, based upon the test results, then custom tailor based upon the lab findings. And so what that tells you is if your doctor is going to pull from the science to guide decision-making, it’s about you, your symptoms, and how you present and learning, kind of, the personality characteristics of your symptoms and not about just treating these numbers.

Katie: That’s so fascinating. And it makes a lot of sense. And it’s good that we’re now, like, being able to differentiate these. It seems like this is gonna be a lot more impactful for people long-term, the more we’re able to get more granular and see what’s actually causing these results. And also, we talked a little bit before we started recording about thyroid problems as well and the connection that often exists here. I was surprised to hear you say only 1% of people actually have thyroid issues, which I would have guessed is a lot higher just based on the number of people I hear from who either have or think they have thyroid issues. So let’s talk about why it maybe seems like thyroid issues are being overdiagnosed and, kind of, what we can then do about understanding that.

Dr. Ruscio: Yeah, and you made a really important point a moment ago, which was disease levels versus optimal. And I totally understand where this is coming from as someone who vigorously tries to optimize myself. And, you know, I’m not trying to put myself into this kind of dichotomous bucket of either you have a disease or you don’t. I think that it’s a spectrum, right? You can’t have a disease, but you can go all the way up through optimization. And so we wanna use lab values, perhaps in that same sort of context. But the thyroid is a very interesting example because people are being given these really specious or, kind of, appealing arguments in terms of, well, I know that your endocrinologist did not say that you have hypothyroidism but your labs aren’t optimal. Therefore, thyroid’s a problem. And that sounds really good.

But unfortunately, what’s being ignored is this large body of science finding that people don’t need, nor do they benefit from medication in these cases where they’re not meeting the traditional diagnostic criteria for hypothyroidism. And by the way, I am on the alternative side of the fence, right? If I have a bias, it lays in the direction of alternative medicine, not conventional, but we shouldn’t just vacuously follow, kind of, party lines, right? It should be about well, if the conventional camp has better evidence, then we’re gonna follow the camp’s recommendation and we’re gonna make it based upon the merit of the evidence for each claim, not my philosophical allegiance to one camp versus the other.

Now, what’s my evidence for this, right? There was recently a meta-analysis published, which a meta-analysis is a summary of the available trials, usually a summary of the available clinical trials. And this meta-analysis looked at over 1,100 patients and found that 34% of them could discontinue their thyroid medication, maintain normal thyroid values, and have no changes in symptoms. That’s 34%, that’s 1 in 3 people out there who are on medication who don’t need to be. Another smaller paper, I believe the researcher’s name was Volta, found that 60% of patients were able to come off of their thyroid medication and maintain normal values and have no symptoms. And he had, I think, a cohort in his sample that had ambiguous hypothyroid diagnoses, which is why it was 60%. Right?

The other meta-analysis looked at conventional medical practices that were more by the book, and even within that camp, it’s 34% of people. Now, this is not to say, just be careful that people should say, “Well, it sounds like me,” and stop taking their thyroid medicine. Make sure you get a second opinion. But the point I’m trying to illustrate is, you know, we now have some good evidence showing that there is a subset of people who are being told they’re hypothyroid who are not. And this subset is anywhere from 30% maybe to 60% of people. The best data shows 34% data, that’s a smaller trial, but maybe have a more, kind of, functional medicine cohort showed about 60%.

Why that matters is because if you…Well, firstly, some people will say, “Well, I went on medication, I felt better.” Placebo is a thing, right? And this is why it’s so important that scientists use placebo-controlled trials because if you look at giving someone a pill and then they report feeling better, you’re not actually measuring the efficacy of the treatment, you’re measuring, in part, the efficacy of placebo. So that’s why you do a placebo, you get a sugar pill, and the other group gets the actual medicine or the agent. And then let’s say one improves by 40% and the other improves by 20%, that delta of 20% is the actual effect. Right? And so when people say, “Well, I went and I saw a doctor, and they said I had Hashimoto’s, hypothyroid.” Okay, what do they do? “Well, they put me on Armour.” What else? “Fish oil, selenium, probiotics, vitamin D, and I went on a paleo diet.” Okay, and you’re claiming all the benefit is from the thyroid medication? Right? So this is why the scientific literature, albeit not always perfect and has limitations, can help us answer some of these questions. So, you know, there’s more there to unpack. But I guess let me pause for a moment just to make sure I’m not monologuing too long on this one point.

Katie: I think that’s a super important point, though. And the fact that there might be a lot of people listening who are on some type of thyroid medication and who now might be wondering if they actually need to be. If someone’s in that type of…Because also, I think often when someone gets that diagnosis, they’re told this is a lifelong thing and you need to be on medication for the rest of your life. So how could someone maybe in that situation know if they could be able to taper off?

Dr. Ruscio: Right. If you can find the lab work that made the initial diagnosis and review that, meaning before you went on the medication, that can be incredibly insightful. Now, if you don’t see the TSH elevated, most labs use a cut-off of 4.5 of TSH with a corresponding low free T4, and the range there is 0.8 to 1.8, and then it may vary from a few points, but that’s essentially what you’re looking at. So if you don’t see TSH above 4.5 paired with a T4 below 0.8, then it’s extremely likely…Well, firstly, that means you do not fit the diagnostic criteria for hypothyroid. And it’s extremely unlikely that you will benefit and need to be on thyroid medication. And your point is so important that the reason why we should be so scrupulous about this diagnosis is because it’s lifelong medication.

And that’s why I think this meta-analysis was so insightful is that it exposed that doctors aren’t questioning this. And this is something that…we even have a section of our paperwork now that asked specifically about, you know, what type of doctor diagnosed your hypothyroidism? And if someone’s in the integrative camp, as I am, so this is not a dig, but we’re gonna double-check the diagnosis because you’re using these other ranges that we’re just learning…you know, give all the doctors the benefit of the doubt, trying to help people, try and do the right thing. But I think this is a theory that now the more evidence is pouring in, the better evidence doesn’t support it. People can still cherry-pick, and they do for lower-quality evidence. But, you know, as I’m sure you can appreciate having a footnote next to a point doesn’t mean it’s a good footnote. Right? So, yeah, I love you’re shaking head in agreement.

So, the better evidence now is showing that these patients who don’t fit that diagnostic criteria do not benefit from medication. And there’s even more data here, which is…So we have TSH and T4. For some people, their T4 is normal, but their TSH is legit elevated, 5, 6, 7, 8. Remember the TSH shouldn’t be above 4.5. So these people who have just flagged TSH with normal T4, there’s been a lot of study on, well, do these patients known as subclinical hypothyroid, do they benefit from thyroid medication? And no, not even they benefit from the thyroid hormone medication. So the functional community will say, “Well, your 3.3 on you’re TSH, right, and you’re 1 on your T4. That’s not optimal. So let’s put you on thyroid hormone.” But can you appreciate the person at 3.3 and 1 is being told they need medicine, but the person who’s at 7 and 1, that that group has been studied and shown no benefit? Can you see how egregious the claim is that even if you have more normative thyroid, some providers are telling people you should go on medication?

Katie: That makes so much sense. And I’m glad we got to dive into that as someone who has in the past been on thyroid medication and was told I was gonna be on it for life and now am not, and my labs are within actually optimal ranges. I think this is…I’m so glad we’re getting more evidence on this because it seems like a really important conversation, especially when you’re talking about something people are conceivably taking for the rest of their lives.

Dr. Ruscio: We are working right now on…because we’re aggregating these cases from the clinic, and documenting them, and we’re currently putting together a case series. A case series is when a doctor or a clinic or center will take maybe seven cases that all fit the same profile and just publish it a medical journal so other doctors can go, “Oh, my goodness, seven cases that came in with, you know, functionally low thyroid with all these symptoms, they were able to stop that medicine, be okay, and gut-based care was actually what resolved their symptoms.” And so we’re going through publishing that case study. I’ll be very happy when we have it out there just because, you know, I’ll have or we’ll have a piece of evidence that’s gone through peer review and is now in a medical journal that we can really point people to maybe if they are circumspect about our argument, and I would understand that, but I would just, you know, again, remind clinicians that I think we’re all on the same team.

Some of this is really exciting because there’s nothing worse than being a doctor and having a patient who you say you can’t help. So when a new hypothesis emerges, a lot of times we’re all in on it. This is one that ample data has come through now, disproven the hypothesis, and we need to pivot to other solutions.

Katie: Such an important point. And I know you have a lot of information available. I’ll make sure we link to your site so people can find and connect with you because I think it’s hard to find a clinician who actually understands this, especially right now.

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You’ve also mentioned the term SIBO a couple of times, and I’m guessing a lot of people listening understand what that is. But for people who don’t, can you, kind of, broadly explain what SIBO is? And you mentioned that there are effective tests for identifying SIBO. So let’s talk about SIBO a little bit.

Dr. Ruscio: Yes, thank you for clarifying the acronym. SIBO is small intestinal bacterial overgrowth. And this is where essentially, there’s too much bacteria in your small intestine. And this is really important because as much attention as some of the stool tests get, they don’t really tell you what’s going on in the small intestine. The small intestine is where leaky gut really occurs. It’s the most sensitive and the most prone to formation of leaky gut. It’s where the vast majority of caloric and nutritional absorption occurs. And because all that absorption occurs, it’s the most amino active, meaning it’s most prone to have inflammation. So the small intestine has been a little bit neglected because it’s in between the mouth of the stomach on the one end and the rectum, large intestine on the other side. It’s hard to get to so it’s hard to study, therefore, you know, only more recently, I think has adequate attention being given to the small intestine.

Now, there’s various tests that can be done. There are really only two validated measures are where, through endoscopy, sampling is taken, which is not something that can be done routinely. You have to have adequate alarm signs or suspicion to warrant doing an endoscopy. It’s not something that can be done more in an exploratory fashion, outside of, you know, exceptional cases, obviously. But what’s nice about the SIBO breath test is you can do this in an office or even at home test kit. And you essentially breathe into a tube every 20 minutes for about 3 hours. And the gas levels, how they change throughout the test, can be diagnostic of SIBO. And this has been recognized by two major bodies in gastroenterology, the Rome Society. People may have heard the Rome criteria for diagnosing IBS. It comes from the Italian group, hence the Rome Society guidelines. And then the North American Consensus, which is a group of experts in SIBO and gastroenterology in North America, of course, have both endorsed this test and have guidelines for test interpretation and for treatment. Yeah, so that’s how you test this. And some of the hallmark symptoms are either constipation, diarrhea, or an oscillation of the two, abdominal pain, bloating, and distention.

Katie: You’ve mentioned also parasites. And I’m curious to learn a little bit more about this, especially because it seems like there’s been a big movement toward parasites being bad and I see all these parasite cleanses being advertised, some of which seem pretty harsh. And purely anecdotally, I don’t have any research history with this but my thought had always been that as humans, we’ve lived outside and interacted with our environment throughout history. And so, when I hear people saying like, “Don’t go outside barefoot, don’t, you know, interact with the soil, you might get parasites,” that just seems so counterintuitive to me. And I wonder if even there is a natural occurrence of certain organisms like this that are supposed to or can be helpful in the gut and we’ve, kind of, thrown the baby out with the bathwater when it comes to parasites.

Dr. Ruscio: Great question. And you’re totally dead on that we have to be careful with how, kind of, loosey-goosey we are with using the term parasites. And the box of organisms that we’ve organized as parasites, that box is to some extent shrinking. H. pylori, which is a stomach bacteria, in some cases may actually be considered part of the normal commensal bacteria. And certain medical centers are actually putting worms into people and showing this anti-inflammatory effect. It’s known as helminth or helminthic therapy because worms, to survive, may exert this immunosuppressive impact locally. And so we may have evolved…One of the analogies that’s used in this great book called “Epidemic of Absence” by Moises Manoff is our immune system wants to attack, but the immune system needs a counterpressure to prevent it from falling into being overly zealous, over-inflammatory, and autoimmune. And part of that might be some of these organisms like worms that actually push back with this anti-inflammatory immunosuppressive effect so that they can, kind of, live symbiotically with us.

Now, we understand this. We understand that we don’t want to have no bacteria in the gut, that would be bad. Right? So this is, kind of, just going a little farther in the other direction of organisms being good. So to your point, yeah, very important one, and the line that distinguishes between parasitic and commensal is being a little bit blurred. And this is why I really recommend that people work with a responsible clinician, not all clinicians are. Some clinicians are still, I think, caught up in a bit more of an antiquated model, which is, you know, anytime something’s positive on a stool test, guns a-blazing with a whole concoction of herbs, or antibiotics, or what have you, and that needs some serious re-examination.

The way that we are at the center and also in “Healthy Gut, Healthy You,” I try to discuss gut health care is really like tending a garden. And that may sound a little bit hippie-dippie, but it’s actually the most scientific because we know that there are multiple inputs that influence the community. And it’s a community of bacteria, hence a person and not just a lab number, right? So, there are many things that we can do to foster a healthy community. And it may not be about the one or two organisms or the smaller array of the over a thousand. The small array, you can test on the stool test compared to the over a thousand that are in an individual and how that community gets along with the immune system, that’s much more of a treating the person and personalizing the available therapies to them endeavor as it is to, well, here’s one or two bad things and antimicrobials, antimicrobials, antimicrobials.

Yeah, so you are right, we’re rethinking and modifying what’s considered parasitic and what’s considered commensal. And it’s all the more reason why we should be careful with how quickly we, kind of, jump to antimicrobials or antibiotics. Because if you knock out an organism but the ecosystem is still incredibly unhealthy, you’re still gonna have problems. And one of the examples I use in “Healthy Gut, Healthy You” is if you have a community that’s laden with crime and you clean out one of the stores, you know, you get the criminals, and maybe there’s, you know, a crack workshop or something in, you know, one of the old warehouses…if you clean that out but the entire community is still laden with crime, another unsavory thing is gonna occupy that empty warehouse, right? But if you can improve the community and make the community healthier, then you’ll have people in businesses and schools, and the whole community will be healthier. That’s, kind of, how we have to start looking at the gut. It’s not just this micromanagement, but it’s rather treating the individual in a more holistic but scientifically-informed way.

Katie: Yeah, it seems like in the health world, we get, kind of, the shiny object syndrome sometimes when new research emerges, and then we hyper-focus on one thing. I saw this in, kind of, the gene area when I deep dived into that research of as we learned about different genes and what they did, people would, for instance, hyper-focus on MTHFR, and try to supplement for MTHFR, and then throw out of balance all these other things that were getting too much of something. So I think that holistic approach with personalization really is key. But that makes me wonder, we’ve talked about a lot of the problems, are there any generally helpful things…I know there’s a ton of personalization here, but are there generally supportive things we can do for gut health?

Dr. Ruscio: Yes. I mean, absolutely, there’s a whole array of supportive measures. And just to speak a little bit to some thinking underlying this, and I’ll get to your question, what we do at the clinic is we essentially have taken the therapeutics that work for the highest number of individuals and are the safest and listed them at the top and then going down where the therapies that are maybe more invasive or work for less people. And we, kind of, have this list and then upon the intake process, people’s history, their family history, their symptoms, and their prior response to therapeutics, cross some off, move some up the list, and really personalizes that hierarchy to them. So we can say, “Okay, you know, this person is exhibiting multiple signs that they may do well with hydrochloric acid. This other person is exhibiting no signs.”

So now we can, kind of, morph this list. And then once we have the list conified in a stepwise process, we’ve worked through it, again, starting with the things that are the most foundational, treat the most root cause issues, give the body some time, see what symptoms are still standing, and then we, kind of, personalize a little bit further as we go down the, kind of, order of operation, so to speak. And some of the therapeutics that are in that model would be a basic elimination diet, like a paleo framework, and that’s a great place to start. Whether it’s higher carb or lower carb, I think that’s more individual-specific than it is, you know, one’s better for whatever reason.

The other thing dietarly that I think will lose a lot of people is the FODMAP or the fiber and prebiotic content. And you’ll see some people come in who are doing everything right and they’re on, kind of, a traditional moderate, lower-carb paleo diet. But they still have all these symptoms, and that’s because they have some residual imbalances in the gut, and the high amount of fiber and probiotics, albeit mechanistically healthy, are actually feeding overgrowth and result in leaky gut, inflammation, and then this cascade of symptoms. And you just make that one change, low FODMAP. And we have…that we use a vegetarian low FODMAP if that’s someone’s dietary preference, a paleo low FODMAP, and a standard low FODMAP. So you can personalize it to the person’s paradigm. And you’ll see great resolution in some cases. And in fact, the most recent meta-analysis, I believe, found a 63% response rate to the low FODMAP diet. So that’s a great place to start. And then we’ll wait and see.

And then probiotics are, kind of, the second thing that we’ll use. And the approach we use from a perspective of probiotics is a bit novel, and we’re currently collecting data on this and hoping to publish on this in the near future. But we use what’s known as probiotic triple therapy, meaning essentially we’re using three different probiotic formulas at the same time. Now, triple therapy antibiotics has been used for certain infections. What we’re doing is inverting that and saying, “Well, if we know that one probiotic works really good for this and another one works really good for those other things, why not combine them to have the highest dose and most multi-spectrum probiotic therapy possible? And so that’s the next thing that we’ll use is probiotic triple therapy. So probiotics can be very, very helpful.

And elemental diets, which are essentially these hypoallergenic meal replacements, work very well essentially to give the gut a rest. And the analogy I like to use is if you had sprained your ankle, you wouldn’t necessarily get super worked up about ankle pain. You’d know, okay, like three weeks off of it and I should be able to resume function, but you need that time off, that rest, in order to heal. This is very similar to what elemental diets achieve. By giving you this pre-digested, looks very much like a protein shake, to supplement some of your meals, that gives the ankle some rest, so to speak, on a daily basis and can allow the gut to heal just through reduced usage. And there’s been a myriad of trials mainly in inflammatory bowel disease showing that elemental diets can improve nutritional status in some cases due to reducing inflammation and improving absorbance, and also reducing the autoimmunity and inflammation that occurs in inflammatory bowel disease. And there’s been one study in SIBO using the elemental diets.

And then there’s also antimicrobials or antibiotics that are, kind of, the killing agents. But I mentioned those lastly because those should really be used at this time point because if you work these other steps, people will oftentimes see a resolution of their symptoms. But if you don’t, you’ve really positioned the person to respond adequately to the antimicrobial intervention. And there was a trial recently that found using I believe it was rifaximin, kind of, the most used…most preferential antibiotic for SIBO, when you added probiotic therapy coadministration to the rifaximin, you saw a 30% jump in the cure rate of the small intestinal bacterial overgrowth.

So, the sequencing can be really important. And that’s why I think some people only see a short-term or partial responsiveness to their SIBO is because they’re jumping right to an end-phase recommendation, treating a number and they’re not treating the person and saying, “Well, your diet is chronically inflaming in your gut. How far are we going to get with an antibiotic if you’re still in this space, and you’re not even using probiotics, and there’s over 20 clinical trials showing that probiotics can clean out SIBO? Well, let’s go there next. And then if there’s still residual symptoms, after all that groundwork, this is when we’re the most well-positioned to use something like herbal antimicrobials or antibiotic therapy.”

Katie: That makes sense. And as we get close to the end of our time, I wanna make sure I leave people with practical resources. So, for people who may be resonating with different points of things that we’ve talked about, whether it’s thyroid, whether it’s a gut issue, or now a symptom that they may not previously have thought was related to their gut, where are some good jumping-in points to continue their research? I know you have a lot of work on this.

Dr. Ruscio: Sure. Yeah, thank you. There’s a number of resources that we have out there for people. The main hub is the website, drruscio.com, drruscio.com. And you can click through to go to the clinic there or the podcast. I also have a book, “Healthy Gut, Healthy You,” which gives people, kind of, a do-it-yourself iteration of what we do in the clinic. And yeah, I mean, there’s more than that. But I think those are the few, kind of, jumping-off points that are the most salient.

And if people need help, please feel free to reach out. We’re really passionate, especially at the clinic, about helping people double-check some of these diagnoses or giving them competent care. I don’t say that lightly. You know, we’ll see the patients who break down crying after a year of being, kind of, mishandled. And, again, I wanna try to be careful not to criticize the field too much because I think we’re all on the same team and we’re trying to do the work to help people, but I wish we were seeing less of these cases that were mishandled.

And, you know, so that’s why I’m really passionate about having these resources for people because I, myself, had gut issues that really got me down. And I was able to get the right care in six months. I can only imagine if it took me six years. And that can be all the difference. You know, you can label yourself a chronic case but that could just be chronically incorrect treatment protocols. And when you finally get to the right care, you go from a chronic case to like everyone else in two months. So I just wanna maybe give people that little bit of empowerment that don’t be too quick to label yourself as a chronic or complex case. And yeah, there’s a lot of resources there and we’re more than happy to help anyone however we can.

Katie: Wonderful. I’ll make sure those are linked for all of you listening while you are exercising or driving. Everything we talked about will be at wellnessmama.fm under the show notes. And lastly, I’m curious to know if there’s a book or a number of books that have had a profound impact on your life, and if so what they are and why?

Dr. Ruscio: Yeah, I mean, there’s been a number of books. I haven’t been reading as much in, kind of, the health space lately because it’s what I’m ensconced in all day. But a recent read that I did like was by Scott Carney, and it’s called “What Doesn’t Kill Us.” It was Scott Carney’s, as an investigative journalist, attempt to discredit Wim Hof. He went out there to investigate him and actually really became infatuated with Wim Hof and all he was doing. And I like that book because I think it really gives people more empowerment. And I think it provides a nice counterbalance to we read about all this stuff with our health and all these things that could be wrong with us as an attempt to learn how to be stronger and healthier. And that can, I think, sometimes skew your perspective to think more in a sickness model rather than being reminded, you know, as to how healthy we are.

And another one that that was really good is “Breath” by James Nestor. And it’s about the importance of healthy breathing and healthy respiration, especially nasal breathing. And for some people who have chronic symptoms and they can’t figure out why, it can be a breathing problem, especially at night, that once you correctly identify that, it can really be a game-changer for some people.

Katie: Perfect. I will link those in the show notes as well for all you guys listening if you wanna read them. I’m gonna buy the first one. I haven’t read that one yet. But second, your recommendation on “Breath,” I think it’s really a fascinating read. And I’m so grateful for you spending your time and sharing your knowledge and your wisdom with us today. Thanks for being here.

Dr. Ruscio: Yeah, thank you so much. This was a real pleasure.

Katie: And thanks as always to all of you for listening and sharing your most valuable resources, your time, your energy, and your attention with us today. We’re both so grateful that you did and I hope that you will join me again on the next episode of the “Wellness Mama” podcast.

If you’re enjoying these interviews, would you please take two minutes to leave a rating or review on iTunes for me? Doing this helps more people to find the podcast, which means even more moms and families could benefit from the information. I really appreciate your time, and thanks as always for listening.


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