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Dr. Michael Ruscio, DC - 14th August 2019 (LDN, low dose naltrexone) from LDN Research Trust on Vimeo.
Linda Elsegood: Today, I'd like to welcome back my guest, Dr Michael Ruscio. Thank you for joining us today, Michael.
Dr Michael Ruscio: Thanks for having me.
Linda Elsegood: Now you're a speaker at the LDN 2019 conference in June in Portland, Oregon. This is a prerecorded radio show, so we've actually had the conference. Could you tell us about the presentation you're going to be giving at the conference?
Dr Michael Ruscio: Sure I'd love to. There is a growing problem in progressive thyroid care that I'm seeing at an alarmingly increasing rate. And I think it would really benefit providers of all stripes to better understand this: essentially there are maybe two or three big misses that are occurring in thyroid care. One is over-diagnosis of hypothyroidism, or you could turn this another way - when someone isn't truly hypothyroid, but they're being offered thyroid medication as support. What often happens is the patient doesn't realize that this is being used as a temporary support. The provider doesn't make that clear delineation that they're not truly hypothyroid. Some of your levels look a little bit low, so we're going to give you this medication to try to improve your symptoms. They don't make that delineation. The patients stopped seeing that provider, but they kept taking the medication. And now, there are a fair number of patients who've been on medication for years that they don't really need to be on. And so without getting too far into details of that, that's one key component, and we can fill in some of the rationale and the facts there in a moment. But over-diagnosis of hypothyroidism in cases that are not truly hypothyroidism is becoming fairly endemic in functional medicine.
Linda Elsegood: And where is the source of the problem coming from, because of course, clinicians are trying to help these patients?
Dr Michael Ruscio: I don't think anyone is over-diagnosing hypothyroidism with malicious intent. I think we're all saying, well, here's the patient presenting with fatigue, depression, brain fog, constipation, dry hair, skin, nails, whatever it is. What can we do to help this patient?
And I think what we can do to help these patients in part is better to understand the importance of gut health. There is documentation to show that various maladies in the gut can contribute to thyroid function. Autoimmunity can contribute to non-responsiveness and malabsorption of thyroid medication. And by addressing these things, we can finally see these patients respond who had otherwise been unresponsive. And sometimes it involves using no medication, or even a reduction of the thyroid medication. So that's kind of the 30,000-foot view. And I’m happy to go into more detail on any of those points.
Linda Elsegood: It's really interesting. I've met over the last few years, many people with thyroid conditions, and they don't generally tend to reduce their medication until they're on LDN and find that it's more effective than it was before. But that was interesting you saying, and I took it to be less, was more in some cases that you don't need such a high level over time. How, how does that correlate to the gut. I know that a lot of people with thyroid conditions say that they improve greatly if they don't take gluten. What else should they be doing? Say, if you've got a patient who's got thyroid conditions, what do they need to do to try and get that gut health in the right place?
Dr Michael Ruscio: You make a great point, which is therapy like LDN, through its ability to positively modulate the immune system, can positively modulate the gut. And that could help with malabsorption that could be occurring because of a problem in the gut. So that's one area that is sometimes overlooked, where someone may have various digestive symptoms, and the clinician may not fully connect that. Those digestive symptoms indicate that the person is not adequately absorbing their thyroid medication. And this may account for some of the instability seen when tracking someone's thyroid levels. And there are some papers that are documenting this now, most namely in either H pylori infection or those who have ulcers, showing that the treatment of H pylori specifically can actually lead to a reduction of thyroid medication.
And of course, as you noted, there are papers published on those who have celiac disease, who when they follow a gluten-free diet, can reduce their thyroid medication. Most clinicians are probably having their patients experiment with a gluten-free diet, so that is a great recommendation. It's probably not offering the clinician anything new that they haven't heard before, but looking into something like small intestinal bacterial overgrowth or H pylori, that may offer benefit. And again, sometimes we attribute this to healing the thyroid. This hasn’t been fully borne out by the research yet, but my thinking is when you see a change in the need for thyroid medication where someone actually needs less medication that occurs over the course of a few months, that is almost for certain not going to be due to healing the thyroid gland, but more so due to improved absorption of the thyroid medication. We see this in some of the H pylori studies where patients were able to decrease their dose of medication. And we've published on our website a handful of case studies where we've been able to reduce, in some cases as much as half someone's thyroid medication dose.
At the same time, the patient is losing weight in a positive direction, meaning they were a bit overweight, and now they're at a healthier weight. They have better energy, better skin, less joint pain.
And there's another parallel here that reinforces the same finding, which is using the liquid gel tab form of thyroid hormone known as Thyroxine. And also some research has been performed showing that in patients who have been unable to obtain stability in TSH and T4 and/or the resolution of symptoms use Thyroxine and actually are able to get many patients to a more stable TSH and T4 and improve their symptoms. And this is almost again for certain because Thyroxine being in a liquid gel tab is much more easily absorbed than some of your more traditional tablet forms. That's just a couple of ways in which the gut can directly impact the absorption of thyroid medication, which again, I don't think is being given the amount of attention that it deserves. And I can say in clinical practice. That can be the difference between success and failure in some of these cases.
And I'll just juxtapose that with - sometimes the clinician is really floundering with a patient on Levothyroxine and maybe they need to add in some T3 Cytomel, or maybe they need to switch them into a desiccated form something like Armour Thyroid or even WP Thyroid or Nature-Thyroid, or anyone of these medications that's a T4-T3 combination.
And that's not really what the cause of the problem is. The cause of the problem is inconsistent absorption, and that is oftentimes addressed by improving the diet. As you noted, with something like gluten-free or if someone's already gluten-free, then considering some type of dysbiotic or infectious issue in the gut can then be what improves the gut health and allows the patient to more consistently absorb the medication, and then their blood levels look better and then their symptoms also look better.
Linda Elsegood: So how do people know what their gut health is? Like? How, what are the symptoms?
Dr Michael Ruscio: That can be one of the biggest challenges because we're starting to learn that you can have - and actually, some of the older celiac research has shown this for a while - that you can have an active inflammatory issue in the gut that only manifests extra-intestinally. Meaning you have no digestive symptoms, but you may have something like atopic dermatitis or depression or fatigue or joint pain.
So one of the challenging things can be figuring out whether the gut is the root cause of this problem. Because you may have no gut symptoms, testing is oftentimes offered as a solution here, which it can be; but the testing is really imperfect, in my opinion. There are a number of things that we can test for, but there's also a number of things where the testing still hasn't been fully mapped out yet. And just as one example, we know that small intestinal fungal overgrowth does exist. Dr Satish Rao has published some research on this. But because doing a sample directly from the small intestine is impractical, then that's not something that we can really readily assess in clinical practice. So if someone could do a breath test for SIBO and a stool test for other types of bacterial and fungal dysbiosis, that's a great start. But we still might be missing something like small intestinal fungal overgrowth.
So, in answer to your question, what can be used to help assess the health of someone's gut? Testing gives us a slice of information that can be helpful, but it doesn't give us all the information and the way I look at this is to consider taking steps to optimize your gut health kind of proactively. Even if you don't have a diagnosis of H pylori or small intestinal bacterial overgrowth, consider taking those steps to proactively improve your gut health.
If you've improved your diet, if you have a healthy lifestyle, but you're still not following optimally, well, so you're still not feeling optimal. Well, then. I think it's a good idea at that point to just, again, proactively and almost more so - empirically take steps to improve your gut health, because it can be challenging to get that definitive diagnosis on a lab test of various sorts.
Linda Elsegood: I've had people with thyroid conditions ask me questions about gut health, and they say, how do I know if I've got leaky gut? I've read that there are people that have leaky gut, and I seem to have the same kind of problems. What tests do you do for leaky gut? You mentioned that.
Dr Michael Ruscio: Great question. And this is another area where the testing is really imperfect. We just performed a comprehensive review of the literature, literally looking at every test in humans on the markers, serum zonulin, which may be one of the better markers for assessing leaky gut. No marker really is perfect. Zonulin, that may be the best test now. Zonulin is a marker essentially of tight junction proteins in the gut and can be assessed via blood or stool, and it does correlate with various diseases like diabetes, metabolic syndrome; and in some cases, inflammatory bowel disease and IBS.
So it does seem to correlate with diseases or symptoms, but not in every case. But where the argument falls apart a little bit more, unfortunately, is when we look at what happens when we treat people, we put people on a healthy diet or on a probiotic or what have you, and this is where there are much more inconsistent findings with zonulin.
There had been a few studies showing that in people with symptoms and with high zonulin, meaning leaky gut, they then improve their diet and see a drastic improvement in their symptoms. Yet their zonulin gets either worse or stays the same. Now to be fair, there are also studies showing that zonulin can improve after using something like a probiotic, but there are also studies showing that people will see no improvement in zonulin after taking a probiotic, even though their symptoms have improved. I know this may be a little bit unpopular for me to say, uh, that zonulin may not be quite fully ready for the routine clinical application, as there are some inconsistencies with testing for leaky gut.
So this is why I say testing gives us a slice and it can be helpful, but we really cannot fully hang our hat on test results alone. Because when you look at the data behind these tests, in many cases, what you see is the tests do not perform perfectly. They're only partially informative, and so the best test, arguably, for leaky gut would be zonulin, but it certainly is not something that I think is highly reliable. So it's one slice. But we also want to take the patient's symptoms into account. And so maybe to just paint a scenario here, if someone came in with rheumatoid arthritis and they wanted to know if their gut was contributing to that rheumatoid arthritis, or even their thyroid condition, what we could do is perform some testing, and that would be maybe one-third of the data that informs how we're going to proceed. And if we find something on testing like small intestinal bacterial overgrowth or H pylori, we can treat those. However, if the testing comes up negative, one still may want you to consider a round of treatment. And this is where using things as herbal medicines and probiotics make a much more of a tenable approach, because these things I don't think, require the same rationale as using something like an antibiotic or what have you. But treat the patient for a presumed imbalance in the gut and then monitor their symptoms. If their symptoms are improving or if the dose required for the third medication becomes more stable, or even they start to appear hyperthyroid like they need less medication, then that tells you that you're on the right track.
And again, I know it's easier if I were just to proclaim one or two tests to be the best and one or two markers, and that's the easy message I think we all want. But unfortunately, when you take that easy message into clinical practice, you get really confused. And if you take my message, which is a little bit more nuanced, albeit being a little bit more complicated, I think you'll see, it really interfaces into the clinical practice more consistently and delivers better results.
Linda Elsegood: Well, I mean, unfortunately, your stomach and your bowels, you can't see, can you? It's not like psoriasis on your hands or something that you can see what's going on there. When I have spoken to doctors and asked what they think are the top four supplements that people should be taking, probiotics are always number one that people should take. What kind of a probiotic would you suggest to patients who wanted to take that to improve their gut health?
Dr Michael Ruscio: That's a great question, and I would certainly agree that especially for someone who's trying to improve their gut health, then a probiotic is a fairly inexpensive intervention and very safe, or even now showing some secondary health benefits. For example, one analysis has documented improvement of mood. Other research has shown a small but significant ability to improve cholesterol, blood sugar, and even blood pressure. Again, the effects there are small, and I would say not clinically significant, but at least you're getting a small movement in a healthy direction.
So I'm just trying to showcase here the neutrality, or at least small side benefit, of probiotics rather than there being some downside. We know that probiotics can improve things like H pylori and, and be synergistic with H pylori antibiotics. And in my opinion, may help to kind of re-establish a healthier balance of H pylori colonization. And they can help to eradicate things like SIBO, and intestinal fungal overgrowth. So certainly the end reduces leaky gut and there's a lot of benefits that we can attribute to probiotics.
It's your question that’s a more challenging thing: what probiotic do I use? And this is where I think both the clinician and the consumer are confronted with just a dizzying array of options in terms of the probiotic formulas out there. One of the things I write about in my book is organizing probiotics into three different categories. And this greatly simplifies the landscape in probiotics. And when, when you read enough of the research on probiotics, and you sift through enough of these meta-analyses that summarize the high-quality clinical trials, you start to see that we can break probiotics down really into technically four categories. But one category is hard to obtain, especially in the US, so I typically focus the conversation on the three categories.
Category one is a blend of lactobacillus and bifidobacterium strains. The exact formulas differ slightly from product to product, but then, the underlying and unifying theme is you will see the strains in the formula are predominated by various strains of lactobacillus and bifidobacterium. Your category two is just one strength, typically, which is the healthy fungus, Saccharomyces boulardii. And then your category three - you have typically anywhere from one to maybe five or six strains that are often known as soil-based or spore-forming probiotics. What I like to do with patients is have them use a moderate dose of all three of these; or in more sensitive cases, they will likely have reported some reactions to probiotics in the past.
And what you want to identify as a clinician is what category do they seem to be reacting to? Because oftentimes people are taking a category one probiotic that's the most popular and common probiotic out there. They may have tried two or three or even four different probiotics, not realizing that each one was a category one, a category one, a category one, a category one. And so they come in and say they just can't do probiotics, they react really negatively. And that's where taking a quick history and seeing if they know the names of the probiotics, quickly looking them up and determining, okay, all of these were in fact category ones. So then you can have them start with category two and category three. There are some patients by just going through that exercise of having them try a probiotic category one at a time, you can pinpoint that that is a category that you react negatively to. Now we can use the other category or categories that you do tolerate, and then you can obtain that fairly impressive benefit that can be vectored by probiotics and help the patient navigate around that reaction that had been kind of slowing their progress previously.
Linda Elsegood: Well, the first time I wanted to buy some, I went into a whole food shop, and they had rows and rows of probiotics, and some started at 10 pounds, and some went up to 50 pounds. And I was trying to read on the bottle what was in the 10-pound one, what was in the 50, and what everything in between was. And I was just so bewildered by the end of it I asked for some help, and the young man didn't know either, really. So I just went for a middle-priced one to try it to see what it was like. But you have to do your research. It's not easy to find out. It's a minefield because there are so many things on the market and some that are similar like you're saying category one, but they're still not the same price. You know, the convenience. Sometimes if it's a really well-known brand, I think you may pay more for the name as well.
Dr Michael Ruscio: So thank you so much for making that comment, and you're absolutely right, which is the quality of a probiotic does matter. We want to be careful not to think that more expensive automatically equates to better. And we also want to be careful that if something is drastically cheaper than others, then there may be some corner-cutting that is occurring.
So there are things that you can look for. These can be, I think, challenging for consumers, and also probably challenging for clinicians if you're not used to fact-checking these types of things. But you can look whether a company is following good manufacturing practices and is also having third party testing to ensure that their probiotic meets its label claims. And then also looking for companies that aren't using fillers. That can be irritating, especially when we're talking about people who have sensitive guts. Some probiotics, this more so happens with cheaper probiotics, they're not very potent, and they're kind of watered down with other fillers or things like prebiotics, which are significantly less expensive.
Another way around this is just finding a couple of companies that are fairly reputable and just try to use the probiotics that fall into the category system. Find those reputable companies - that's quite a bit easier than just going into a health food store and trying to figure out their 15 different probiotics. Which ones can I trust? Which ones can I not?
Linda Elsegood: And of course, it's the same in America as it is over here. I mean, supplements aren't regulated, so you can have labels that make claims of what's inside it, but they don't have to put a percentage, so if it's not like pharmaceutical grade, where they can prove, as you were saying, what is actually in there is on the label. It is reassuring to know that you have done the best you can to try and find out what is in the probiotic or supplements of any kind, because the layperson just wouldn't know - so trying to get a good manufacturer, that's what I'm trying to say, is really the starting point, in my opinion, as a consumer. Someone that you can trust, because you can spend a fortune on the cheaper brands that, as you said before, might have fillers and all of this kind of thing. And actually not have that many ingredients that are actually going to help you. But you know, if something is a quarter of the price, it's a waste of money if it's not going to work, isn't it? So sometimes you have to pay that bit more to make sure that you've got a product that is going to do what it says it's going to do.
Dr Michael Ruscio: The way that I learned was with protein powders, where I was using the most expensive protein powder and I noticed it. You make your shake, and sometimes you put it in one scoop, maybe sometimes you're a little more hungry, you want a thicker shake, so you put it in maybe two or three scoops. And if I ever had more than one scoop, I would get bloated. And I later learned from one of my friends who owns his own manufacturing company, that you have to really watch out for companies putting in excipients, which are powders that help the machines run more quickly. And he explained to me that because the machines run more slowly when making his protein powder, he had to pay extra to have them not put the excipients in. So it is a legitimate thing, and especially if you have a sensitive gut, just making sure that who you're getting your product from cares about these things. And it may not be that a manufacturer is trying to do you harm, but they may be saying, well, we're trying to cater to a market that is very price sensitive. So we're gonna use excipients to cut down our costs.
We're trying to provide these items that are most gut-friendly and maybe a little bit more expensive. But I think the customers that we're trying to appeal to understand that. A slight increase in expense, the quality would be worth that. So, yeah, it is important to find a company who is going to be attentive to these things and, and make those tough decisions of making the product more expensive when it's really in the best interest of the consumer.
Linda Elsegood: Let me ask you, what's your diet like, Michael?
Dr Michael Ruscio: I loosely eat a paleo diet. I do eat quite a bit of dairy, and thankfully I have no problem with dairy; most meat, vegetables, fish; and I don't eat much in the way of grains. I do have some rice. I do generally avoid gluten. I do notice if I eat too much gluten, I do have a problem. Even though the healthcare consumer is told that everyone should avoid gluten, I think it is incorrect. And that's not borne out by what the best research on this topic has found. But essentially - lots of vegetables, meats, healthy fats, fish, moderate to kind of lower-carb diet. So some gluten-free grains, but not a high amount. Some kind of a moderate lower carb, paleo diet with some dairy would maybe be the best label that we could put on it.
Linda Elsegood: Some people say that they find diets for eliminating food really restrictive. And they will ask if once they’ve started down that road of eliminating these foods, will they ever be allowed to eat them again? So you were saying that sometimes you still have gluten and you know when you've had it, so obviously you don't exclude it completely.
Dr Michael Ruscio: Right, and you make a great point, which is we want to be careful with diets. Not to think that an elimination diet means you eliminate forever. Most elimination diets follow the pattern of cutout foods that could be a problem for maybe a month, maybe two months. And then once you feel you've improved, then bring the foods that you can back in a kind of systematic manner, where you're bringing maybe one or two in at a time, so you can identify what foods sit well with you and if any foods are triggers.
And then it's not to say that because a food is a trigger you can never have any, but you want to be a bit more judicious with how you use it. That is really, in my opinion, a key distinction to draw because what I see happening with patients is they become so scared of food, and they may have little to no reactivity, let's say, to gluten. So they can get away with having some on some occasions. Now, if you're noticing some reactions to gluten, would I recommend making a dietary staple? Absolutely not. Right? There's also this ability to live in the world without being afraid.
And this is where I think some of the hard-line messaging on gluten is really damaging people from a psychological perspective, because now these people are at a restaurant with their friends and should be enjoying themselves, and they're worried. They're sitting there frantically worrying internally, trying to hide it behind a smile on their face, about is there gluten in the sauce here? And now again, there are some people who are exquisitely gluten sensitive, and they have to operate like that, but I don't think that they would wish that on somebody else who at worst may feel bloated in forty-five minutes if they have some gluten. So, your level of avoidance should be required with your level of intolerance. I know that the gluten-free staunch advocates will take issue with that, but you have to weigh that against the psychological damage we do to people who don't have much of a physiological reaction but are inculcated and feared into thinking that they will have massive damage if they have gluten. And now every day in their life, they have this baseline level of fear that is damaging their health. And so when you weigh these all out, I think it's clear to see that, yes, we want to identify gluten as being a problem in those that it is and help them avoid it as best they can. But people that have little to no reactivity, they have some leeway, and we don't want to fear them into thinking that they have to eat like they have celiac disease.
Linda Elsegood: Wonderful. Well, we've come to an end and where's the time gone? It's been amazing. Thank you so much.
Dr Michael Ruscio: Yeah. It's been a pleasure chatting. Time always flies when you're having fun, right?
Linda Elsegood: Well, we'll have to have you back again, so thank you very much for having been my guest today.
Dr Michael Ruscio: Thank you again. It's been a pleasure.
Linda Elsegood: Healthy Gut Healthy You by Dr Michael Ruscio is a long-anticipated and comprehensive guide to completely resetting and healing the gut. Arm yourself with the education tools to heal yourself from the inside out today. Visit drruscio.com for details.
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I look forward to hearing from you. Thank you for joining us today. We really appreciated your company. Until next time, stay safe and keep healthy.