Recently, I interviewed Dr. Eric Balcavage, and we talked the connection between thyroid function and bile physiology. We discuss the functions of bile, its importance for thyroid hormone regulation, risks associated with excessive bile acid supplementation, factors affecting T3 levels, the significance of bilirubin levels, the importance of addressing underlying health issues, and more. If you would prefer to listen to the interview you can access it by Clicking Here.
Dr. Eric Osansky:
I am super excited to have a return guest, as we are going to have a chat about bile physiology and of course tie this into thyroid health. We have Dr. Eric Balcavage, who is the owner and founder of Rejuvagen, which is a functional medicine clinic in Concordville, PA.
He is a nationally recognized speaker and educator on various health-related topics, including thyroid physiology, bile physiology, detoxification, oxidative stress, methylation, and chronic illness. Dr. Balcavage is a functional medicine practitioner and licensed chiropractor in PA.
He is also the host of the Thyroid Answers podcast. The podcast focuses on answering the pressing questions those suffering with chronic hypothyroid symptoms can’t get answered elsewhere. You can find his educational Thyroid Thursday videos on both Instagram and YouTube.
Dr. Balcavage has made it his mission to change the way medicine looks at hypothyroidism. He is the co-author of the book The Thyroid Debacle. The book is co-written by Dr. Kelly Halderman, and it addresses the problems with current allopathic and functional medicine approaches to hypothyroidism as well as the solution to restoring thyroid physiology. It is always a pleasure welcoming a fellow Dr. Eric. Thanks for joining us again on the podcast.
Dr. Eric Balcavage:
Thanks, Eric. Pleasure to be here.
Dr. Eric O:
Really excited to talk about bile. Just want to have you jump into it. Before we start recording, you said that years ago, you did a three-day conference just focusing on bile physiology.
Dr. Eric B:
Yeah, the co-author of my book, Dr. Kelly Halderman, that’s why she is the co-author of the book. I was in the process of writing the book. Kelly reached out to me and said, “I need your help on a bile presentation for a supplement company called PHP, Professional Healthcare Products.” “Kelly, I don’t have time to help you with that. I have this book to write.” “I really need your help.”
We had gotten together over a bile presentation I had done for Ben Lynch, when he used to have the Seeking Health conferences. I did a discussion about the significance of bile physiology as it relates to SIBO. Kelly was in that presentation and got more interested in bile physiology after hearing it. She got deep into the woods, which led to us working on that project.
I said, “Listen, I will help you with the bile presentation, but then you have to help me work on the book.” Sometimes, you just need somebody else to help keep you motivated to get something done. Kelly needed some of that, and I needed some of that with the book. It all worked out really well.
Dr. Eric O:
Awesome. I would never have thought you could spend so much time talking about bile physiology.
Dr. Eric B:
I don’t think most people would have thought that. Three days of bile physiology… It was intense, and we got really nitty gritty. This was for clinicians, not the general population.
Bile physiology is so important to our overall health and being. We wind up taking gallbladders out and think, “Hey, nothing changes. Everything is just fantastic. This organ doesn’t need to be there. Let’s just get rid of it.”
But I don’t think we really consider how important appropriate bile physiology is in the scheme of metabolism. We talk about thyroid hormone regulation and the significance of gut and GI function, which are critically important along with significant things like detoxification. Some of these things that create stress and inflammation out of the body appropriately.
Dr. Eric O:
Let’s talk more about the functions of bile, including the components, like bile acids and bile salts.
Dr. Eric B:
You have this organ called the liver. Liver makes this substance we call bile. It’s 95% water, which is really important because if you don’t drink a lot of water, dehydration could have an impact on your ability to make healthy, fluid bile.
The other pieces in there are cholesterol, which is a big piece of it; phospholipids; nutrients; toxins. What the liver is doing is making this substance that is almost like soap. That way, it can carry through these water-soluble substances into the stool, the urine, so we can excrete it. This soapy substance can also break down fats that are coming into the GI tract, so we can break it down and absorb those fats appropriately into the body, so we can use them.
From a soap perspective, the bile is cleaning. It has direct and indirect effects on the bacteria coming into the GI tract to help break them down and not allow them to overgrow or colonize, especially small intestines.
Bile has really significant impact on a lot of different processes in the body. It even plays a role in its ability to help regulate potentially the conversion of T4 to T3 in cells and tissues outside the GI tract because bile acids activate a receptor called TGR5 that increases that conversion. Too much bile acids in circulation could actually create more hyperthyroid signs and symptoms. It’s really important stuff.
We can break it down even more. You just tell me where you want to go.
Dr. Eric O:
I definitely want to talk more about bile and the thyroid. It’s also involved acts like an antimicrobial of sorts, but keeping bacteria in check, you would say, and other microbes in check.
Dr. Eric B:
When we eat food, we put the food into our mouth. It goes down into our stomach. Then the stomach produces acid. The role of the acid is to start breaking that food down into what we call chyme. It’s this predigested mix of stuff. As the chyme is moving into the small bowel, the duodenum, it starts to trigger the release of chemicals from the pancreas bicarbonate and digestive enzymes. It also can trigger the release of the substance that is coming from the liver and the gallbladder called bile.
The liver makes bile with the help of thyroid hormone. That bile is excreted into the bile duct and then goes into something called the gallbladder. In the gallbladder, that bile gets concentrated from maybe a diluted soap to a more concentrated soap.
When we get the signals from the stomach, “Hey, food is coming in here,” then the gallbladder squeezes some of those contents down into the tubes. The tubes from the gallbladder and the pancreas come together. It’s called the sphincter of Oddi. The pancreatic enzymes and bile acids enter into the upper part of the GI tract to start breaking down the foods into a more absorbable form.
But the bile acids and some of those digestive enzymes coming from the pancreas impact the bacteria that is coming from the food and our oral cavity, especially the bile. It’s a direct antimicrobial at the upper end of the GI tract. It can start breaking down the coating of the bacteria with these bile acids.
In the upper part of the GI tract, bile acid is a direct antimicrobial. As the bile acids and all that food move down in the GI tract, the bile acids start to get resorbed in the GI tract. At the lower end, those resorbed bile acids are an indirect antimicrobial.
As the bile acids are resorbed by the intestines, they’re actually initiating defense mechanisms at the lower end of the GI tract to make sure that bacteria doesn’t overgrow at the lower end of the small bowel as well. Plays a really important part on the bacterial levels in the bowel, especially in the small bowel/small intestine. That shouldn’t be the area that is as heavily compromised.
I think when we talk about SIBO (small intestinal bacterial overgrowth) or SIMO (small intestinal microbial overgrowth), one of the big things I think is missed in people who are treated for chronic SIBO is they have lost the innate immune system of that small bowel, which is largely influenced by the amount of bile and the quality of the bile that is moving into the GI tract. If they don’t have good bile flow, then you can take an antimicrobial and knock the bacterial load down.
Without the innate immune system that bile plays a big role in, there is a really good chance that the bacteria is going to start to grow back again because you’re constantly bringing in bacteria from your oral cavity. Bacteria and fungi off of your food are constantly coming off of the GI tract. If you lose the direct and the indirect drive from the innate immune system, you are probably going to have chronic infections or dysbiosis.
Dr. Eric O:
It’s way similar to hydrochloric acid. Obviously, a different location. HCl of course is also important for breaking down protein and minerals. It also has antimicrobial effects, just like bile acids.
Dr. Eric B:
They both have antimicrobial effects. They both do different things. The acid is really breaking down some of the heavy protein structure and getting that process started. The acidity of the chyme that is entering the duodenum plays a massive role in what is being released from the surrounding tissues.
With acids, enzymes, bicarbonate, how much of this stuff needs to enter. If we lose HCl production, then we will have reduced acidity of the chyme. That will influence enzymatic input, bicarbonate. It is going to potentially impact the amount of bile that is entering into the GI tract. It all does start from the top.
What else is important is you need appropriate levels of T3 in the stomach to make stomach acid. You need appropriate levels of T3 at the liver and gallbladder. You definitely need appropriate levels of T3 at the liver to make appropriate bile and help regulate bile. You need appropriate levels of T3 in the GI tract to allow the sphincter muscle to open up to allow the bile and pancreatic enzymes into the GI tract.
Thyroid hormone plays a critical role in stomach acid production, bile acid production, but also the release of both pancreatic enzymes and bile into the GI tract. Thyroid hormone is a part of all of these components to a healthy gut function.
Dr. Eric O:
You explain how thyroid hormone affects bile. Also, you mentioned how bile affects potentially conversion of T4 to T3, so there is that interplay there. You need healthy thyroid hormones to have healthy bile production, healthy conversion of T4 to T3, but maybe not too much bile.
Maybe as far as supplementation- I was going to save the supplementation for later, but we can talk about it now. When you are taking something like an ox bile supplement, that is essentially bile in a capsule?
Dr. Eric B:
It sounds good on paper, right? If you don’t have good fat digestion, maybe you have a gallbladder issue, maybe you think that you should take bile.
Now, when we eat food, and the liver is making bile, and the gallbladder is releasing bile into the GI tract, that bile is doing its job. Then it’s being resorbed. About 95% of the bile acids are resorbed back to the liver. You probably cycle those bile acids five, six, seven times through the process of trying to digest food.
There are primary bile acids, which is new bile acids made by the liver.
Then there are secondary bile acids, which are when those primary bile acids get into the lower part of the GI tract, into the large bowel. Bacteria, which is primarily in the large bowel, the colon, acts on those bile acids and convert the primary to secondary. We have both of these things recycling through the digestive process.
A small percentage of those bile acids get out of the paddock bloodstream and into the overall bloodstream in the body. It’s those bile acids that play a role to some degree in metabolism because more bile acids in our overall circulation can then bind to receptors on cells and increase the conversion of T4 to T3.
Taking ox bile can be great because that can help someone who is really struggling with fat digestion. But we have to be cautious, too, because this has happened to me. I was using ox bile on somebody, and they started having hyperthyroid symptoms.
I wasn’t aware of this when the person mentioned it to me. This was maybe 10 or 15 years ago. The person said, “I think my hair is getting thinner. I am having these symptoms. I think it’s the ox bile.” I said, “I don’t think so.” I think it might have been one of the first times I used ox bile as a supplement. The person is having these negative symptoms.
That is when I really realized I was giving them more bile acids than they needed, or more of those bile acids that I am providing them in that ox bile is getting into the bloodstream, and that is creating a hyperthyroid effect. As soon as we stopped the ox bile, the symptomology improved. We were back to normal.
Ox bile is a really common supplement that people use to help when there are bile issues, fat digestion issues. I think we have to be cautious with it and be aware that you could create some hyperthyroid symptoms in some of the tissues in response to using it, if more of it is getting out of that hepatic flow and getting into the bloodstream proper.
Dr. Eric O:
I see a lot of people with hyperthyroidism. I’ll admit, I’ve had hyperthyroid patients take bile salts. I guess the thing is, rarely do I give separate bile salts. I don’t know if I have seen the hyperthyroidism increase, or if it has, but I wasn’t aware of it.
Usually, if I give it, it’s part of them taking digestive enzymes and butane HCl, like one of those common multis. It’s a small amount of ox bile compared to if you are giving a separate ox bile supplement that has who knows how much bile salts. Either way, something to be aware of. Even a small amount in some people might be problematic.
Dr. Eric B:
Prior to that experience, I hadn’t used a lot of ox bile unless it was a part of a formula. One of my colleagues recommended the ox bile. This is what they use. “Why don’t you try it?” “All right, let me try it. Let me see what goes on.”
It just so happened the first person I tried it with was a learning experience. The patient was fine. It was just one of those things where we both learned supplements are meant to be supplemental. Just because we think they’re all good doesn’t necessarily mean they always do what we want them to do, or there can’t be negative consequences from these things. It’s a good learning experience.
For someone who is thinking they have gallbladder issues or fat malabsorption issues, be cautious. If you start to get some hyperthyroid signs or symptoms, and this person was starting to have some hair loss as a result of using it, let me try a formula that either doesn’t have ox bile directly in it or has a much smaller dose of ox bile. Some of these formulas have supportive ingredients.
Dr. Eric O:
You mentioned the importance of T3. If someone is having a conversion problem, normal T4, low T3, or both T3 and T4 are low, that could also affect not just bile production but a few other things that could be problematic.
Dr. Eric B:
This is a good topic because it presents a couple different talking points. When we think about thyroid hormone’s effect, the primary impact of thyroid hormone is via T3. A lot of tissues where most of the T3 is made, there are some tissues that only can use T3 from the bloodstream. There are other tissues, maybe 50% of the T3 that the cell is using is made within the cell.
That is important because if we look at somebody’s thyroid panel, we see appropriate levels of T4 and low T3, the initial thought process might be, “I’ll give them T3 to offset what the body isn’t making.” They assume that if we give them more T3, it’s going to have the same effect that the cell would if it was making its own T4 into T3. Unfortunately, that’s just not the case.
Do you know Dr. Bianco? He just wrote a book on thyroid physiology. He has Deiodinase.org. He is an MD, smart guy. Really well known in the thyroid world from a medical standpoint. Dr. Bianco, we just talked about this the other day. He had a paper where he discussed how long the T3 that is coming from the bloodstream stays in the cell versus how long the T3 that is made in the cell stays in the cell.
T3 that comes in from the bloodstream, I think that number is pretty short. Maybe a half hour or less. That T3 is in the cell. It comes in the cell and goes back out of the cell.
But the T3 that is generated inside the cell may stay in that cell for closer to eight hours. That’s significant. It has a different impact when we convert T4 to T3.
I say that because in an effort to think we’re optimizing somebody’s thyroid physiology or potentially try and make someone feel good, we see that reduced conversion of T4 to T3 and may say, “I’ll give them the T3, and that should fix the problem.”
It may manipulate the blood levels, but it may not improve the function of the tissue. Why? Because that T3 may not get into the tissue as much as we think it will. We assume that the T3 in the blood correlates with what’s inside the cells and tissues, and that is not necessarily the case. It may not hang out there as long.
When we see somebody who has reduced T4 to T3 conversion, and we see that they have fat malabsorption issues going on, then what we need to do is ask a better question, which is what is driving that reduced conversion of T4 to T3 and impacting the liver and gallbladder and sphincter of Oddi versus let me just throw more T3 into this system.
In that situation, what should we do for the person who has fat malabsorption while we try to figure that out? That is where we can use these supplementation strategies. Make sure we are supporting the butane HCl if they have HCl issues. Add some of these good gallbladder support formulas that are available. There is a ton of them. We can support the fat metabolism while we try to address what is driving the adaptive decreased conversion of T4 to T3. My opinion.
Dr. Eric O:
When it comes to taking T3, would you say there is a difference between something like Cytomel, synthetic T3, compared to desiccated? I agree with you that you want to try to address the cause of the conversion problem. I am wondering if someone were to take desiccated thyroid over T3, if that would make a difference.
Dr. Eric B:
I don’t think so. If you think about what is really going on at the cell level, if the person has appropriate T4, and they have an inflammatory stress cell response going on that reduces the conversion of T4 to T3, and increasing the conversion of T4 to reverse T3, we might look at that and say, “Let me give them T3.”
The same enzyme, deiodinase 3, which is supposed to be deactivating T4 to reverse T3, will still deactivate T3 to T2. We are just not seeing it. We might get a temporary change in some symptoms. Long-term, that T3 is not going to stay in the tissues very long.
There are negative implications that come from taking that medication. We are now chasing the symptoms, so we want more and more. As you increase T3 intake, that starts to saturate some of the tissues in the brain and the pituitary gland.
Now, there is a reduction in TSH. When you have a reduction in TSH, if you were getting some output from the thyroid gland, now you get less T4 production by the thyroid gland. Now, you have to make a decision. If I am increasing T3 to try to have an effect, is that then saturating the central axis, resulting in less T4 production by the gland? Now I either need to provide more T4, or I am going to need to provide more T4 and T3, based on what the provider is trying to do.
At the same time, we still may not have addressed what is creating that cell stress response. We haven’t addressed what is resulting in the reduced T4 to T3 conversion. We still may not improve function of the tissues that are struggling. We may see changes in the blood value, but the blood value doesn’t always correlate with what’s going on inside the various tissues. They can all self-regulate to some degree independently of what’s in the bloodstream.
Dr. Eric O:
Makes sense. If T3 is really low, let’s say if it was 1.5 on a blood test, you will still want to address the cause of the problem. Would you be in favor of giving T3? Would you say it depends on the person, the symptoms?
Dr. Eric B:
I would say it depends on the situation. I would think about why somebody might have low T3. There are three big considerations we have to take. Does the person have low T3 because the gland is not producing enough T4, or they are not taking enough T4? We have to evaluate that.
Even though we have gotten away from running total T4, it doesn’t mean it doesn’t have value. It does. If you just have free T4, and it’s normal, high, or low, it still doesn’t tell us what the total are. Is the thyroid gland making enough thyroid hormone? You may not know.
You could look at reverse T3 and say, “If I have high reverse T3, and I have a normal or high free T4, then maybe I am making enough T4 in the thyroid gland.” But we don’t know. I think it’s important to run it.
If the thyroid gland isn’t producing enough T4, and you’re not taking T4 medication, that could be one of the reasons why T3 and free T3 are low. We’ll know that by looking at a fuller thyroid panel. When we look at the totals, we get an idea.
The other thing we can do is we should be able to take a look at the free T3 to free T4 ratio. If there is a global hypothyroid condition—the gland is not making enough, there is not enough T4 in the bloodstream—what we should see is a higher ratio of free T3 to free T4. Why? Because the cells are starving for thyroid hormone, and they want that converted into the usable form as quickly as they can get it.
In a true glandular hypothyroid condition, where there isn’t enough T4 and T3 in the system, and the T3 and free T3 are low, in that situation, we would look at that and say, “Ooh, this is a person who either needs iodine because they can’t make enough, or there is destruction of the gland, and they will need some support.”
In that situation, would I recommend T4 and T3? I don’t prescribe, but I would say it is probably appropriate to give T4 first and see how they convert.
The second reason somebody might have a lower T3 or free T3 is that they have some cell stress inflammatory mechanism going on. It is an adaptive change, where the body is not wanting to convert T4 to T3. That’s why it’s low. If that’s the case, then we’ll see that free T3 to free T4 ratio be low.
In that situation, I wouldn’t recommend more T3 because if the body is trying not to convert T4 to T3, and we give them more T3 that the body probably didn’t want, is that helping them? You could say, “Sure, their signs and symptoms feel better.” But am I really helping them? That’s the question.
If your patient has a fever, should you give them aspirin or Tylenol to reduce the fever? Somebody would say, “Sure, it might make them feel better.” I might say, “Maybe not.” I’ll give them a cool compress and put them to bed because if they spike the fever, the fever isn’t the problem. It doesn’t make us feel good. But the fever’s job is to help in the healing process. People could argue both sides. In a situation like that, again, I would say no.
The third reason that somebody might have reduced conversion of free T4 to free T3 and have a lower total of both is they are taking way too much T4 if they are taking medication. Too much T4 in circulation results in the ubiquination of deiodinase 2, so they turn down that T4 to T3 conversion in the peripheral tissues. Now they will have a lower T3 and free T3. In that situation, again, I wouldn’t recommend more T3. I would recommend that they reduce the T4 dose.
The fourth issue that we have to take into consideration is that this could be a person who has a genetic polymorphism that does not convert T4 to T3 very well. If that is the case, they could have up to a 20% reduction in T4 to T3 conversion in the periphery. I would say it might be justified to do it.
The fifth situation would be somebody who has had a thyroidectomy, had their gland damaged, radiation, whatever. The thyroid gland typically makes 5-10mcg per day. In that situation, if we are taking away the gland’s function, then we should mirror the production. That should be maybe somewhere between 5-10mcg that the thyroid gland would traditionally make. In that situation, I would say that’s a person who probably needs T3.
When someone just has low T3 or free T3, I don’t like them to be on thyroid medication just to improve some of their symptoms because my goal with my clients is to figure out how to help that T4 to T3 conversion. It’s my feeling that in a lot of cases, giving T3 while creating short-term benefit, it is problematic in the long run to help normalize normal, homeostatic thyroid physiology.
Dr. Eric O:
Thanks for that explanation. I know we got off track with the bile metabolism. Thought it was important to bring that up.
You did chat a little bit about this during our first conversation, especially testing the total T4 and not just relying on the free hormones, especially in the case of hypo. With hyperthyroidism, I still just test free T4 and free T3. But it does make sense with hypothyroidism when looking at the total output of thyroid hormone, not just to rely on the free hormones.
Dr. Eric B:
I don’t remember if we talked about it or not. When we look at the free hormones, we also have to consider is the free hormone low because of what’s going on with the binding globulins? The binding globulins, those transport proteins, can have an impact on how much is actually free.
What influences those? Estrogen increases those binding globulins. Taking too much thyroid medication can potentially increase those binding globulins. There are things that influence the free values. If we are only looking at it in isolation, are we really seeing the full picture? I don’t think we are. I think we need to take a look at that.
If somebody is hyperthyroid, we know. They have plenty of thyroid hormone available. That is usually not the issue. Sometimes, these things, depending on what your patient population is, it may change it. My patient population is primarily people who are struggling with hypothyroid symptoms or overmedicated or trying to find a magical dose.
I do get some hyperthyroid-based patients. A lot of times, if I get them, I say, “Call Dr. Eric. This is what he does every day. Check with him. That might be the better match.” I do have patients who want to work with me who have hyperthyroidism, or they’ve had treatment for hyperthyroidism. Now they are on thyroid medication and back in the wheelhouse of how do I find that magic dose?
In that situation, if you’re on the weight and age-appropriate dose for someone who doesn’t have a gland, and it’s not working, then you have what I talk about every day. There is still some type of cell stress response going on that is driving the immune inflammatory process. In those situations, once we get them close to what the thyroid gland would have made, then we have to get busy trying to find those stress responses.
Even though we both work in the thyroid world, what labs I think are important and what labs you think are important are really going to be centered around our patient population and what we deal with.
Dr. Eric O:
Makes perfect sense. You mentioned the effects of estrogen on the binding globulins. I also wanted to ask you about estrogen and its effect on bile metabolism as well.
Dr. Eric B:
Estrogen, especially excessive estrogen, can have an impact on thyroid hormone production and iodine intake into the thyroid gland. If you reduce iodine or thyroid hormone production, that can trigger problems downstream in thyroid hormone’s ability to regulate bile physiology.
As we have increased estrogen, estrogen can influence the binding proteins. Because it can influence the binding proteins, that can reduce the amount of available T3 and T4 to get into the liver and the bile ducts and help with that regulation.
Estrogen also impacts the sphincter of Oddi, which is the valve that needs to open into the duodenum to allow bile flow and pancreatic enzymes to move into the GI tract. If you have too much estrogen in the system, that can cause constriction of the sphincter of Oddi and keep it from opening up. That can lead to problems with reduced bile flow into the GI tract, so that can lead to fat malabsorption, gas, bloating, pressure, loose stools, permeability issues, and inflammation. It can also cause the bile to become thicker and lead to stone formation and gallbladder disease.
Unfortunately, we need estrogen. It’s really important. When we take a look at any of these systems, regardless of what somebody’s diagnosis is, we have to figure out how all these systems tie in. What is causing it?
If we have fat malabsorption signs and symptoms or on a stool test, we might rush in there with some bile support. I often do because I understand how important it is. Let’s get you absorbing. Let’s get some support for fats and fat digestion. Then let’s start considering all the possibilities and probabilities that are resulting in reduced T4 to T3 conversion and what else might be impacting bile production and bile flow into the GI tract. Especially for women, estrogen issues could be top of the list.
Dr. Eric O:
If someone is taking an oral contraceptive, that also could potentially lead to, depending on what they are taking-
Dr. Eric B:
Depending on what’s in there for sure.
Dr. Eric O:
That could lead to gallstones by making the bile thick and sluggish.
Dr. Eric B:
Obviously, if someone has gallbladder disease, and it’s problematic, I get it. Maybe it has to come out. But if we just remove the gallbladder and have the ducts straight from the liver into the GI tract, and we still have a T4 to T3 conversion issue, or we still have an estrogen issue, did we really fix anything?
We took the diseased tissue out. Now we have lost the concentration of the bile. It’s not as effective. It doesn’t have the same antimicrobial effect. It doesn’t have the same ability to break down those fats appropriately. It doesn’t have the same ability to absorb those free fatty acids across the membrane. It doesn’t have the same effect that this more concentrated bile might have. It would be like washing your dishes with a concentrated soap versus a really watered-down, diluted soap. It doesn’t have the same effect.
I think that happens all the time. People say, “You have gallbladder disease. We will just take your gallbladder out, and you’re going to be good.” Well, the first question we should be asking is what are the issues that cause that gallbladder to become diseased to begin with? What was the patient’s estrogen level? What is their T4 to T3 conversion? Do they have dysbiosis? What are their lipids like? Is their cholesterol in the bloodstream high? Maybe that is having an effect on bile absorption. Are there things blocking the transport of bile flow in and out? What are the reasons that we have these issues and problems versus just take it out and you’re good? I think that happens too often.
Dr. Eric O:
Yeah, you want to try to fix the problem before it gets to that point. Years ago, my dad, when I was a teenager, he had to get his gallbladder removed, before I had the knowledge I had now. To me, it was a big deal because he was getting the surgery. They told him the same thing, no problem living without a gallbladder. He never even thought about addressing the cause. It might have been too late. It’s been a long time, so I don’t remember everything. By that time, even if he wanted to address the cause, he might have been too far gone. There are a lot of things people can do before getting to that point, is what you’re saying.
Dr. Eric B:
The other thing we have to consider for the patient is how would you even know if you have a bile issue or gallbladder issue or problem with the production? Gas, bloating, reflux, loose stools, greasy stools. You go to the bathroom, and there are stool stains on the side of the bowl.
Some people talk about floating stools because maybe there is more fat in the stool. I have seen literature that says it’s more likely to be greasy stools. When you wipe, you will wipe a bunch of times. That is a greater indication there is higher fats in the stool.
Even reflux. A lot of people are told they have too much stomach acid. You can get bile reflux if you are not breaking those fats down appropriately. If you have gas, bloating, pressure, loose stools, greasy stools, indigestion when you eat fats, there is a good indication that you’re starting to develop some challenges with your bile production.
Dr. Eric O:
Similar if someone has issues with fish oils. If they take fish oil supplements and are experiencing a lot of burping, that could be a sign, too.
Dr. Eric B:
I think it could be. I guess there’s some argument about the quality of all the oils that we’re buying. Are they oxidized or not? Someone gave me a bit of an in-depth education on the fats. To really make a high-quality fish oil derivative product is difficult because it’s easily oxidized in the processing. A lot of what may be creating issues—maybe it is liver, gallbladder issues, or maybe it’s the quality of the product we’re getting. Unfortunately, just looking at the back of the label may not give us the answer.
How would you know? The average person wouldn’t know. If you are just buying fish oils or a fish oil derivative. If you are eating a lot of fats in the diet, and you are having more indigestion—burping, belching, looser stools—there is a good chance you are having some challenges.
Dr. Eric O:
How about high bilirubin? I wanted to talk to you about that and Gilbert’s. Some will say that Gilbert’s is not really a big deal. When I went through my Institute for Functional Medicine training, I don’t know if you’re familiar with Dr. Robert Roundtree.
Dr. Eric B:
I know the name. I don’t know him personally.
Dr. Eric O:
He was teaching the detox course. He had literature showing it was a big deal. You can’t just overlook something like Gilbert’s even though there is a genetic component. I wanted to get your thoughts on Gilbert’s and high bilirubin in general.
Dr. Eric B:
It is generally learned in school that as bilirubin levels are going up in the blood, we have problems with liver and gallbladder function. Do I think it’s important? I don’t care what the disorder is, if someone has it named. If your bilirubin is going up, you have a problem.
There is a breakdown of liver and gallbladder problem. Someone might say AST or ALT are still good, so it’s not an issue. That’s nonsense. The vast majority of people, if they have elevated bilirubin, we should take notice regardless of what the diagnosis is. It shouldn’t be that high.
You could have a genetic predisposition to that being higher. If there is no signs or symptoms, and everything else looks good, maybe it’s not important. I think it’s really unusual that you see an elevated bilirubin, and there is not something going on.
For the listener, bilirubin is a waste product. We break down red blood cells and the heme in red blood cells into something called biliverdin. That gets converted into something called bilirubin. Bilirubin is in your bile and should go out.
If we are starting to see higher levels of bilirubin in the blood, that means it’s not getting through the liver and the gallbladder. It’s building up in the bloodstream, which is potentially problematic.
Just so you know, the reason your stool is brown is because of bilirubin. Your urine is yellow because of bilirubin. If someone says you have clay-colored stools, the reason they are clay-colored is you don’t have as much bilirubin getting into the stool to make it that darker black/brown color. It does give some of the pigmentation.
If it’s elevated, it should be a warning sign to a clinician. I usually look at a range of .5-.8. If it’s in that range, we’re probably good. Then again, we also have to take a look at red blood cells. Am I anemic at .8? If I’m anemic and .8, maybe that’s too high, versus if I’m not anemic.
The other issue is low bilirubin, which gets no attention. If you look at a lab report, as long as it’s less than 1.2, you’re good. I don’t think that’s the case either.
Low bilirubin, does that mean you have a gallbladder problem? I don’t know if that means you have a liver problem or a gallbladder problem, but it probably means you have an oxidative stress problem. Bilirubin can be converted back to biliverdin, and biliverdin is a potent antioxidant. The body can help deal with the oxidative stress in the body by instead of excreting the bilirubin, it would convert it back into biliverdin so it can have an antioxidant.
We need to look at the highs and lows. Even when it’s normal, we have to interpret it based on what our other values are.
To summarize that, regardless of what your diagnosis is, if you start to see your bilirubin creeping up above .8, you have to start to look at the rest of the labs: ALT, AST, GGT. You can look at the AST:ALT ratio. If that is elevated, then we have to start considering that something is already developing fatty liver disease. If they are starting to develop fatty liver disease, is that going to affect bile function and physiology? Absolutely.
What does that mean about thyroid physiology? It means you probably don’t have great T4 to T3 conversion supporting the liver. Then I can’t burn those fats as a fuel. I can’t burn the glucose as a fuel.
Definitely when you think about that bilirubin number, regardless of the diagnosis, if it’s creeping up above .8, somebody should take notice. If it’s below .5, we should take notice and say, “What the heck is going on here with the oxidative stress or this liver/gallbladder physiology?”
Dr. Eric O:
It’s interesting. I admit I’m guilty of not paying attention to lower bilirubin. It’s not red flagged if it’s low. I know you can’t just rely on labs. I look at the high side and the low side. I did not know if it gets too low that there could be potentially a oxidative stress problem, so that’s good to know.
Dr. Eric B:
We have to look at the red blood cell population. If they have an anemia pattern, that could be why it’s low. There are not as much red blood cells breaking down. They are hanging around longer because you don’t make as many.
This goes back to interpretation, which hopefully we do better than sometimes in allopathic medicine, where they are just looking for H and L. In functional medicine, we should be interpreting the labs and saying what story do these labs tell us about my client? How does that match with their signs and symptoms? That way, we can be more specific with a treatment strategy.
Dr. Eric O:
Makes sense. For current gallstones, there are all these remedies out there. As far as supplements, not necessarily for gallstones specifically, but supporting bile metabolism, not just bile salts, but there are other supplements like things with beets for example to help with bile metabolism. If someone has an existing gallstone, if it’s not serious, if it’s not blocking a bile duct, is there anything they could do as far as shrinking the stone or breaking the stone? Are those things that are out there not really breaking gallstones?
Dr. Eric B:
There is a lot of things that are out there for gallbladder cleanses and hydrogen peroxide that people drink to try and break up the stones. I don’t try to do that necessarily. I don’t have people do them.
I think the chances of things going well, maybe they’re good, maybe not. I have had patients in the past who did these things and wound up with emergency gallbladder removal. What happened with whatever they were doing, using some fats and hydrogen peroxide, whatever their cleanse was, actually created more stress and expansion and inflammation.
Some of these strategies are trying to force the flow. If there are things restricting flow, and you are creating this real need to force the emptying of a gallbladder, you’re going to be in trouble. I don’t typically recommend those strategies.
I think the better model here is a number of different supplements out on the market that are either designed to help support better bile production or to support healthier bile flow. Lots of companies have those things out there.
I would suggest that whomever thinks they have issues should work with your functional medicine practitioner to guide you in the right direction as to what might be the best strategy in your situation. That is step one. Step two is what is causing this problem to begin with?
Dr. Eric O:
I’m glad you brought that up. I wanted to get your perspective. I don’t recommend anything to break up gallstones. Like you said, there is risks as well of doing that. Just because it’s a supplement you’re taking doesn’t mean there is no risk. Like you said, you could end up in the ER. Not to say it will happen most of the time, but even if it’s 10% of the time, or whatever percentage, that’s a risk.
Dr. Eric B:
I read a paper a while ago, and they started breaking down those gallstones. It was interesting. In this one paper I read, what they were finding was a lot of bacteria at the center of those stones. What was the underlying cause?
It is one of those things that we have to consider. Is bacteria getting somewhere in that area of the body, maybe getting up the duct into the gallbladder? Is the stone really the problem in some of these situations? Or again, is that the body’s adaptive response? Hey, we have this bacterial. Let’s surround it and encase it versus obviously there could be a problem, especially if they create a congestion issue.
The body is pretty cool. A lot of the things we think are the problem are the body’s adaptation to try to protect itself. In a situation like that, if we actually knew then, we don’t typically have the ability to pull a gallstone and throw it under a microscope at home and see what is at the center of it. That is one of the things we have to consider. What is going on even from a gallbladder function or dysfunction related to organisms? It can be.
Dr. Eric O:
The last thing I wanted to ask you is life after gallbladder surgery. If someone sees you and has already had their gallbladder removed, but they are still having the underlying bile metabolism problems, does that person necessarily need to be on support permanently since they don’t have a gallbladder? Obviously, you want to address the cause of the problem. Once it’s addressed, can they be off of bile support supplements? Is that something you think they need to take continuously?
Dr. Eric B:
I tend to lean toward people using something longer-term. Again, I would look at labs and signs and symptoms. We can look at high cholesterol or high triglycerides in the stool. If we see higher fats in the stool, it’s a good indication that this is maybe a person who is not absorbing their fats very well. In that situation, we might want to have them on it.
If it looks like they are a person, especially if you look at their labs, their triglycerides and VLDL are relatively low, and even LDL is relatively low, we might consider they are not doing a great job of absorbing triglycerides into the system.
As you well know, the difference between VLDL and LDL and HGL is the amount of triglycerides and ratio to cholesterol that is on those lipid proteins. If their triglycerides are low, and you ask them what they are eating, if that’s what they are eating and their triglycerides is low and VLDL is low, this person will probably need some gallbladder support.
Triglycerides is another one of those things where the lab range says less than 145 or whatever. But whether it’s high or low, it’s telling us a story. If I have someone who has low triglycerides and low VLDL but has low glucose issues and other issues going on, there is a good chance that they have fat malabsorption going on. Especially if they have chronic mineral deficiencies, you really have to look that way.
I wouldn’t say it’s a blanket statement; everyone has to have it. I would lean more toward that people are going to need some support because they have lost that bile concentrating ability when they have lost their gallbladder.
Dr. Eric O:
With triglycerides, what do you consider too low? Less than 50?
Dr. Eric B:
Yeah, probably under 50. But it would depend on what their diet was like. That would be a flag for me. If I saw it under 50, I’d be like, “What’s going on here? Tell me what you’re eating.” Based on that, let me look at the VLDL. That’s low, too. “Tell me about your stools. Tell me about your gas, bloating, pressure.” If the picture sounds right, put them on it.
If you do a stool test, and you can see elevated steatocrit, or you do Vibrant’s Gut Zoomer test and see triglycerides and cholesterol elevated, they are getting some support.
Dr. Eric O:
Makes sense. This was amazing. Is there anything else that I didn’t ask you that I should have asked you with relation to bile physiology? Again, you spent three days, so I’m sure there is another few hours we could go on. Anything really urgent?
Dr. Eric B:
Bile acids also play a critical role, not just in the immune system of the GI tract, but the permeability of the GI tract. They help to manage those tight junctions. For the person who has maybe been told multiple times, “Hey, you have chronic leaky gut,” especially if you have had multiple episodes of chronic dysbiosis, and nobody has looked at bile physiology for you, that really should be considered because the bile acid resorption helps maintain the tight junctions of the GI tract.
It is not just an issue of fat digestion; it is not just an issue of antimicrobial capacity at the top end. If you don’t have healthy bile physiology, it can lead to the chronic leaky gut. Most of us are aware it can lead to chronic inflammation, food reactivity, food intolerances, even systemic infections from what’s going on in the GI tract.
Dr. Eric O:
That’s important. Leaky gut is pretty prominent.
Dr. Eric B:
Yeah, could be.
Dr. Eric O:
All right. This was amazing. Thank you so much for getting together again to discuss bile physiology. Where can people find out more about you, Dr. Eric?
Dr. Eric B:
The Thyroid Answers podcast, which you’ve been a guest on. We’ll get you back again. Anywhere you can get podcasts.
Instagram and Facebook, I’m on, too. We do our Thyroid Thursday videos there. I answer a lot of questions on there. The book is The Thyroid Debacle.
My website is RejuvagenCenter.com. They can reach out there. I do discovery calls. Every day, I do at least two over my lunch break to help answer questions for people who are not quite sure where to go or what to do or are confused about their health in some way or their thyroid physiology. I use that time along with the other platforms to help give people the answers that they are looking for that they maybe aren’t getting elsewhere.
Dr. Eric O:
Of course. Thank you so much, Eric. This was great. Appreciate you taking the time to dive deep into bile metabolism.
Dr. Eric B:
I appreciate the opportunity, Eric.
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