Recently I interviewed Evan Brand, and we talked about mold-gut-thyroid connection. If you would prefer to listen to the interview you can access it by Clicking Here.

Dr. Eric Osansky: 

I am very excited to chat with Dr. Melinda Ring. I am going to dive into her impressive bio, and then we will talk about culinary medicine. 

Dr. Ring is director of Osher Center of Integrative Health and clinical associate professor, departments of medicine and medical social sciences at Northwestern University, Feinberg School of Medicine. She has an active clinical practice, directs medical trainee education, and clinical and faculty fellowships in integrative medicine. She founded the Cooking Up Health culinary medicine course and conducts research as well. 

Dr. Melinda contributes to textbooks and research articles in the field of women’s health and integrative medicine. She has published several books on integrative medicine, including The Natural Menopause Solution. She is a frequent contributor to news outlets. 

She is the chair of the board of the American Board of Integrative Medicine. In 2021, she received the Bravewell Distinguished Service Award from the Academic Consortium for Integrative Medicine and Health, which is one of the highest honors in the field of integrative health. Dr. Melinda, thank you so much for joining us. 

Dr. Melinda Ring: 

Thanks for having me. Looking forward to our conversation. 

Dr. Eric: 

Same here. Before we dive into culinary medicine, if you could give a little bit more of your background. How did you start focusing on that? 

Dr. Melinda: 

It’s an interesting question because if I think back to my childhood, I grew up in the ‘70s and ‘80s. Food was very much processed food and Wonder bread and TV dinners. That is what was healthy. I never actually learned how to cook. What we knew about nutrition was very different from what we know about it now. 

I had a brief window of time between college and medical school. I begged my way into getting a job as a sous chef at a fancy restaurant in Ann Arbor. I spent the summer making salmon en papillotes, making our own sausage from scratch, and doing a lot of different things I had never learned before. 

When I went to medical school, we learned nothing about nutrition. The only real nutrition we had was about IV nutrition for inpatients. Even when we were talking about diabetic patients, where it’s such a difference, we learned about how to dose insulin, but we didn’t learn how to counsel patients on what to eat.

When I was in practice, I knew to tell someone to eat a low sodium diet. Giving them a handout doesn’t translate to real-world nutrition. After my integrative medicine training, which was very nutrition-focused, as you know, I started to think about bringing those together. That’s where this idea of marrying culinary medicine, which has been defined as the art of cooking with the science and nutrition of medicine, really appealed to me. We decided to create a course for health professionals, so we can try to train more doctors, more health professionals to help their patients down the road. 

Dr. Eric: 

Very cool. How long have you been doing this? 

Dr. Melinda: 

Probably for the past eight years. We started a course at Northwestern, and now we’ve expanded it. It’s being taught at other institutions. It’s not a patient directive. I get inquiries from my own patients, “How can we take your culinary medicine class?” Right now, that’s not what we offer although there are definitely others who offer things like that. I might do that myself down the road. But right now, Cooking Up Health is aimed at making sure people’s doctors and other health professionals understand culinary medicine, so they can help their thousands of patients. 

Dr. Eric: 

Is it mostly other integrative doctors? Do you actually get conventional medical doctors who express interest? 

Dr. Melinda: 

We’re trying to start early. In a few weeks, we are starting a cohort of first- and second-year medical students. They will go into all kinds of fields. Nutrition is relevant to everything, from surgery to dermatology to primary care. It’s definitely focused on everybody, not just integrative doctors. 

Dr. Eric: 

Wonderful. How do you incorporate it into your actual practice? It sounds like you don’t actually teach your patients how to cook; you just encourage them to eat whole, healthy foods. Do you encourage them to use recipes? 

Dr. Melinda: 

To some degree. Nutrition is always a part of what I talk about to patients. Yes, providing resources for them. I tend to have a very educated, health-oriented patient population. They tend to already be aware to some degree, but it’s really diving more deeply into how to make this a practical thing in an already busy life. 

We can’t do cooking that takes three hours to prepare when somebody has other things going on. When I have a patient who has two jobs and is raising kids, telling them to use this fancy cookbook to prepare food is just not gonna work. It comes down to what are some of the quick and easy ways to make healthy nutrition realistic and delicious? 

Dr. Eric: 

Makes sense. Batch cooking, do you recommend that? 

Dr. Melinda: 

Love batch cooking. Absolutely. There is a cookbook I got recently by this nutritionist cook, Love and Lemons. In it, for example, she says, “You just got organic zucchini from Costco, and you have a whole bunch of it. Here are three nights of completely different recipes you can do. You prep this on day one, and then you will use this day two and this day three.” Those are the kinds of things I think help. 

They also help reduce food waste, which is such a big issue in our country. People buy all this stuff and throw it out at the end of the week because they’re starting to not look so great or are a little wilted. Helping people learn to avoid some of that food waste is important, too. 

Dr. Eric: 

How important is food when it comes not to just overall health, but when dealing with health conditions? You know the listeners of this podcast here pretty much consist of people with thyroid and autoimmune thyroid issues. What role would you say food plays in helping someone to recover, or from other autoimmune health conditions or conditions like cancer? 

Dr. Melinda: 

To me, integrative medicine always starts with lifestyle. Diet is one of those pillars of health. I love dietary supplements. I love other approaches, like acupuncture and energy therapies. Those will do very little if somebody is not also addressing nutrition, getting enough sleep, moving, managing stress, having joy in their life. It’s essential basically. 

I think it’s critical both to feeling better with whatever you’re dealing with now, but also it’s one of those root cause things, which is having a healthy diet will prevent disease down the road. You have to start there.

Dr. Eric: 

Good answer. I agree with that. 

One question I have is picky eaters. Growing up, I always used to be really picky. Even these days, I’m still more on the picky side, but I eat more of a variety. How do you deal with picky eaters as far as someone who wouldn’t use a lot of spices to make it more flavorful? Do you have any feedback for those listening who might just want to have their burger and sides? Hopefully not French fries. “These are the five foods I’m eating on a regular basis.” Maybe it’s a vegetable or two sometimes. If you could give some advice on how they could increase the variety. 

Dr. Melinda: 

I have two boys. One of them is a picky eater. I think it depends on what we’re talking about. With kids, it’s a very different situation than adults. 

With kids, the bottom line is you need to get those fruits and vegetables into the diet. Getting those things started early, when they’re developing a taste for it, is important. Now, I am a little bit of a purist, and maybe not the best example because I actually prefer all of my vegetables and fruits without a lot of sauces, without a lot of spices. I love them just in their natural taste, maybe steamed or roasted, but not with a lot of stuff on it. 

For other people, trying to- For example, if they are pasta lovers, adding vegetables into that, even if they’re frozen, and mixing them in. Doing muffins and making them zucchini muffins and hiding it in. Finding ways to incorporate it. Smoothies are always a great way. People love to get things in that way. I don’t love the fruit and veggie blend powder type things. I don’t think they’re a replacement for real food. 

It takes a while to develop a taste for something new. If somebody has been eating a very restricted diet, sometimes they have to give it a chance and say, “I am going to commit to eating this, at least three times, before I say I don’t like it.” Even if it’s one piece of broccoli, allow their taste buds to adapt and appreciate it. Maybe eat it mindfully. Notice it more. Appreciate it more. 

Dr. Eric: 

Those are good points. Growing up, I really didn’t eat vegetables. As an adult, I wasn’t crazy about eating vegetables. Going through chiropractic school and learning about nutrition, I realized I needed to eat healthier and incorporate vegetables. It was a slower process. A lot of it was a mindfulness around eating them and realizing how much good it’s doing to my body. The smoothies, which I still to this day incorporate into my practice. It’s best to start when you’re young. 

I still come across adults, and I’m sure you do, too, where they are hardly eating any vegetables. Some listening to this absolutely love vegetables, I’m sure. When someone refuses to eat vegetables, it’s more of a challenge. 

You also brought up the powders. I’ve had people bring that up, too, as a substitute. “Can I have a veggie and fruit mix powder?” Exactly what you said. I tell them the same thing. It’s probably better than nothing, but it’s definitely not the same as eating whole veggies and fruits.

Dr. Melinda: 

ConsumerLab.com did a review of them. The FDA came down on them because they will make these claims like, “Has 12-14 servings in a single drink.” That’s some false marketing.

Dr. Eric: 

Good to know. You said Consumer Labs? 

Dr. Melinda: 

ConsumerLab.com. Are you familiar with them? 

Dr. Eric: 

Yeah. 

Dr. Melinda: 

They test the quality of supplements and see what they’re supposed to have and that they don’t have things they’re not supposed to have, like heavy metals. That’s another resource I oftentimes will recommend to patients for supplements. It’s one of the better ones. 

Dr. Eric: 

You also mentioned as far as when you eat foods, sometimes you’ll steam them. Sometimes, you’ll roast them. Do you also eat them raw? Do you recommend a combination of raw and cooked veggies? Or is it mainly cooking? 

Dr. Melinda: 

I think it varies. It depends on the patient really. I don’t only see autoimmune issues. I see all kinds of things. A lot of my patients have gut issues. They may do better or worse, depending on what their situation is, with raw versus cooked. 

Cooking alters the nutritional content of food. It alters its availability, sometimes in positive ways, and sometimes in negative ways. When we talk about something, for example, like goitrogens, which are a big topic in thyroid, cooking degrades them. In that case, cooking may be the preferred option versus eating a bunch of raw broccoli dipped in a dip. I don’t have a universal, I only eat cooked food. I’m certainly not a raw foodie either. I like it all. For patient tolerance, it really depends on their situation.

Dr. Eric: 

That makes sense. If someone is experiencing a lot of bloating when eating salads or cruciferous vegetables, it’s probably easier, at least for the time being, to cook them. On the other hand, If someone is fine eating salads and other raw vegetables, it sounds like you just go with the flow and let them continue eating raw vegetables. Pretty much how they prefer it as long as they are able to tolerate it without any symptoms. 

Dr. Melinda: 

Yeah. I also am envisioning this shift to a more integrative culinary medicine movement. For example, if we think about ayurvedic medicine and how it describes people as having different doshas and different combinations of doshas, in Ayurveda. Somebody who has a Pitta, a more heated dosha constitution, may do better with raw, cooler type foods. Somebody who is more Kapha may need more cooked foods. 

There are different ways of looking at food and food preparation. Looking at what’s right for someone, it’s certainly what feels good to you, but it can go even beyond that, depending on what is the lens through which we’re looking at food.

Dr. Eric: 

One thing I didn’t say in the beginning: Are you a vegan, or just vegetarian? 

Dr. Melinda: 

I like the term “plant-forward” or “plant-based” more than vegan. That makes it sounds like I will never eat this, versus I will eat a lot of these great, lovely plants. I do have some dairy in my diet. Not a huge amount. Certainly some honey. Occasional eggs. I am not completely vegan for sure. 

For me, it’s a combination of health, connection to the world, and being an animal lover. It’s a big holistic reasoning for me versus just for health. 

Dr. Eric: 

Okay. It’s philosophical, not just health reasons. 

Dr. Melinda: 

Philosophical, environmental, spiritual, you could say. I’ve done some things like shamanic journeys, and my spirit animal was this beautiful, big deer who came. I’m not eating you anymore. You can look at it in a lot of ways. I’m just very happy that science backs me up. Eating a lot of plants is a good way to go. 

Dr. Eric: 

I can’t say I’m vegetarian, but I do agree that you want to eat a lot of plant-based foods. I would recommend mostly plant-based. I think you would agree that if someone does choose to eat meat, like beef, it should be grass-fed beef, preferably organic. If they eat chicken, organic, maybe pasture-raised. You said sometimes you eat eggs and dairy, so I imagine when you do that, you try to eat organic. Do you prefer raw dairy, or is it just regular organic? 

Dr. Melinda: 

Organic, yeah. You have to be knowledgeable about the labels. Organic eggs don’t necessarily mean that they’re healthier. It doesn’t necessarily mean that the chickens had free range. You do have to be a little cautious. Unfortunately, unless you have your own chickens, those free-range options may be more expensive. That’s what I get for our family. 

Dr. Eric: 

You get organic, pasture-raised then? 

Dr. Melinda: 

Yeah. 

Dr. Eric: 

How about spices? I know you said for vegetables, you usually eat them plain. I would think with other- 

Dr. Melinda: 

I do love spices though. 

Dr. Eric: 

Can you talk about some of your favorite spices? 

Dr. Melinda: 

I’m sure you can guess what my favorites might be. Turmeric is certainly one of them. The vibrant yellow spice that comes from the curcumin longa plant. It’s been used in culinary traditions for thousands of years. It is used in Ayurveda and is used for all kinds of conditions. 

One of its major constituents is that curcumin, which makes up 2-5% of turmeric, really has so many therapeutic effects. Everything from antimicrobial, protection against cancer, anti-inflammatory for sure. It helps to inhibit this NF-kappa beta molecule that turns on genes related to inflammation. Whenever we talk about inflammation and autoimmunity, curcumin is one of my top choices, and turmeric, whether it’s used in golden milk or a good curry.

Dr. Eric: 

I think a lot of people are familiar with the benefits of turmeric, curcumin, even though a lot of people take it in supplement form. That has benefits, too. Therapeutic value. Including it in your food enhances the taste, and you’re still getting those therapeutic properties. 

Dr. Melinda: 

Another one is ginger. I love ginger. Typically, raw. It has gingerol in it. That is anti-inflammatory and antioxidant. It’s been studied more when we talk about inflammatory conditions for things like osteoarthritis more than, say, Hashimoto’s or Graves’. It’s been shown to have benefits comparable to pain medications for something like knee osteoarthritis. 

I do love ginger. I use that in all kinds of ways. It might even just be taking some raw ginger and brewing it in hot water and having ginger tea. Easy to do. A. lot of people like to add some raw ginger, if they are making smoothies. It adds a little bit of a bite to it. I think it makes it a richer taste. Ginger is for sure another one of my tops. 

I love cinnamon. We think about it for diabetes, blood sugar regulation. Maintaining that blood sugar is so important for lowering inflammation. Cinnamon may activate these insulin receptors and inhibit enzymes that inactivate insulin. Cinnamon, top favorite. Love it on my oatmeal and on a baked apple, on just about anything. I will highly recommend cinnamon. Those are my top three. 

Dr. Eric: 

Those are a good top three. As far as diet goes, there are a lot of different diets. There’s paleo, Mediterranean, carnivore, autoimmune paleo, etc. Do you have a favorite diet? Are you of the mindset that there is not a single diet that fits everybody? 

Dr. Melinda: 

I think that’s probably been a little bit of my hard part in terms of writing a book or doing some things. I don’t think there is one best diet, and only one diet that works for everybody. I do think that anti-inflammatory is the way to go, which means a lot of plants. That doesn’t necessarily mean no meat, but it means very little meat to me. 

The diets that are more meat-heavy I would say are the only ones that I have a bit of a conflict with. I’m sure there are people who feel great when they eat a lot of meat. From my research, that’s just not the direction that I recommend patients go. 

Often, patients are told not to eat gluten or dairy if you have an autoimmune disease. Don’t eat grains. Those to me get more nuanced. 

Dr. Eric: 

Nightshades as well are pretty common.

Dr. Melinda: 

And the nightshades fall into that category as well.

Dr. Eric: 

It’s a little bit different. There are health properties to tomatoes, eggplants, and peppers. Everybody is different. I’ll admit that my autoimmune patients, I tell them to at least take a break from nightshades. I don’t say to avoid them forever. There are some people who choose not to. Maybe they follow more of a paleo diet. Eat some nightshades, and they might still progress well and do okay. It’s almost like playing it safe. Let’s see how you do without them. Eventually, you have to reintroduce them.

With gluten, I know some of your thoughts because I mentioned I listened to some of your other interviews. I guess gluten, I’m more strict on. The question is does everybody need to avoid gluten forever? Is it bad if someone goes to Giordano’s in Chicago or other good Chicago pizza? Is it a bad thing every now and then to have gluten? Let’s hear your thoughts on that. 

Everyone listening knows my thoughts. I tell them to avoid gluten at least while healing. Even dairy. Nightshades, definitely not as bad as gluten in my opinion. They have some good health benefits. I’d love to hear what you think. I know it’s different than what I think.  

Dr. Melinda: 

It may or may not be. I will often recommend it for my patients who are coming to me initially with autoimmune disease who are not feeling great, even on their optimized thyroid medication. I will oftentimes recommend a gluten-free, dairy-free, elimination diet. We may do a trial of that, especially if there is some concern about leaky gut. Then we are trying to do some gut healing. 

To me, then we need to eliminate all of the major things that could be exacerbating the inflammation while we give the gut time to heal. Because there is such a high prevalence of Celiac in people who have diabetes and people who have autoimmune thyroid disease. For one, they have to get tested. It may co-exist. If they have Celiac, then it’s 100% no gluten. Sometimes, there is no gluten even in your skin products or other kinds of things. 

The question comes down to: Is this a forever diet versus a temporary one? Then it comes down to how does the patient respond to me when they reintroduce it after being off it for 8-12 weeks? When we think their gut is healed? I listen to the patient. I always tell my patients that I am not just treating a lab or a number on the paper, even if it’s a food sensitivity test. We always have to look at the patients and what their responses are. 

Dr. Eric: 

I look at it that way, too, as more of an elimination diet, not a forever diet. With the nightshades, definitely. With dairy, I can’t say I have been dairy-free. I dealt with Graves’ in 2008 and have been in remission since 2009. I can’t say that I never have a dairy. 

I can’t say that I have been 100% gluten-free, where I haven’t had any gluten or cross-contamination. If you have Celiac, you want to be super strict. If you don’t have Celiac, there are some people who choose not to completely 100% avoid gluten even if they don’t have Celiac. There is no need for us to have gluten. Some will say it’s playing with fire if you have a history of autoimmunity. Even if you don’t have Celiac, it could cause problems because it could potentially cause permeability of the gut. 

To me, it does depend on the person. For the most part, I am gluten-free just because like you, I am eating whole, healthy foods. If you are eating whole, healthy foods, you are typically avoiding gluten. I can’t say I haven’t fallen off the wagon every now and then. It sounds like you maybe share the same thoughts. Some people, if they don’t have Celiac, might be okay if they occasionally get exposed to gluten. It’s not going to be a problem with everybody. 

Dr. Melinda: 

Whole grains are very healthy. It’s not just quantity; it’s also quality. You’ve probably had reports of this, too. People go to Europe and are eating Italian pasta and bread, and they’re like, “I have no issues here.” They come back here and then aahh. Some of it might be pesticides and not necessarily the gluten itself. 

I have patients who are eliminated, and they feel great. Then they have no desire to do it. Then they know, “If I go and eat this birthday cake, I won’t feel so great the next day, but I’m not causing permanent harm.” I have others who have families, and it’s just easier for them. They don’t feel differently after doing an elimination diet. For them, it’s fine to keep it in moderation. I think I’m a little more lenient on those.

Nightshades, same thing. They have alkaloids in them. Some people do have reactions to them. Those tomatoes and peppers, all those bright colors, lycopene, have such health benefits with those polyphenols that I hate to cut out a whole category unless someone clearly has a reaction to it. 

This is where I get into testing and seeing what’s going on when you’re eating those things. If we eliminate them, and you get better, then you are reacting to them perhaps.  

Dr. Eric: 

You also mentioned the quality, which is important. Someone might say, “Well, I went out to eat, and I had a gluten-free pizza.” I also used non-dairy cheese like Daiya. There is probably glyphosate in whatever dough they’re using. Also, the oils that they’re using are probably not the healthiest. Some people get so caught up on gluten and dairy and other allergens but don’t look at what kind of oils they are cooking with. That’s not good for you. 

It’s one of those things where people want to live and go out to eat. Same thing. Every now and then, I want to go out to eat. I can’t say I’m perfect all the time. Some people get so caught up on gluten-free, dairy-free and overlook other sources.  

Dr. Melinda: 

Other aspects of the diet. It’s like when you go back to the ‘70s and ‘80s when fat was evil. Everybody was like, “I’m eating healthy. I’m eating all of these fat-free Snackwell cookies.” Of course, what happened? Now we have this sugar/diabesity epidemic. 

What are people replacing gluten with? If they’re eating all of these gluten-free cookies and other gluten-free processed foods, that’s not moving in the right direction for sure. I would rather have somebody have a clean, whole-wheat piece of bread than gluten-free cookies full of sugar and processed vegetable oil. But that’s me. 

Dr. Eric: 

Good point. You can get the Ezekiel bread, like the ancient grains, organic. Is that worse? That’s not gluten-free. Is that worse than eating gluten-free Oreos? Who knows what else they have? There Are healthier gluten-free cookies that are dairy-free and have everything natural. That would be a more interesting conversation, I guess.

As far as comparing, I would go with the Ezekiel bread. Maybe taste-wise, people would prefer Oreos. Who knows what else is in that Oreo though? 

Dr. Melinda: 

You have to look at the whole thing. If you’re doing whole foods, that’s one thing. We’re running into the same thing with the plant substitutes, like Beyond Meat and other kinds of things that are just rich in saturated fat. Whenever you try to eliminate and replace, and an industry makes something that’s artificial, it never turns out well down the road. 

Dr. Eric: 

Definitely agree. How about oxalates? I interviewed Sally K. Norton, who wrote the book Toxic Superfoods on oxalates. There is at least one lab, Great Plains, who is now Mosaic Diagnostics, that does urinary testing for oxalates. You can’t completely eliminate them. Are you concerned at all about really high oxalate foods, like spinach or Swiss chard? 

Dr. Melinda: 

It’s a bigger category, too. Yes, spinach, kale, beans, chocolate. Chocolate has oxalates. 

Dr. Eric: 

Sweet potatoes, yeah. 

Dr. Melinda: 

This whole idea of these anti-nutrients. Back to the gut. Do the oxalates irritate the gut lining in some people, causing leaky gut? Some of it may be gut. There are some studies about oxalate affecting some of our immune cells, these monocytes and macrophages and having them release pro-inflammatory cytokines and chemokines. 

What can I say? I think it’s an individual sensitivity. Those foods are healthy in general. Traditionally, we’ve always thought of oxalate elimination for people who have kidney stones. The question is: Do others need to? I just recommend balance. 

This is where I think people get nutrition confusion. They will be told, “Eat a low oxalate diet.” What’s a lower oxalate diet? Broccoli. “But I can’t eat cruciferous vegetables because I was told they have goitrogens in them. I can’t eat oxalates, and I can’t eat goitrogens. I can’t eat gluten, and I can’t eat dairy.” Then they end up on a super restricted diet and get malnourished. They don’t enjoy food and have orthorexia. 

For me, it will usually come back to moderation. If somebody is not eating handfuls of spinach and kale every day, then I’m not going to eliminate it from their diet. 

Dr. Eric: 

I agree. I used to say I stuff my smoothie with spinach. Then I randomly did an organic acids test that showed I had high urinary oxalates. That was one of the major changes I made. Not to say I will never have spinach, but if there are other substitutes for spinach. 

I can’t say I tell people not to eat sweet potatoes, dark chocolate. It’s difficult. Like you said, when combined with other foods, you could end up with hardly anything to eat, with oxalates, lectins, goitrogens, and other compounds. 

Dr. Melinda: 

It’s individual. We have to remember that we have different genes. Some people have a gene that may lead to a problem with oxalate breakdown. They do have a problem with it. Maybe that, too. 

You saw on the test that you had high oxalates in your urine. That doesn’t mean everybody has that. It also relates to the gut and the gut microbiome because the gut bacteria are involved in how we metabolize things. Our nutrient status involves how we counteract oxalates. It’s so complex that any broad generalization always turns me off.

Dr. Eric: 

I get it. 

Dr. Melinda: 

I like that you tested. That’s the answer. You individualize it to you, and you know. That’s really the best. If patients have access to integrative/functional medicine practitioners who can help refine what they need, that’s always going to be the best.

Dr. Eric: 

Even in my situation, I cut out the spinach, but I can’t say I really made a lot of other changes. When I did a retest, the levels dropped significantly. They were within the normal limits. According to Sally K. Norton, that might not mean someone still doesn’t have oxalates. On the test itself, it still looked a lot better without the spinach. It’s not like I cut out sweet potatoes. It’s not like I wasn’t eating any nuts and seeds. The spinach is one of the higher ones. I’m not saying never to eat spinach. I was just loading my smoothies with spinach every single day. Just like you said, everything in moderation. 

Dr. Melinda: 

Moderation is my mantra.

Dr. Eric: 

Before we wrap things up, I did want to talk about seafood. Besides philosophical reasons, I have concerns about the environment, not just heavy metals, but PCBs. Do you also have those concerns? If someone says, “I want to have fish,” would you say, “Maybe have it, but in moderation?” 2-3 days a week than every single day because of concerns. 

Dr. Melinda: 

If there is one category beyond- I’m sure you’ve seen this. There are the roots; that’s the best. Have a lot of roots. Fish is the next category. Then you stay away from the two-legs and four-legs. They get progressively worse. I tend to say if you are going to have some fish, especially those Omega-3 fatty fish in moderation, that can be a healthy part of an anti-inflammatory diet. Like you said, not a lot of high mercury fish. Get good quality. Don’t overdo it. In moderation.  

Dr. Eric: 

Excellent. Anything else that you wanted me to ask you that I didn’t ask you?  

Dr. Melinda: 

Riff on anything? No. I think people with autoimmune disease, thyroid disease, we’re gaining a better understanding of different medications that can be beneficial, different alternative treatments like LDN.

Here is a more eloquent way of saying it: I have some patients who come in and say, “I don’t feel well. I need to change my thyroid medication.” Or, “I’m not feeling well. I think we need to tweak my thyroid medication.” Sometimes, that’s the case. 

But a lot of times, it’s these other things, like lifestyle and diet and stress and not getting enough sleep. Those are the things that are the factor, not finding that magical proportion of T3/T4. That’s the bottom line. Sometimes, that helps, but ultimately, you need to have a great base for your lifestyle.

Dr. Eric: 

It’s amazing that you do that. A lot of medical doctors would just adjust the thyroid medication, and that’s it. It’s great that you obviously incorporate all the diet and lifestyle stuff that we’ve been chatting about here. 

Can you let people know where they can find out more about you? Share anything you’d like, like your website and any place people can find you.

Dr. Melinda: 

My best place is my link in bio, since it has links to everything. DrMelindaRing.com has links to free downloads on anti-inflammatory culinary medicine; a little booklet I created; my Instagram; my website at Northwestern; and all kinds of things. Just go to DrMelindaRing.com, and they can link to whatever they like. 

Dr. Eric: 

You’re on YouTube and TikTok? 

Dr. Melinda: 

A little bit. I’m not so consistent. I need to get better. 

Dr. Eric: 

That’s okay. I’m on YouTube, but as of recording this, I haven’t done any TikTok videos yet, so that’s okay.

Thank you, Dr. Melinda. It was a great conversation. Appreciate you being open and honest about everything. I agree with what you said: Moderation is the key as we all know, but we sometimes lose sight of that. Thank you so much for your time.

Dr. Melinda: 

Yeah, I enjoyed it. Thanks, Eric. Have a great day. 

Dr. Eric: 

You, too. Thank you.

Recently I interviewed Dr. Emily Kiberd, and we talked about mold-gut-thyroid connection. If you would prefer to listen to the interview you can access it by Clicking Here.

Dr. Eric Osansky: 

Hello, everyone. I am very excited to chat with today’s guest, Dr. Emily Kiberd, as we are going to be talking about keeping fit and muscle mass. This is the first time I am talking to anybody on the podcast in depth about exercise, building muscle mass, what to do and what not to do. 

Let me give Dr. Emily’s bio here. Dr. Emily Kiberd is a chiropractor, mama to Elvis and Brooklyn, and the creator of Thyroid Strong, which is the only doctor-designed exercise program for women with Hashimoto’s to learn how to work out with the burnout. She has been featured in Vogue, Women’s Health, Self, as well as Fortune for her expertise in strength training, injury prevention, and ergonomics. She also has a wonderful podcast called Thyroid Strong. Thank you so much for joining us, Dr. Emily.  

Dr. Emily Kiberd: 

Thanks for having me. Excited to be here.

Dr. Eric: 

Let’s talk a little bit about your background. Obviously, I gave a very brief bio right now. How did you make the transition? Were you always helping people with muscle mass and exercise? Over the last few years, did you make that transition? 

Dr. Emily: 

I have been a chiropractor since 2007. Coming out of school, it’s like adjusting, maybe doing some soft tissue work. It gets very boring in my opinion very quickly when you are doing the same thing every day. A certain number of people get better, and a certain number of people come back, “I still have some pain here.” Obviously, as a practitioner, you want to help as many people as you can.

The journey evolved. A lot of it was doing yoga teacher training and using yoga therapy in the practice. Then it evolved into doing strength training, knowing where there is too much mobility, too much movement, and where there is not enough movement. People assume there is a tight muscle, or something feels stuck, so we should release it. Get a massage or stretch or release. Oftentimes, that can be compensation for something else that’s not stabilizing. You have to work on that other place that is stabilizing that compensation. Sometimes, that tight place will let go. The practice slowly evolved into that.

As with anyone’s practice, it should be an evolution, I think, as you learn more. I am always curious and hungry for knowledge. In 2016, I had my first kiddo, Elvis. For the first year, I was just exhausted. All those symptoms that you think are “normal,” everyone’s like, “You’re a new mom.” This is not good. 

18 months post-partum, he’s walking around. I was exhausted. My hair was falling out. The outer third of my eyebrow was missing. Couldn’t lose about 25 pounds of baby weight. Every time I ate, my tongue would swell, and I had a little bit of eczema on my hand. I went through the primary care/endocrinologist. 

I went to two functional medicine docs, until I met my current functional medicine doc, Dr. Gabrielle Lyon. “How come no one has tested more than TSH? You have an autoimmune condition. You have the presence of thyroid antibodies. The official diagnosis would be Hashimoto’s, but it’s good that we caught it early. If you catch it early and figure out what the trigger is for that inflammation, you can go into remission.” That is exactly what happened. 

When on this journey of changing how I was eating. I let go of gluten. Basically anything I was eating, I was reacting to. I was having histamine intolerance. Kind of like mast cell activation syndrome. I could smell someone’s clothes. I knew they washed them in Tide, from 50 feet away. Especially in NYC, where you can smell everything. There are lots of odors. It was very intense. 

Part of the journey was finding out I had mold in my apartment, which can cause a histamine response and cause that overactive immune system. It can trigger Hashimoto’s as well. I had water damage and mold and Aspergillus. I did a lot of developing country travel in my 20s, so I had about three different parasites: hookworm, roundworm, and pinworms. I went on that journey of starting to decrease that inflammatory load. 

I was over training, which was the birth of Thyroid Strong. I was trying to lose the baby weight, and I was going to spinning classes. Sometimes, I’d do a double spinning class, so two 45 minutes back-to-back, so 90 minutes of spinning, about four days a week. Or I’d do a spin class and walk across the street and then do a high intensity interval training class, Barry’s Bootcamp. The weight would not come off, and it was very frustrating.

Part of this journey was not only addressing those underlying root causes but changing how I was eating and that lifestyle factor of dialing back my exercise and getting smart about it. Through my own journey, I was then seeing more autoimmune women coming into the clinic. I was co-treating them with different functional medicine docs in the area in NYC. They were addressing functional medicine, internal stuff. All the women had joint pain, muscle aches, and low muscle tone. The docs were like, “Hey, I need you to get them out of pain and put some muscle on them.” 

Probably in 2017, that was this evolution of seeing more autoimmune women. From that lens, from the angle of “How are they moving?” Normally, when you see a doctor, you’re sitting down across from them. They’re reading your labs and giving you a game plan or a supplement protocol, and “we’ll see you in X months.” I’m getting them moving, checking what’s moving too much? What’s not moving enough? How can they pick up things in certain ways? Checking their tone of the muscle, checking their deep tendon reflexes, which can change when you are hypothyroid, and looking at them through that lens. 

I’m going to guess a lot of women who have an autoimmune condition are not assessed in that way. A lot of doctors don’t do that. I don’t think there are a lot of doctors who are functional medicine or endocrine and do rehab and strength training. That was the birth of Thyroid Strong and seeing more women in person struggling. From the clinical practice, there were certain things that I picked up. Oh, this is a consistent finding, which is interesting that no one is talking about. It was really an evolution, starting in 2015. 

Dr. Eric: 

Wow, that’s some journey. Obviously, every person’s journey is different. I am also a chiropractor by trade and dealt with Graves’ Disease. I didn’t deal with mold, which it sounded like you had some serious mold issues, or parasites. 

One thing we have in common is I was also overtraining. I was overtraining prior to my Graves’ diagnosis and should have known better, both of us being practitioners. It’s not like they teach that in chiropractic school about training. Rehab to some extent. What you’re teaching definitely is not taught in school for chiropractors or medical school. It’s great you’re helping others, and it’s great you’ve been in remission with your Hashimoto’s condition. 

I don’t know where you want to start. Do you want to start with what you actually recommend as far as different types of exercise? There’s cardio, resistance training, high intensity interval training (HIIT). Do you recommend one of those, a combination, or maybe something different? 

Dr. Emily: 

Because fatigue is such a big component of Hashimoto’s, I want my exercise to be efficient and effective. I used to train for triathlons and marathons. Long states of cardio. I find that there is also, as you know, an adrenal component to Hashimoto’s. If I’m thinking I want my exercise to be efficient and effective, and I know being hypothyroid, it is harder to keep muscle on the bone. Muscle is essential to help with the turnover of thyroid hormones from the inactive form, T4, to the active form, T3. It happens in certain places: the gut, the liver, and the muscle tissue. 

Knowing that, I know that women want to lose weight. Those are the two biggest struggles: I’m exhausted, but I’m overweight, and I want to lose it. If I want my exercise to check those boxes, I like resistance training. Feeding the muscle tissue. 

I like women to be walking. A lot of women are like, this cultural mindset of, “Oh, I need to lose weight. I will put on my running shoes and go for a run.” It’s not the right message to be sending. 

When we put more muscle on the bone, the more muscle we have, the more calories we burn at rest. If we want to lose weight, but we don’t want to cause a Hashi flare-up or be bed-ridden for three days because there are definitely women who are so fatigued they can’t get out of bed, I like resistance training. I like it on the heavier side, so you can hit that fatigue. Lower reps and long rest breaks in between sets. I like kettlebells because they’re very forgiving when you are first learning form. They’re portable. You can travel with them. We can talk about why kettlebells are so great. That’s what I prefer. 

I would prefer that over HIIT, especially if that adrenal component is there. If women are burning candles at both ends in other aspects of their life. As you start to put on muscle, you’ll have more energy. You’ll be changing your body composition. The number on the scale might be the same, but you’ll notice your clothes are fitting better. The number on the scale might be the same because muscle weighs more than fat. 

I think this focus on let’s feed our muscle tissue if we want to lose weight, versus “Oh, I need to lose the fat.” When we talk about losing fat, it comes from this place of deprivation. Put yourself in a caloric deficit. Try to run it out. Versus if you focus on feeding the muscle tissue, your body composition will change. Your clothes will fit better. You’ll be burning more calories at rest. You’ll have more energy. 

Muscle is a very expensive organ. It requires more feeding of it. Ideally, protein. It’s almost like changing your body from a place of elevation, feeding your muscle, to this place of deprivation, which is starving yourself to lose fat. 

That’s how I like to get women to work out. If they want to run, like if it fills their soul, like if they have been a runner before, you still have to strength train. Even if someone likes to walk, I’ve had women who can walk 30 minutes, and then their back starts to hurt. Maybe it’s more core strength, more glute strength. Maybe it’s strengthening your butts or hamstrings. If you get that woman to resistance train three times a week, for someone who is deconditioned, I will work them up to three to four times a week. Then they can go for a walk for an hour and don’t feel pain.

I don’t feel like there is any downside to having more muscle on the body. The way you will get there is through picking up something heavy, putting it down, and doing it again, as well as making sure you’re getting your optimum protein every day.

Dr. Eric: 

We have people with both Hashimoto’s and Graves’ listening to this. I agree for both. Resistance training for those with Hashimoto’s and Graves’, it’s very common to lose muscle mass. With Graves’/hyperthyroidism, a lot of people are losing weight. Some people with hyperthyroidism do gain weight. Sometimes, it is the opposite problem. Either way, I like what you said. You might not see the changes on the scale. Not that they won’t. Some people will. 

Dr. Emily: 

Yeah, for sure.

Dr. Eric: 

But if not, some might get discouraged. It’s important you mentioned that because muscle is denser than fat. Just to set those expectations. 

One thing you recommend in between sets is to take longer breaks. Are we taking two minutes or five minutes in between typically? 

Dr. Emily: 

If you go to a boutique or aerobics class, there is not really a break until the end of class. Maybe there is a 30-second break. I like women to do 60 seconds, 90 seconds. If someone is more seasoned, and they’re lifting really heavy, up to 2-5 minutes. It really depends on where they’re at on their workout journey. 60 seconds minimum. 

During that time, I like to have women toning their Vagus nerve. With Hashimoto’s especially, stress is a big piece of the puzzle. Stress can come in the form of emotional stress, physical stress, environmental stress like mold or parasites. There is this cultural message of “Don’t stress. Destress. Avoid stress.” Stress is inevitable. How can you lean into that stress to make you more resilient? 

One of the ways to do that is when you’re in a stress state, the quicker you drop into that calm parasympathetic, everything is okay, the quicker you can get out of the stress state and back to the parasympathetic state, usually the more resilient I find people to be, high performing. 

If you pick up a weight, it’s elevating your heart rate, breath rate, getting you out of breath. You take your rest break and have this moment to drop back down into the parasympathetic. I have some inside Thyroid Strong sing with their tongue on the roof of their mouth and try to extend their exhale as long as possible, ideally twice as long as their inhale. It’s almost like you’re training your nervous system. A lot of people train their nervous system seated or in a meditative state. You’re doing it after putting a stressor on your body. I like to do that during the rest breaks. 

It also makes the time go by faster if you’re not used to taking 60, 90, 2-minute breaks. People are like, doo doo doo. You get them to sing and hum and extend their exhale twice as long as their inhale, and it goes by quicker. That’s also why I like long rest breaks.

When women do that, I find they don’t get into that “Oh my god, I’m so tired after my workout I need a nap.” That’s very common. Women are like, “oh my god, I worked out, and I’m totally tanked out. I can’t function the rest of the day.” Our workouts shouldn’t take away from our day; it should enhance the rest of our day. It shouldn’t take us bedridden for a nap. It should energize us, if we fuel properly afterwards, and enhance our day. 

When you take a little bit of a longer rest break, and you’re doing these things that can help you drop back into the parasympathetic state, women feel more energized and not so tanked out the rest of the day.

Dr. Eric: 

Very cool. I’m going to try that during my next workout, too. You’re right. Even if people are taking a minute or 90 seconds or a couple minutes, depending on the intensity, most people are not doing anything. They’re just hanging out. Going to the gym- 

Dr. Emily: 

Checking their phone.

Dr. Eric: 

Half the people are on their cell phones. That’s great advice. How about frequency of resistance exercise? Do you recommend four times a week or less or more? 

Dr. Emily: 

Women with Hashimoto’s are on the spectrum. There is the Crossfitter, burning the candle on both ends, overtraining, six days a week. I’d probably drop that person to four times a week depending on their fatigue and symptoms. Maybe three. If you do three, they are itching for another day. So four days a week.

On the other end of the spectrum is a woman who is more deconditioned. She maybe walks 2,000 steps a day. She has maybe never touched a weight and is scared of them. That person needs to be worked up to three days a week. I do encourage walking as a form of exercise. I know a lot of women love to walk. It’s not resistance training or walking; it’s doing both. If someone is very deconditioned, this can be a lot. 

Those are the two ends of the spectrum. A sweet spot would be three days a week. If someone needs more, four days a week. Even my friends who are doing bulking hypertrophy programs, where they’re eating 2,500 calories a day, 250 carbs a day, they work out four times a week. They’re not doing six days a week. It’s too much, especially for the Hashi population, where you have to consider the inflammatory load. You have to consider fatigue and adrenal health when designing a program. 

Dr. Eric: 

Do you work out four days a week on average? 

Dr. Emily: 

Yeah. I try to walk every day. Bike my kids to school. Depending on what I’m working on, yeah. I would say 3-4 days a week. 

Dr. Eric: 

When do you prefer working out? Is there a best time to work out, like first thing in the morning or in the afternoon? 

Dr. Emily: 

If someone is trying to reset their Circadian rhythm, so maybe they have low cortisol in the morning and are dragging, it would probably be better to try to work out in the morning to spike your cortisol when it should be highest. Maybe out in the sun to get some sun in your eyes would be great.

Just by my nature, I am a mid-day worker-outer. Around lunch time. If I work out after 2pm, when I lived in NYC, I would get done with work at 7pm and go to a spin class at 7:45pm. Then I would be wired until 2am and wonder why. If I work out after 2pm, maybe 3pm, I get a second wind at 10pm when I should be going down. I try to push it earlier in the day, mid-day. 

Dr. Eric: 

I definitely want to talk to you about the kettlebells. Before we get into that, what do you recommend as far as protein intake? 

Dr. Emily: 

I think a lot of women are under-eating protein. I think protein should be prioritized. For people who are bedridden, the more muscle they have on their bones, the more likely they are to recover from their injury or sickness. 

For protein, I like to shoot for 1g per pound of ideal body weight. If my ideal body weight is 150 pounds, I will have 150g of protein a day. I will dose it equal. Sometimes, culturally, we dose dinner as a higher protein intake. Ideally, you would want it in more even amounts. In this example, like 50g for breakfast, lunch, dinner. I try to eat my protein first, and then I take in fiber, so vegetables. 

I have a history of being a grazer. I don’t sit and eat. I try to make myself sit and eat. There is a dose dependency, like a time frame. I try to get my protein within 25 minutes, versus eating a little bit, doing something, and eating a little bit more. 

There is a dose dependency to trigger toward, then muscle protein synthesis. We are eating protein for the amino acid profile. Protein is very satiating. It’s almost impossible to overeat protein. You would probably throw up if you did. Especially for the women who want to lose weight, it’s great because it’s very hard to overeat protein. It’s important to get protein in the morning after we’ve been in that fasted state and sleeping. Most women are undereating protein. 

Sometimes, I have women just change their protein intake, not even pick up a kettlebell yet, and they’re like, “Oh my god, I have so much energy, I don’t even know what to do with myself.” All they did was try to hit 30g minimum per meal. That triggers muscle protein synthesis. You get your 3-5g there. That’s what I try to shoot for. That’s really from the work of Donald Layman, who is a researcher who is retired now. But he was in that field, especially around boosting. 

Dr. Eric: 

I’m sure someone who is listening to this is thinking, “There is no way I can get 1g per 1 pound of body weight.” 

Dr. Emily: 

Ideal body weight. 

Dr. Eric:

Animal protein I would imagine is your primary source then of protein. 

Dr. Emily: 

Yes. Just so there is a complete amino acid profile. When I was first diagnosed with Hashimoto’s, and I was reacting to everything, I had H-pylori, stomach acid. I couldn’t really eat that much. I was doing a pea protein shake as a medical grade food because that was all I could tolerate while I healed my gut and worked through those triggers. 

I prefer animal protein. I know for some women who don’t eat a lot of animal protein, “five eggs for breakfast?” They feel like they are choking them down, and they’re full up to their chin. You might have to work up to that. I would say animal protein is my main source. 

Dr. Eric: 

Would you recommend if someone initially is struggling to get it through food, is it okay if someone wanted to supplement with protein powders or take amino acid supplements or both? 

Dr. Emily: 

Yeah, I think that’s fine. I have a protein powder that is made out of beef, Equip. The research is mixed. There is some research that shows the amount of protein you actually absorb from plant-based protein is less than what is stated on the package. Animal protein is a more absorbable form as a protein source. The newer research shows they’re equally absorbable. 

I wouldn’t be pounding soy protein, I’ll just say that, if you have a thyroid condition. But if you wanted to mix it up- Five eggs is 30g of protein per breakfast. Most women can’t eat five eggs. Why don’t you try two eggs and two sausage links, like chicken sausage? Or maybe you have two eggs and a protein shake. It doesn’t feel like you’re stuffing yourself full of food.  

Dr. Eric: 

That makes sense. Let’s talk about kettlebells. Why do you like kettlebells? What are some ways you recommend for people to use them? Do you just recommend kettlebells for resistance training? I’m sure you’d be okay with people using weights and bands. Do you just stick with the kettlebells, or do you have other things you incorporate into a routine for resistance training? 

Dr. Emily: 

As you go heavier in weight, you’re going to need heavier weight. If I deadlift 1.5 times my body weight, picking up 2 100-pound kettlebells is awkward because they are so bulky. Then I would use a hex bar or barbell. You have to learn the form with the barbell; it’s not very forgiving, especially as you are trying to get around your shins as you’re lowering down. 

If you take the deadlift, which is basically a hinge movement where you’re sitting your hips back, standing upright, squeezing your butt. If you think about a barbell, you have to navigate the barbell around your shins. It’s awkward as you’re lowering it down. 

You could use dumbbells. Where do they go? You have to shave your shins with them. Kettlebells, you can literally get right below your center, right below your crotch basically. You can sit your hips back, pick them up, and put them right below your center. A barbell is a little bit in front of you, so it’s away from your center. Little nuances like that. 

If you start someone with barbell deadlifting, it’s a little intimidating and awkward. Kettlebells, they’re much more forgiving when you’re first learning form. Your form ideally would be good and almost perfect, so you don’t injure yourself. But if your hips are too low or too high, you won’t injure yourself. But with a barbell, your form has to be dialed in, 98% perfect, in my opinion.

I also like kettlebells because there is this offset weight. Let’s say you will press overhead. If you have a dumbbell, the weight is on either side of your hand. With a kettlebell, the bell sits on the back of your wrist. When you’re holding the kettlebell in front of your chest, what we call the rapt position, you have to curl your wrist into neutral. You don’t want your wrist to be cocked back. You want it neutral. 

If they put their hand up and make a fist, and if you push down on the hand with the other hand, and then you make a straight fist, and you push, you can literally feel the shoulder stabilizing muscles. Your latissimus, your serratus, activate. Because there is this offset weight where the bell is on the back of your wrist, it forces you to create these points of stabilization in your body that doesn’t happen necessarily with a dumbbell. 

The other thing I love about kettlebells is you can use them ballistically. In Thyroid Strong, we do seven moves that are essential for people to do for life to be good at life: a hinge, a squat, some sort of push movement, a pull, a lunge, a carry, like you’re carrying your groceries, and some sort of control of rotation of your core. We work up to over the six weeks of kettlebell swings. We do drills, so you’re not just swinging a bell all over the place. Get your heart rate up. It’s a tool to get you breathy, get your heart rate up without going for a run, without doing more of a HIIT, where you’re doing 15-30 seconds of all-out work, and you’re getting your heart rate up to 80-85% of your maximum heart rate, and then doing 15-30 seconds of rest. That is more of a HIIT. You could do 10 kettlebell swings and get your heart rate up.

The other tools that could be used as ballistic moves would be a barbell. Now, you’re getting form. If you cleaned a barbell up to your chest, now you have to get your form dialed in. I like kettlebells because they have that ballistic potential to help you get your heart rate up.

Dr. Eric: 

It sounds like those who go through your Thyroid Strong program will become experts in using kettlebells. When it comes to form, I might be wrong, but I think you’re saying it’s not as important with kettlebells or dumbbells, but it may be easier to keep proper form with kettlebells. 

Dr. Emily: 

It’s more forgiving when you’re first learning. Because the weight can be under your center, versus in front of your center with a barbell, if you do a heavy carry, like if you have two bells and they are down toward your sides, and you are packing your shoulders, if you did that with a dumbbell, they are hitting your legs, and it’s awkward. Kettlebells are not. You can hold them down to your sides, and they glide past your legs. It’s just more forgiving when you’re first learning form. There can be a little more margin of error because that’s what happens when you learn form. You do it not that great the first couple of times. 

Part of Thyroid Strong is there are really good cues in working with patients in person to get someone into the perfect deadlift setup. Versus you might work with a trainer. Sit your hips back, grab the bell, stand up. Where do my feet go? Where do my knees go? Are my hips too low or too high? In Thyroid Strong, there are cues. You can get someone in the perfect starting place. 

There is just more margin for error when you’re first learning with kettlebells than maybe some of the other tools out there. 

Dr. Eric: 

That makes sense. I don’t know if you mentioned this earlier. Obviously, you spoke about having longer breaks in between sets and doing the Vagus nerve exercises, stimulating the parasympathetic nervous system. Do you have someone do 12 sets or 10 sets or just until they’re fatigued? Does that depend on the person? 

Dr. Emily: 

If women are more new, I typically have them do three sets. Someone who is more conditioned, four sets. In terms of reps, which is the number of times you pull a weight, and then a set- 

Dr. Eric: 

I mean, how many reps and how many sets. I meant to say repetitions specifically first.

Dr. Emily: 

For someone who is scared of picking up a weight and is more deconditioned, I might start them at three reps to get them to grease the groove of the movement, create that muscle memory. Once they’re starting to get into a groove of working out, 6-8 reps. I very rarely go over 10 because I am trying to factor in not wanting to fatigue someone, especially if they haven’t dealt with those other inflammatory loads in their body. That’s when I say, “You build muscle when you hit fatigue,” and fatigue, when you’re working out, by the last couple reps, on a scale of 0-10, you’re hitting a 7 or 8 in perceived exertion. That’s one way. That doesn’t resonate with me really well. 

The other way to think about it is by the last couple reps, you ask yourself, “How many more could I do?” If you have two more in the tank, that’s a good place to be. If you could do five or 10 more, then you need to pick up a heavier weight.

The third way to talk about it is on the last couple reps, the concentric phase, where you’re shortening the muscle, fatigue is when you can’t get full range of motion on that phase. That would be another way of considering failure. That’s where hypertrophy happens. That’s where muscle maintenance, growth happens. 

The fourth way that I talk about that a lot of people don’t talk about is do you lose form in default into this extension compression conversation? This is from learning and studying for the Prague School in the Czech Republic this technique called dynamic neuromuscular stabilization. They basically looked at how babies learn their movement patterns and how they hit their milestones. For example, the first six months of life, maybe three months, is literally trying to bring their knees up to 90 and create rigidity and a brace in their core. 4.5 months, they roll. At six months, they’re sitting. There are these milestones babies hit. 

A baby who is not developing properly, which is about 30% of babies, will default into this extension. If people don’t know what an extension is, it’s an arching of their back—to compress their spine to execute a movement. Versus using their intra abdominal pressure. Babies who don’t develop well will do that. They’re flaring their ribs and cranking their back out; you can see their paraspinals activated. 

We do that as adults when we hit fatigue. If you have ever seen a Crossfitter do a muscle up where they are holding rings and pushing through and pushing up, when a Crossfitter hits fatigue, they will literally crank into extension in their low back and neck to try and execute the movement. Versus using their core and using good intra-abdominal pressure.

Same thing when you fatigue in any other move. You will basically default into this extension/compression compensation. Basically favoring extension in the low back and neck. You will see this in a deadlift. People stand up and are pulling, pulling, pulling, and will over push through their hips and crank up their back. You will see it in a plank. Someone is simply holding a plank. Once someone starts to fatigue, their back will start to arch, and they will lift their chin to crank on their extensors. That is another way to know that you’re hitting fatigue.

In terms of reps and sets, you want to hit about 8-10 sets per muscle group per week. It’s a good place to be if you want to gain muscle or maintain muscle.

Dr. Eric: 

Like you said, if it’s toward the end of each rep, especially if it’s the last set and still kind of easy, that’s an indication to increase the weight. 

Another question with that: Do you recommend them for people in general, women and men, to keep on increasing the weight? Do you recommend a wellness weight, where they have reached a weight, and they should stay at that weight? Do they keep increasing the amount they lift? 

Dr. Emily: 

You want a program that has progressive overload. There is progression of the weight over time. There are other ways to progress without necessarily picking up heavier weight. It’s basically more time under tension. 

An example would be you do a squat. You hang out on the bottom of the squat for an extra second or two, or an extra breath, before you stand up. You didn’t increase the weight, but you increased your time under the load, which will then increase the volume. 

You could do 1.5 reps, so you go down in a squat, come up halfway, go back down, and then stand up. It’s another way to increase the load without necessarily picking up a heavier weight. 

I do that in Thyroid Strong because it’s a home base program. I don’t want women buying 20 kettlebells because they’re expensive. They don’t want to clutter their living room. So you have a 12-kilo, 14-kilo, and 16-kilo. That’s what we have to work with. Instead of you investing in a heavier bell, we’re going to do these techniques to keep more time under tension without necessarily having to pick up a heavier load. 

Yes, you want progressive overload. A great way to do it is to slow down the e-centric phase of any move. The e-centric phase, if you’re doing a bicep curl, this is the concentric, and this is the e-centric. Your muscle is lengthening under the load versus concentric, which is shortening. Any move where it has an e-centric phase, you make that 3-4 seconds. You stand up with a dead lift. As you’re lowering back down, you take 3-4 seconds to lower. It’s a great way to not necessarily have to pick up a heavier weight.

Dr. Eric: 

Women listening don’t have to keep on purchasing kettlebells. That’s one reason why I was asking that. 

One of the things prior to the interview that we were talking about is hypermobility. Talk about hypermobility and autoimmunity. 

Dr. Emily: 

I haven’t found any research on this. I go to PubMed every week and type something in and try to see if there is any research on it. 

What I noticed with women with autoimmune conditions that I was treating in the clinic was I’m looking at them through a lens of movement. What’s moving too much? What’s not moving enough? I will check a Beighton score, which is a physical therapy orthopedic test looking for hypermobility. The places you look are the knees, elbows, thumbs, pushing down and touching the soft part of the forearm, pinky bending back beyond 90. The last point is someone standing straight, bend forward, touch the floor, they can palm the floor. Kind of like a yogi, but they probably created biomechanical hypermobility. If those points come up in a Beighton score, there is a sign of tissue laxity/joint hypermobility. 

I was finding this in women with autoimmune conditions. It wasn’t 100% of the time. It was probably like 80-90% of the time. But it was significant enough to be like, Hmm, okay. All these women are coming in with joint pain and muscle aches, and they all want to get adjusted and a massage. 

Listen, no amount of massage is going to help create that stability and rein in that joint that is hanging out of the ligaments. We need you to resistance train, get stability and strength in the right places. A lot of women will feel tight in their mid-back. We can do some mobility drills and adjust you there, but you need ultimately strength. No amount of stretching or yoga is going to rein in the integrity of the joints. I noticed this in a lot of women with Hashimoto’s. 

Other people I have talked to, like Jessica Drummond, who is on the East Coast and is a physical therapist, she has noticed a lot of women with long haul COVID having this intermittent joint hypermobility or joint hypermobility post-COVID. Some of the trainers that I talk to who also do resistance training or programming for women with Hashimoto’s, they notice a lot of Hashi women have joints that are totally hypermobile. It was a clinical observation, but it was something that really guided how I cued and programmed inside Thyroid Strong.

Dr. Eric: 

Very interesting. Do you talk about that more in your program? 

Dr. Emily: 

Yeah. Let’s say you’re standing up from a dead lift. You’re at the bottom, and you stand up, knees straight. Most trainers would say, “Grab the weight, and stand up.” Someone who is hypermobile, and their knees hyperextend, don’t know where their center is. If you just ask that person to stand up, and they jam into their knees, they will get joint pain, probably on top of their hypothyroid condition causing joint pain anyway. 

I teach women to foot dial, which helps bring tension from the feet up the legs. Professional lifters do this. If you stand with your feet, toes turned out ever so slight, and as you’re standing up, you squeeze your heels together, but you don’t move your feet. You will literally draw tension, like your whole leg will activate: your quads, your glutes. You can stand up with straight knees without jamming them into hyperextension. That’s one example.

In the plank, if your elbows are straight, their elbows will hyperextend. You can get them to push through their index knuckle, which comes from how babies crawl. Babies who crawl and develop properly will ground their index knuckle into the ground. Babies who don’t develop properly will actually hang out on the pisiform side of their hand and crawl like this versus actually pushing through. In a plank, you can get someone to push through their index knuckle and turn their elbow crease toward their thumb and get them out of hyperextension. That helps activate your serratus. It helps your shoulder stability. 

If you did a plank where you are hanging out on the outside of your hands, and you’re hyperextending your elbows, you won’t fuel your shoulders into protraction, into the shoulder blade wings going down and wide across the ribs. Those are cues that are very specific from my background of studying how babies move as well as working with women and trying to get them into good form. Simply being, “Oh, don’t put a little bend in your elbow.” That’s not enough. If you just put a little bend in your elbow with the elbow hyperextension, you won’t feel your shoulder stabilize, which is important in a plank. Most people think of plank as a core exercise. It is full body tension. It is connecting shoulder stability to core stability. 

Dr. Eric: 

I’m sure many listening are eager to get started. Where should they get started? I’m thinking Thyroid Strong should be a good starting point. If there is anybody who is maybe not ready to think about doing it on their own, could you give a few tips prior to joining you in Thyroid Strong? 

Dr. Emily: 

Thyroid Strong is six weeks. I have shorter two-week programs. If someone isn’t sure they want to fully invest, these courses are under $50. They are full recorded videos of workouts. 

I do a lot of stuff on my Instagram. My website is DrEmilyKiberd.com. Different workouts, moves, form cues. A lot on social media.  

Dr. Eric: 

Also, your podcast, which is also called Thyroid Strong. Is there anywhere else where they can find you? 

Dr. Emily: 

I’m on YouTube and TikTok. And I do have a private Facebook group for women who want to find out more. Sometimes, people don’t necessarily want to email or DM, so there is a Facebook group. Women are like, “Oh my god, I’m not alone. Here is 4,000 other women who also have Hashimoto’s and extreme fatigue or exercise intolerance when they work out.” The group is called Thyroid Strong. 

Dr. Eric: 

That’s not just for people who join Thyroid Strong. Anybody can join that? 

Dr. Emily: 

Yep. I have a separate Facebook group for people who join the program. Then we get really nitty gritty. There are videos and form checks and keeping people accountable and creating accountability buddies for their workouts. We talk a lot about protein and weights. 

Dr. Eric: 

Thank you so much, Dr. Emily. Appreciate your time. I always learn a lot when having these conversations, and today was no exception. I definitely learned a lot. Thanks again. 

Dr. Emily: 

Awesome, thank you.

Recently I interviewed Dr. Eric Balcavage, and we talked about  thyroid physiology. If you would prefer to listen to the interview you can access it by Clicking Here.

Dr. Eric Osansky: 

I am very excited to chat with Dr. Eric Balcavage, as we are going to talk about thyroid physiology. I am all about talking about the thyroid, but we can’t get into everything in his book. That’s why you need to get his book The Thyroid Debacle. Let me give Dr. Eric’s background. We will dive right in after. 

Dr. Eric Balcavage is the owner and founder of Rejuvagen, a functional medicine clinic in Chadds Ford, Pennsylvania. He is a nationally recognized speaker and educator on various health-related topics, including thyroid physiology, biophysiology, detoxification, oxidative stress, methylation, and chronic illness. Dr. Balcavage is a functional medicine practitioner and licensed chiropractor in PA, and he is 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 also find his educational Thyroid Thursday videos on Instagram and YouTube. 

Dr. Balcavage has made it his mission to change the way medicine looks at hypothyroidism. He is also the co-author of the book The Thyroid Debacle. The book is also co-written by Dr. Kelly Halderman. It addresses the problems of current allopathic and functional medicine approaches to hypothyroidism as well as the solution to restoring thyroid physiology. Dr. Eric, thanks for joining us. 

Dr. Eric Balcavage: 

Thanks for having me on, Eric. 

Dr. Eric O:

Before we talk about your book and thyroid physiology, what led you and Dr. Kelly to write the book in the first place? As you know, there is no shortage of thyroid books out there. Yours definitely takes a different perspective.

Dr. Eric B: 

I got into functional medicine really by accident. I had a family member who got diagnosed with hypothyroidism, fibroids, and anemia. They were told they were going to need a hysterectomy, iron supplementation, and thyroid medication for the rest of their life. That’s just the way it goes.I was asked to help, and I said, “It’s not what I do.” When your brother asks for your help, you start figuring it out.

I went back to my roots of chemistry. I was a medical technologist before I made the decision to go off to chiropractic school. I looked into chemistry, realized what was going on there, started doing my functional training with DatisKharrazian and Apex. That was a great footing. I’m sure you did some of those courses early on because Datis was the man early in the day.

As I started working in my chiropractic base and talking about what I was learning, I realized how many of my chiropractic clients were on thyroid medication. I really didn’t pay that much attention to it early on. I was more focused on what I was doing chiropractically. As I was talking to them, most of them felt maybe a bit better, but a lot of them still had signs and symptoms. A lot of them had weight issues, most of the classic signs and symptoms. I started talking about Hashimoto’s because that was this big thing. It’s an immune issue, not just the gland doesn’t fail one day. There is an immune-driven process. I started getting more into functional medicine.

As I was doing that, we had this philosophy in functional medicine, at least for my teaching, that the immune system was out of control, and it just started damaging the thyroid gland. Our job was to look for some of those stressors and triggers. Not that there was a lot of hope. This is an autoimmune condition. Your immune system has lost control and will damage your thyroid gland.

The other piece we looked at was T4, T3, reverse T3, and these other values that weren’t traditionally being looked at in medicine and making those decisions. The thyroid gland makes both T4 and T3, so maybe we should be doing a little bit of a different job. Maybe we should be recommending T3 as well. These silly medical doctors aren’t aware that T4 is not converting to T3 well, and it’s deactivating reverse T3 and changing the treatment based on that thought process.

The challenge I had the longer I went into this was I really struggled with the idea that the immune system just lost control and woke up one day and decided it was going to destroy the thyroid gland for no apparent reason. That didn’t sound like good logic. Why would the immune system just start attacking our own tissues? I thought there had to be something else going on. I was talking to a friend of mine. It doesn’t seem quite right that the immune system would do this. I never really liked the term “autoimmune condition.” It’s an immune-driven condition, but I don’t like the idea that the body willy nilly attack ourselves.

A friend of mine, Dr. Ben Lynch, who you know, we were preparing for a conference. He sent me a paper on the cell danger response. He said, “You need to read this.” When I read that paper, I was like, oh, we operate in two modes. We are either in low stress, homeostatic regulation, or we’re in a different state, allostatic regulation, which is an excessive stress response. I said, “This makes a lot of sense.”

Dr. Naviaux showed how depending on the situation, we use micronutrients for one pathway, but in other situations, we may use micronutrients for a different pathway. Our physiology adapts to our environment, to the stressors, to what’s going on. Maybe that is really what’s going on here. The cells change their physiology, and the immune system changes its physiology based on what’s going on in the body. I thought, maybe what we were seeing was more of an adaptive change versus this systematic control because if your immune system is out of control, it doesn’t sound like you will ever recover. If it’s an adaptive physiology, then we could find out what it’s adapting to. 

I got into a really deep look into the literature, papers, and research. The more I looked at it, it’s my philosophy in general that a lot of what we see with thyroid physiology is an adaptive response to some type of excessive stress response. If we can identify what those stressors are, reduce them, remove them, we can support the recovery of the physiology. In many situations, we see improved T4 to T3 conversion, reduced immune damage to the thyroid gland, and a thyroid gland recover in time. Many of my clients need less thyroid medication. The medication they take converts better, and a whole bunch of them in time don’t need it at all.

Dr. Eric O:

Makes sense. You’re not saying people with Hashimoto’s and even non-autoimmune thyroid conditions don’t need thyroid hormone. Most doctors are neglecting the physiology, so maybe some of these people don’t need to take thyroid hormone replacement. Others might not need to take as much as they are currently taking.

Dr. Eric B: 

In the allopathic model, the focus has always been on TSH and free T4. Early on, we’d say, “These silly allopathic doctors and endocrinologists are only running two tests. They’re not running thyroid antibodies. They don’t know that this is an immune-driven process.” I don’t think that’s the case. I think most of them realize it’s an immune-driven problem. We pretty much know it’s either an iodine deficiency issue or an immune-driven problem. If you’re in an area where there is sufficient iodine either in the environment or in our food sources, it’s probably not an iodine deficiency. That leaves me immune. Depending on what you read, it’s thought to be that 95% of cases of thyroid, especially hypothyroidism, are immune-driven.

I would argue that whether there are antibodies or not, almost all of them are immune-driven. If you look at the immune system of people who have glandular hypothyroidism going on and negative antibodies, if you look at their T cell panels, they are Th1 dominant, which will result in lower antibody production typically anyway. It’s still an immune-driven process.

The challenge in functional medicine to some degree is- At least I think what I was taught is the antibodies are like little Pac-Men eating away at the thyroid gland. TPO and thyroglobulin gobble it up. The literature shows that thyroglobulin doesn’t create any damage to the thyroid gland. TPO antibodies create very little. If they are not creating much damage, what is causing the damage? It’s the immune cells getting to the thyroid gland and creating the damage. In that situation, the T cells are creating a lot of damage, but if you’re Th1 dominant, you may not see it.

For the most part, what we’re seeing is an immune-driven process. The allopathic world knows that, I think, but they are coming at it from a point like, “We’re not going to suppress the immune system. We know the thyroid gland will get damaged. There will be a point where it can’t make enough anymore. We have a simple solution. We give them more T4. The thyroid gland primarily makes T4, so we will give it what it can’t make, and the patient should be good. The indicator that we’re going to use that shows that we have reached euthyroidism or normalized thyroid physiology, a TSH within a preset range. If I give someone enough T4 to bring the TSH into range, everything is right in the world.”

Unfortunately, that doesn’t work for a whole bunch of people. For the listener, T4 is the pre-hormone. It does have some functionality, but most of the functionality in the thyroid world comes from T4 being converted to T3 inside your cells and tissues. T3 binding to receptors, and that’s what is turning on your metabolism. We can make the assumption that if the thyroid gland is not working, and I just give the T4, it’s going to convert to T3. That doesn’t happen; we can measure what it converts into: T3 and free T3. Or reverse T3. 

In the allopathic world, they typically don’t measure those things. What you don’t see, you can’t manage. If you don’t measure it, you can’t manage it. If you don’t see it, the problem doesn’t exist. When we take a broader look at the panels, we can see that model. In a lot of patients that are taking T4-only medication, their conversion of T4 to T3 is not very good. That’s probably why they’re still symptomatic. They’re taking more T4 than they probably need, which is impacting the conversion factor. 

It also misses out on one other key piece: the assumption is that thyroid physiology is regulated by just how much thyroid hormone the gland makes. That’s not true. All the cells and tissues of your body have the ability to regulate how much thyroid hormone gets into the cell and how much T3 gets to the receptors. Cells have individual control. The analogy I typically use is- Do you have kids? 

Dr. Eric O:

I have two daughters. 

Dr. Eric B: 

Has there ever been a time where you told them to go to their room, clean it up, and they didn’t do it? 

Dr. Eric O:

Definitely.

Dr. Eric B:

Just because we put T4 into the bloodstream doesn’t mean that those cells and tissues are going to convert it into T3, which will stimulate the metabolism and upregulate the physiology. 

There is a challenge in that model that just assumes that that was going to happen. In functional medicine, I think we are aware that it doesn’t happen. Matter of fact, when you start to look at the panels, the more T4 you start to give somebody, and this happens sometimes in that allopathic model. When someone says, “I’m still tired. I still don’t feel good,” and maybe their TSH is 2, a physician might say, “Let’s drive it lower. I’ll give you more, and that must make it work.” If you look at a fuller panel and look at the T4, T3, and free T3, and maybe the reverse T3, you will see that as T4 goes up, there is a point where T3 conversion often goes down. That’s a big reason why a lot of people struggle with chronic hypothyroid symptoms, even though their TSH is either normal or maybe on the low end of the normal range or even lab low.

Dr. Eric O:

Does it all come down to addressing that cell danger response? I’m sure you’ve heard and learned that about 60% of that conversion takes place in the liver. Some of it takes place in the gut. There are other factors. Do these all tie into the cell danger response? Would you say it’s separate, where people need to do other things to optimize their liver health, gut health, adrenal health, but at the same time, also look into stressors that relate to the cell danger response? 

Dr. Eric B: 

I think the first part of it is some of the things we were taught about where T3 was made. The literature today is showing that those things aren’t correct. I was taught the same thing: 60% of the T3 was made in the liver by deiodinase 1. That doesn’t appear to be true in the current literature. 

What it shows is that on any given day, the average person is generating about 30mcg of T3. About 5mcg, maybe 10, depending on the individual person, is coming from the thyroid gland. Another 5mcg, probably coming from the liver. Another 5mcg coming from the kidneys. The rest of the T3 is coming from the peripheral tissues that can convert T4 to T3. The vast majority of T3 that is made in the body is not deiodinase-1 driven at the liver; it’s by deiodinase-2 conversion in all the tissues that have deiodinase-2. The cell brings T4 into the cell. It has this enzyme called deiodinase-2 that converts T4 to T3. That T3 goes to the receptors and gets used. It pops back off the receptors and into the bloodstream and contributes to the circulating level of T3 that we see on a lab report.

I think that we have to keep that in mind. Some of this stuff that we learned isn’t actually correct, based on the most current science. Do I think it’s important that we address the cell danger response? I think it’s critical. In my opinion, based on everything I’ve seen and read over the years, we assume that it’s just about how much T4 to T3 is in the bloodstream. Really, the individual cells and tissues have the ability to control what happens at that cell at that tissue. 

If I am a cell in low stress mode, I’m in manufacturing mode. I want to bring glucose, thyroid hormone, as much nutrition into that cell so I can make peptides into proteins. I can make hormones, generate hair, generate skin, burn tons of energy, feel and function awesome. Manufacturing mode. I need lots of T3 active inside the cell to do that. That high concentration of T3 also helps to contribute to turning off the immune inflammatory process.

If I’m a cell perceiving danger or a threat, whether it’s an organism, a toxin, hypoxia, whatever it is, what Naviaux and other people who talk about different aspects of the danger response within the cell, what a cell is typically going to do when it senses danger, is slow down the manufacturing process and ramp up the cell defense. 

One of the mechanisms that it uses to regulate almost every step of the cell danger response is the amount of T3 in the cell. Cells under stress, cells in danger, cells that are hypoxic are going to decrease the conversion of T4 to T3 inside the cell. 

It sounds like it’s a bad thing. It will slow down the metabolism. Actually, it’s a protective response. We are going to see that if somebody has got excessive cell stress going on, the thing that’s causing that toreduce conversion of T4 to T3 isn’t oftentimes an inability to convert T4 to T3; it’s not reverse T3 blocking receptors, but it’s the cell defense mechanisms in place that are saying, “We are going to downregulate the metabolism.” If you want to get into why that might be important, we can get into it.

For a simple standpoint, for the listener, think about your cells and tissues just like people. If I’m in low stress mode, I’m eating, sleeping, having sex, pooping, doing all these great things. If I’m perceiving danger, you can make me the best meal in the world, but I’m not eating it or digesting it well. If I’m fighting for my life, I’m not going to nap or have sex. I will be in defense mode.Our cells are like us.

Dr. Eric O:

When you say “stressor,” some people might think of emotional stressors, but you mentioned hypoxia. I’m sure there might be some people wondering what that is. “I’m probably not dealing with hypoxia.” How common is hypoxia? Can you talk more about that? Iknow on other episodes and in your book, you talk about things like mouth breathing, which a lot of people do. 

Dr. Eric B: 

A cell runs most efficiently when we have oxygen. We have these little engines inside the cells that are called mitochondria. The mitochondria can burn fuel, food energy, glucose, breakdown proteins into energy, or burn fats. Essentially, we take food energy, and we convert that food energy into cellular energy. We all learned about the mitochondria in 7th grade science class. We learned about the Krebs cycle, which nobody loved, because you had to memorize this thing. What that thing is doing is taking a glucose molecule and turning that thing into 36 ATP, which is your energy currency. We can use that ATP to do a whole bunch of chemistry reactions in the cell that make us feel and function good.

Thyroid hormone plays a critical role in that. But to run those mitochondrion efficiently, you need oxygen. Oxygen is a key piece. If somebody has decreased oxygen getting into a cell, the cell now becomes more anaerobic, without oxygen. It runs more in an anaerobic state, which essentially turns down the mitochondrial function. We become less efficient at getting cellular energy from our food. 

If a cell is in a low oxygen state, the mitochondria downregulate. We won’t make as much energy. What does that feel like? We may not poop as well. We may be more tired or fatigued. We may feel more dehydrated. We may feel chronic thirst. There are a whole bunch of things that we may experience: more pain, more muscle tension and spasms as a result. 

Getting oxygen to the cells becomes critically important. There are a number of things that can inhibit getting oxygen to the cells. One of the most common things that happens is people don’t breathe well. “I breathe a lot. Doesn’t that mean I have alot of oxygen in my system?” It’s not that simple. When we breathe out, we blow off carbon dioxide, and we bring in oxygen. Everyone thinks, “As long as I breathe in a lot of oxygen, I should have enough oxygen.” 

The same thing that we were talking about with T4. It’s not important how much oxygen is in the bloodstream as it is how much oxygen gets to the tissue. If I’m a red blood cell, I’m grabbing the oxygen that is coming in from the lungs, what you just breathed in. Now I’m going around the body and blood, and I will give up oxygen to the tissues, so they can run and function optimally. 

What allows that red blood cell to give up the oxygen? It won’t just give it up. The only reason that red blood cells give up oxygen is there is more of what we call carbon dioxide in the bloodstream. If there is less carbon dioxide, that red blood cell doesn’t want to give up the oxygen. It likes the oxygen, so it won’t give it up. 

If someone is mouth breathing a lot, they are oftentimes blowing off too much carbon dioxide, which means there is less carbon dioxide in the body, the bloodstream. They are breathing in plenty of oxygen. If you look at their oxygen on a medical test, it may show 99% oxygen saturated. That sounds great because the red cells are saturated with oxygen. That oxygen is only helpful when the red blood cells give it up. They will only give it up if there is more carbon dioxide. 

Someone who is mouth breathing a lot has a tendency to be more hypoxic. Someone who is mouth breathing especially at night is going to be more hypoxic. Just mouth breathing a lot through the day, blowing off too much carbon dioxide or mouth breathing at night is going to contribute to a downregulation of your cell physiology and an upregulation of the immune inflammatory response. That becomes a huge issue. 

How big of a deal is it? Diagnosis of sleep apnea is exploding. Everybody is wearing these fighter pilot masks to go to sleep. If you are wearing one of those things, if you have cavities or gum disease or disrupted sleep, especially if you go to bed with some stuffiness or congestion, there is a good chance you’re opening your mouth at night to mouth breathe, which will create hypoxia.

The other driver of hypoxia potentially is if we have carbon dioxide in the bloodstream, that carbon dioxide plays an important role. If there is a lot of acidosis in the body, the body can pull carbon dioxide out of the bloodstream to deal with the acidity in the body. That, too, can drop carbon dioxide and trigger this hypoxic state. Without the carbon dioxide, red blood cells don’t give up oxygen.

Dr. Eric O:

If someone has normal oxygen saturation, that doesn’t rule out hypoxia. If someone does a comprehensive metabolic panel and has low carbon dioxide, they probably have hypoxia. If someone has normal carbon dioxide levels, I assume that doesn’t rule out hypoxia. 

Dr. Eric B: 

No, it doesn’t rule it out. There could be other factors that prevent transfer. What is normal oxygen saturation? Someone might say 99% is normal oxygen saturation. Anything under let’s say 93% is problematic. 

I don’t think 99% oxygen saturation is normal. If you have your monitor on your finger, and it reads 99%, I don’t think that’s healthy. I think that’s a good indication you might not be doing a great job of transferring oxygen to the tissue.

I like to see my patients somewhere in 95-96% because that tells me that they are probably transferring oxygen to the tissues a bit better. Someone who had 99%, they feel and function awesome, everything looks great. Hey, it’s probably fine. If I have someone with chronic health issues, tiredness, fatigue, weight gain, under conversion of T4 to T3, and they have 99% oxygen saturation, to me, it’s a problem. 

As far as the carbon dioxide, oftentimes I assume that if I look at the blood panel, and carbon dioxide is within the reference range, and I typically look at a reference range of 25-28 based on some of the literature as an appropriate carbon dioxide range, the lab reference range could be much lower, down to 20. I don’t think that’s appropriate. I’ll also do calculations with sodium, potassium, carbon dioxide to see from a calculation standpoint if it looks like we have an imbalance. 

Dr. Eric O:

Anemia can also be a factor, which I’m sure is one of the reasons why you run a CBC in everybody. 

Dr. Eric B: 

Absolutely. If someone has an anemia pattern, they have less red blood cells typically to carry oxygen around the body. That can be a potential problem. The broader the panel we can run, the more important. 

Anemia in itself is another can of worms. What we tell most people is they have iron deficiency. The vast majority of people don’t have iron deficiency anemia. The vast majority of people likely have anemia of chronic inflammation. Many times, we are treating that inappropriately. We assume that if iron is low and ferritin is toward the lower end, that’s iron deficiency. I don’t think it is in a lot of cases.

Dr. Eric O:

Talking more about blood tests. You mentioned reverse T3 earlier. Is that something you recommend across the board? Would you say everybody should get reverse T3? 

I’ll say this:With hyperthyroidism, I stop measuring reverse T3 because everyone has elevated reverse T3. It doesn’t add value in my opinion. Again, feel free to give your opinion with that. As far as those with low thyroid or subclinical hypothyroidism, is it something you recommend for everyone? 

Dr. Eric B: 

I like looking at it for a couple reasons, but not the reason the vast majority of functional medicine practitioners like to look at it. I said this early on, too, because it is what I was taught. T4 is this primary hormone that is made by the thyroid gland. Then it gets to the cell, and the cell has these enzymes, deiodinase, that can either activate T4 to T3, or deactivate T4 to reverse T3. That’s Cell-driven. The cell gets to determine if I am letting T4 in to convert to T3, or if I am keeping my metabolism lower and deactivating T4 to reverse T3.

When I’m looking at the thyroid, I never look at a thyroid panel by itself. A thyroid panel without context of someone’s signs and symptoms doesn’t really tell me much. I am going to look at a thyroid panel with at least one tissue marker, but at the beginning, I look at a comprehensive panel. I’m sure you do, too.

What is the significance of it? There are some in our space who say the reason people have tiredness, fatigue when they are on T4 medication is that reverse T3. T4 gets converted to reverse T3 inside the cell. That reverse T3 goes to the nucleus and binds to receptors, the nucleus, maybe the mitochondria, and blocks T3 action. 

It sounds good. People say it’s a mirror image of T3. A) It’s not a mirror image of T3. B) I haven’t seen much in the way of any true scientific data that says that reverse T3 blocks T3 from functioning at any level of significance. I just haven’t seen it. If someone says they have, I’m open to it. I like the idea that it does it, but I don’t think that’s what happens.

When I look at reverse T3, what I’m looking to see is a couple things. If I have a patient who is not on any medication, but they have signs and symptoms of hypothyroidism, and their TSH is normal, their free T4 is normal, whichever one somebody is looking at, I look at both. I want to see what their cells and tissues favor. Are they favoring the conversion of T4 to T3? Are they favoring the conversion of T4 to reverse T3? 

If reverse T3 is higher, and T3 is lower, then we can start to make some assumptions that maybe the reason someone has hypothyroid signs and symptoms is because the cells aren’t converting T4 to T3 the way we want them to. They are deactivating it. Then I know that I need to look for what is driving that under conversion or over deactivation. 

What does the rest of my panel tell me? Are there markers of inflammation here drivingthat process? What is the person’s story telling? Are there traumas, emotional stress, hypoxia, injuries, dysbiosis, faction, sleep disruption? I start looking for the reason why. 

I just don’t think that reverse T3 is the problem. I think the reverse T3 is an indication that there is some cell defense potentially going on. Let’s say there is a normal lab TSH, and reverse T3 is low. Some people think reverse T3 should be nonexistent, and should be really low. I don’t think that’s the case either. If T4 is low, and reverse T3 is low, and T3 is low, I know that we have a person who is not making sufficient thyroid hormone. The gland is not working. Therefore, there is not enough T4 to convert to T3. There is not enough T4 to convert to reverse T3. Regardless of what my antibodies are at that moment, we have a gland problem going on. There is not enough hormone being generated. 

I will go back to my labs, health history, health timeline, and say there are inflammatory mechanisms going on here that would cause thyroid hormone to be downregulated. If I have inflammation, inflammation is oftentimes going to increase conversion of T4 to T3, the hypothalamus, the pituitary early on, and can suppress TSH, even though I might need some more thyroid hormone in the system. I’ll use it from that perspective.

The third reason I want to take a look at reverse T3 is if I have somebody who is on thyroid medication, T4, and their doctor is happy they are getting enough T4 because their TSH is normal, especially if they have all the symptoms, we know T4 can easily lower TSH levels pretty quickly. The receptors in the brain are tenfold more sensitive than most of the peripheral tissues. You can normalize the brain much faster. If you have this inflammatory response going on, that can normalize it faster, too.

At the cell level, what’s happening? If they have high reverse T3, low T3, then I am probably getting an indication we still have this inflammatory mechanism going on. We need to identify what that is. They also may be taking more thyroid hormone than they need, especially if they’re struggling with some hyperthyroid symptoms: brain fog, insomnia, irritability, things like that. That’s why we might work with them to say the dose is too strong.

Again, I haven’t seen enough clear evidence that says reverse T3 blocks anything from happening. If you wanted to block anything, we would blame deiodinase-3, which is the enzyme that deactivates it. That’s how I use it.

I think the better way to assess what’s going on at the cell level is not just looking at reverse T3 because there can be things like reduced liver function that may cause reverse T3 levels to rise. If we just look at the free T3 to free T4 ratio, if that ratio is low, the cells aren’t converting T4 to T3 appropriately. There is probably some type of cell stress, cell danger mechanism going on.

If the free T3 to free T4 ratio is elevated, then we probably have a state where the cells are starving for thyroid hormone. There is not enough T4 in the system. They need to make more T3, and they are willing to do that. That’s where you will see the free T3 to free T4 ratio is high, above what we might call the optimal range of 0.31-0.34. 

In a situation where reverse T3 is elevated, maybe. Really, what I want to know is is it elevated because I have too much T4 in the system? Or is it elevated if I have some other inflammatory response going on? That is where we can look at the free T3 to free T4 ratio along with the reverse T3. If it was on its own, too much medication, we should be able to back that down. Then we should be able to see a better conversion occur. If there are inflammatory mechanisms going on, it doesn’t matter if we can back it down. We won’t see as good a conversion too early too soon if we don’t identify what’s creating that inflammatory mechanism and the downregulation of conversion. 

Dr. Eric O:

I have a few follow-up questions.You don’t want reverse T3 too high, but as you said, you don’t want it nonexistent or too low. If you could say what your healthy or optimal range of reverse T3 would be? 

Also, I think you mentioned the optimal range of free T3 to free T4 ratio, but if you could say that again. 

Also, you mentioned you test the total T4 as well as the free T4. I imagine you do the same for T3, the total and free T3. The optimal ranges for those. Why do you test both total and free hormones? 

Dr. Eric B: 

All right, the first question was what do I use for the range? It’s important to know there is the lab reference range, and there is what some people call the functional range. Where do we get these ranges at? It seems like a lot of practitioners have their own range. Some people may say it should be less than 9 or 10 or whatever. 

For me, when I am looking at the functional range, I am more of a research geek. I am looking at stuff and saying, “Where are we finding numbers here?” I have stayed somewhere in that 9-18 range. 

Every lab value has to have context. If you said to me, “Eric, my reverse T3 is 15. That’s optimal, right?” I don’t know. What’s your TSH, total T4, free T4, total T3, free T3? What are the ratios of these? I don’t know if that’s good. Is it good? Well, if your total T4 and free T4 is low, and your T3 is low, but your reverse T3 is 15, that is probably still inappropriate. You don’t have much thyroid hormone, and you’re still favoring the deactivation and not the conversion. Does that make sense? 

Dr. Eric O:

Yes.

Dr. Eric B: 

Even though I might use a reference range of 9-18, that is a starting point. I have to interpret the rest of the labs to see is that appropriate? If someone had a reverse T3 of 15 and lower values of T4 and T3, is that important? What do I make of that? I’m also going to look at the rest of the labs. Do I have any markers of tissue hyperthyroidism going on? Do I have elevated lipids, elevated triglycerides, elevated BLDL? Do I have glucose resistance going on? If I have tissue markers of hypothyroidism going on, and I have a reverse T3 at 15, and I have lower levels of T4 and T3, I think that reverse T3, regardless of whether it’s in a functional range, is still potentially problematic. 

Dr. Eric O:

Makes a lot of sense.

Dr. Eric B: 

That’s sometimes the challenge, even in functional medicine. We give allopathic medicine a hard time for saying, “They just look at an H or an L outside a lab reference range. We have a better reference range.” Just because our value is in the reference range doesn’t mean it’s appropriate. A lab value could be totally within a normal, optimal range and be inappropriate. It could also be appropriate. 

If you feel and function good, and you don’t have much in the way of inflammation, and your TSH is 1.2, someone might say that’s the optimal. Okay. But if you have inflammation, are tired and fatigued, have all the signs and symptoms, and your TSH is 1.2, is that appropriate? Or is the inflammation suppressing TSH, and that’s causing my T4 and T3 to be low? TSH is normal at 1.2, but my T4 and T3 is low, and reverse T3 is low. We have to interpret it. We can’t just say because it’s in an optimal range, it’s okay. Does that make sense? 

Dr. Eric O:

Yes, it does. Thank you.

Dr. Eric B: 

As far as the ratio of free T3 to free T4, this is a little tricky because the units of free T3 and free T4 are different when you get them on your lab report. I think you can go to Dr. Weatherby’s website. Do you know what it is? 

Dr. Eric O:

I can’t think of it.

Dr. Eric B: 

He has a website with calculators. You can go to his calculator and put in right off your lab report a calculation, and it will tell you if it’s in the ratio range. 

What I do is convert everything to similar units, picomoles/liter, and divide free T3 by free T4. If you look at your lab report, you can say, “How do I convert picograms/ml to picomoles/l?” The calculator will convert it for you. If you convert things to picomoles/ml, you divide free T3 by free T4. Based on the literature, the optimal ratio looks like 0.31:0.34. 

If that ratio is under 0.31, the cells and tissues aren’t doing a great job of converting T4 to T3. That’s where we have to find out what’s causing that reduced conversion. Is it low calories? Is it hypoxia? Is it organisms? Is it toxins? Is it emotional stress? Is it all of those things, a combination of those things? Which oftentimes it is. 

If the ratio is above 0.34, then we might have a situation where even though TSH may be normal, there is still not enough T4 in the system to convert to T3. If there is no cell stress response going on, and they’re in a homeostatic state, they will take as much of that T4 and convert it to T3 as quickly as possible. A certain level of T3 is a biologic priority.

Dr. Eric O:

Gettingback to the thyroid hormone, you always test total and free hormones. Again, I have a habit of mainly testing the free hormone. What is the significance? I know you talked in your book about carrier proteins and binding globulins. If there is a discrepancy with the free hormone and the total, maybe we are looking at a problem with the carrier proteins. 

Dr. Eric B: 

Yeah. For the listener, in the body, we make hormones, but we don’t want those hormones all being free. They would get either deactivated, metabolized, or utilized right away, and we wouldn’t want that. Hormones are made—sex hormones, thyroid hormones, other hormones, cortisol—and they are then bound to what we call a transport molecule or protein, a binding globulin. It’s like an Uber, and it transports it around the body. When there is a cell or tissue type that needs some of that hormone, that hormone becomes free of the Uber or free of the binding globulin. Now, it’s able to get into a cell or tissue. 

Why might it be important to look at both total and free, even though a lot of physicians have gone to just looking at free? “Free hormone is the only thing that matters, so we’ll just take a look at free.” But it does make a difference. If I have low free hormone because I’m not making much thyroid hormone, then I have to figure out why I’m not making as much. If I have low free hormone, but I have plenty of total, then I have to ask, why is it getting out of the Uber? Why is it not coming off a binding globulin? Is it a pH issue, a hypoxia issue? Is some other hormone I’m taking jacking up the binding globulins? We need to find that answer.

If you put more hormones into a system, the tendency is for the binding globulins to go up to manage it. Something is resulting in less hormones becoming free, and we need to figure that piece out. I want to look at both. If someone has low free, I want to know if it’s because they just aren’t making it, they have low total, or if it’s a binding globulin issue. Then I want to address that appropriately. 

If they have high free hormones, I also want to know if that hormone is elevated because they don’t have much. They’re not generating much, so there is not much on the binding globulin, to where maybe something is suppressing the binding globulin and causing a lot of excessive free hormone that is either being used or metabolized too quickly.

Dr. Eric O:

Thanks for that thorough explanation. I want to circle back to the cell danger response before we wrap this up. When it comes to inflammation, I think you look at more than just CRP and sedimentation rate. You look at seven inflammatory markers? 

Dr. Eric B: 

When we look at labs, there are a bunch of things we can look at from an inflammatory standpoint that would be on a general blood chemistry panel. CRP, there is high sensitivity CRP, regular CRP. Homocysteine could be considered a molecule of oxidative stress. We could look at fibrinogen as a marker of oxidative stress. We could look at elevated ferritin levels. 

That is another can of worms. The vast majority of people believe that ferritin levels should be somewhere in the 60-80-90 range. I think that’s absolutely insane. I start getting concerned when I see it over 25, but definitely if you have a ferritin level of 40 or 50, that is an indication of potential inflammation and oxidative stress. Again, needs to be interpreted.

For instance, “when I have low ferritin, I’m anemic.” Hold on. If your serum iron is low, and your ferritin is low, and you’re anemic, maybe you do have an iron deficiency. But we can run a soluble transferrin receptor test to find out if the cells are starving for iron or not. That’s another conversation. 

I don’t think the vast majority of people are. But ferritin could be a marker of inflammation. We could look at bilirubin. Again, we have to take into consideration if it’s low because they’re anemic, or because they are using bilirubin as an antioxidant because there is inflammation and oxidative stress going on.

We can look at elevations of uric acid. We can look at alkaline phosphatase on a general chemistry panel. We can also look at elevations of 125 Vitamin D and low 25 Vitamin D. How many people today are being blasted with Vitamin D probably inappropriately because they have a low 25 Vitamin D when that’s not really the activated form? The activated form is the 125. If they have an elevated 125 Vitamin D, that’s another good indication that they probably have some type of chronic immune inflammatory response going on.

Dr. Eric O:

We’ll need you to come back to talk about the ferritin because that was a surprise to me, that you like to see it at 25 or less, and also talk about the 125 hydroxy. We don’t have time to dive into that. 

I don’t know if you’re familiar with Dr. Alan Gaby. He wrote a big nutritional textbook. When going through my master’s, they were talking about how you don’t want to look at 125 hydroxy because it’s frequently elevated due to a compensation related to the parathyroid gland. This was now 10+ years ago that I went through that, so maybe the science has changed.

I know Dr. Lynch is a big advocate of testing for 125 hydroxy vitamin D. There are differences in opinion when it comes to testing for that.

Dr. Eric B: 

Think of the traditional role of Vitamin D. 25 Vitamin D and 125 Vitamin D with calcium regulation in the parathyroid gland. We know way more than that now. I’d say real simply, without getting too heavy into it, if we think about Vitamin D this way. There is very little food, except for cold water fish, that has any high level of Vitamin D. Right? Where do we get most of our Vitamin D? Sun exposure.

Cold water fish have a decent amount of it. If you believe that there is intelligence in the universe, that might make sense. In the areas where we have plenty of sunshine most of the year, there is very little food that has any appreciable amount of Vitamin D in it. Most of the Vitamin D comes from sun exposure. In areas where there is less sun exposure, there are more cold water fish, where we can consume those things. I don’t think we’re designed to be taking copious amounts of Vitamin D as a supplement orally. I know it’s a $4 billion industry, but it’s just my opinion.

The other thing we don’t know too much about Vitamin D is we only measure one component of it. We don’t measure Vitamin D. We measure 25 Vitamin D. We don’t measure what happens to 25 Vitamin D. Is it being deactivated from 24 to 25? Is it going into the fat cells? That’s another discussion of how that works and what I think is going on. Is it being over converted to 125 Vitamin D? When you do have elevated 125 Vitamin D, is there an inhibitory suppression of Vitamin D to 25 Vitamin D conversion at the liver? Some of the literature seems to show that’s the case. It’s a feedback loop that turns it down. 

I think we’ve taken Vitamin D, one number we can measure pretty easily, and decided that if it’s low, we just give more, more, more. Even in people that were giving 5,000-10,000 IUs per day orally, they still wind up with low Vitamin D. I don’t think we assess it right. I don’t think we look at the chemistry of what’s going on. I would make an argument that early on, it may make someone feel better, but long-term, it’s potentially problematic. 

Dr. Eric O:

Definitely going to dive more into the research and have more of a conversation on this in the future. 

I can’t have you leave without talking about some other things that you mention in the book about addressing that cell danger response. Obviously, a lot of it is the foundations. If you could spend the next few minutes talking about what else people can do. You mentioned hypoxia and breathing better. People know about diet, but you haven’t mentioned anything about diet. I know you’re not a fan of one specific diet;it’s all about eating whole, healthy foods. I’ll let you take over and talk more about that.

Dr. Eric B: 

There is foundational principles. Kelly and I talk about them in the book. I had a couple colleagues who read the book and asked about supplement protocols. They’re not in there because I don’t have a protocol for everybody. I think that’s problematic. Even though it’s not sexy, the things that create health issues are these foundational pieces. 

For the vast majority of us, better nutrition would go a long way to making us healthier, right? Whole food-based diet. One of the problems we’ve had in this industry is that we’ve circled the wagons and shot in. You and I both know that if you’re eating one diet, and you’re not feeling well, and you change to another healthy, whole-food diet, you will probably feel differently. Is there a benefit to doing a carnivore diet for a short period of time? Sure, you will change your gut biome, it will create some change in symptoms. Is a vegan or vegetarian diet potentially going to create a change in signs and symptoms? Probably. I don’t think we should be arguing about which whole food diet is the holy grail. 

What we should be doing is saying, primarily, 80+% of the time, try to concentrate what you eat on healthy, whole, in season if possible, foods. As close to the way it came out of nature as possible. Limit the amount of processed food. If most people did that, they would probably start to improve their health and wellbeing. I see it every day as we start to make those changes in clients.

I think respiration is critically important. This is from a guy who has a deviated septum and should have had surgery a long time ago. Breathing is critically important. We are designed to do most of the breathwork through our nose. A lot of us, because of chronic inflammation and other factors, we do too much mouth breathing. Excessive mouth breathing creates a hypoxic state. Just changing your breathing can change your health.

Going back to food. How you eat is becoming important. Not only should you eat healthy food, but you have to take the time to chew it and help digest it well. You see a lot of people who are eating on the run. Eating healthy food, but not sitting down to eat it, not putting themselves in a situation where they can digest it well, so they still have problems.

Sleep is critically important as well. I’m guilty of this. I went for years wearing a badge of honor that four hours of sleep is all I need. I’ll sleep when I’m dead. What it does is creates-In me, it created chronic inflammation, Hashimoto’s, insulin resistance, and all kinds of stuff because four hours of sleep + running businesses+ training + everything else I was doing broke me down. That was part of my cell stress response.

We hinted about emotional stress. What goes on between the six inches of your ears makes a huge difference as to if you get well. You will be stressed or not stressed. We all have stress in our life, and you will never escape it, whether it’s physical, chemical, emotional, microbial. What we say within our mind consciously or subconsciously plays a huge role in how we heal and recover. Far too many people take in too much negative or focus on the problem and not the solution. I think that drives a lot of angst in the system, a lot of stress response in the system, so that’s hugely important.

Diet, nutrition, sleep. We talked about respiration. Physical activity and exercise. That’s critically important, too. Some people don’t like to do it, but you have to move your body. You have to do some physical strength training. You have to do some level of cardiovascular training. Slow fitness works really well for a lot of people. You want some, not excessive.If you do a lot of excessive training, you have to balance that recovery time. If you’re not, that will be a problem.

Why exercise? I have a healthy lifestyle. Well, the healthy lifestyle is if you train and recover, if you train and train and train, and don’t allow for recovery, you will have chronic health issues. I am a perfect example of that. I drove myself into doing that.

We talked about emotional and microbes. The organisms are everywhere. If they overgrow in us, then that can potentially be a problem. Then we have our environment with the toxins and things we are exposed to every day. You will never eliminate those things completely. The best we can do to have a low tox life, the less stress on the system. I think I got most of them.

Dr. Eric O:

Yeah, I think you did. Most of the foundations, if not all. Where can people find out more about you, Dr. Eric? Feel free to share your website and remind them of your book and anything else. 

Dr. Eric B: 

The book is called The Thyroid Debacle. It’s available wherever you get your books. 

I have a podcast called The Thyroid Answers Podcast. It’s available on almost all platforms. You’ll be a guest sometime in the future. We have an interview scheduled.

I was never much of a social media person, but I got convinced to do some Instagram posts. That is primarily where I put out some content and information. 

One of the things I like to do is my Thyroid Thursdays, where I am trying to educate. I know sometimes, people go on Instagram and want the three simple tips. What I am trying to do with those Thyroid Thursdays is have someone understand the free T3 to free T4 ratio. Why is that important? Why is it maybe less valid if you’re taking T3, and you can’t really use that ratio necessarily to indicate what’s going on? I want to educate people. 

At the end of the day, getting well is not based on how many supplements you can take. I find far too many people are oversupplementing. Getting well and staying well is about understanding a little bit more about your overall chemistry and doing a really good job raising your level of health in all these things that we call fitness factors (your diet, nutrition, exercise, mindset, habits, behaviors). Then you will be healthy. That’s not the stuff that’s sexy.

Dr. Eric O:

Well said. It’s always a pleasure chatting with a fellow Dr. Eric. Thanks for being here and talking about thyroid physiology and blood tests. We will definitely have to have you on again in the future, and I look forward to being on your podcast. Thank you so much, Dr. Eric. 

Dr. Eric B: 

Thanks for having me. I appreciate it.

 

Recently I interviewed Evan Brand, and we talked about mold-gut-thyroid connection. If you would prefer to listen to the interview you can access it by Clicking Here.

Dr. Eric Osansky: 

I am super excited to chat with today’s guest, Evan Brand. He is going to be chatting about the mold-gut-thyroid connection. I am going to dive into Evan’s impressive bio here. He is a Board-certified holistic nutrition and a functional nutrition therapy practitioner, who has transformed the lives of thousands of clients with his online practice by finding and fixing the root causes of fatigue, depression, anxiety, digestive, and other issues. Evan solved his own health struggles using the same advanced lab testing, strategies, and protocols that he now uses in the clinic. 

He has accumulated over 22 million downloads of his podcast and has been featured on hundreds of other health podcasts, webinars, summits, as well as practitioner training events. He also offers at-home functional medicine training courses through his Functional Academy of Medicine and Epigenetics, also known as FAME, on gut, mold, and energy issues. Thank you so much for joining us, Evan. Appreciate you being here.

Evan Brand: 

Thanks for having me. I was looking back because I had you on my podcast six years ago, 2017.

Dr. Eric: 

Wow, that long. It’s great to have you now on my podcast. I know you will share a wealth of information with the listeners. 

Let’s give your background for those who aren’t familiar with you. How did you start doing what you’re doing today, get to the point where you have one of the top podcasts in health? 

Evan: 

The podcast was really just a way for me to learn. I was in it for myself at the beginning. It was very difficult to reach some of these practitioners, naturopaths, and functional medicine people that knew a lot. You’d have to fly to their clinic, or you’d have to pay $500-$1,000 an hour to get ahold of these people. Well, what if I just start interviewing them? I can get information from them to help myself. As I started to get better, I thought, well, other people need these pieces of advice and information. Practitioners are booked. People are booked out. Why don’t I start helping people? 

I had personal training certifications at the time. I went into the Nutritional Therapy Association and picked up the FNTP credential, which taught me food is medicine. I also learned a lot of hands-on things that I ended up using in a brick-and-mortar practice; I worked out of a chiropractic physician’s office for a while. I started getting his patients so healthy that they didn’t need an adjustment every week, so that was a natural parting of the ways there. 

I left the brick and mortar and went full-time online with my practice in 2015. At the time, it was the Wild West. Nobody was doing online telemedicine then. I know that sounds like yesterday, but in the internet world, that was a long time ago. It was a new idea. I can stay here in Oregon, Idaho, or California, and you will send test kits to my house? That was odd. 

I guess I was ahead of my time there because now, a lot of the practitioners that reach out to me for coaching—I do a lot of doctor and business coaching nowadays, and I am coaching these people to convert their brick and mortars. I had a guy in the middle of California in Beverly Hills. He’s a 70-something conventional MD who has been practicing for 35 years. We’ve taken this guy from 25 employees and $40,000 a month in rent for his Beverly Hills office to just online. He has two employees, and he’s happier than he’s ever been.

My joy and love now is helping other practitioners, but also I still do clinical work three days a week. I’ll have people from California to, yesterday, Australia, South Africa, all across Europe. People who are seeking answers that they can’t find locally. People who have been to five, 10, 20 doctors, and they call me as the last effort, the last hurrah. Usually, we uncover things that have never been uncovered before, so it’s a true blessing.

Dr. Eric: 

That is an awesome story. That’s also funny about working for a chiropractor and getting people better to the point where they didn’t need weekly adjustments. Being a fellow chiropractor, I can understand the chiropractors in the practice not being too happy about that, but obviously, that’s good. That’s what you want. You don’t want someone to come in on a weekly basis or 2-3 times a week for many weeks, many months.

Evan: 

It was funny how it worked out. A lot of it was adrenal issues. Nutrition was a big piece of it as well. I still implement a lot of nutritional therapy strategies. These were people back in Kentucky, where they are eating garbage. They come in with their big Polar Pop; it’s this giant, probably 64-ounce soda. They will put that down and put down their Oreos and get adjusted and go right back to the bag of Doritos in their purse afterwards. It was just a mess.

I encourage people if you are in a brick-and-mortar practice like that, and you do have a lot of hands-on skills, I would try to implement the things we are talking about today. You can increase their health and their outcome. If you’re worried about the financial piece of it, like, “Hey, well if I get everyone so well, and they don’t need adjustments every week,” now they will tell all their friends and family, “This guy turned my life around.” The referrals you’ll get will totally maximize your ability to help more and generate more revenue. If you’re freaked out about getting people so well there will be nobody left to help, I promise that won’t happen.

Dr. Eric: 

How long have you been helping people with mold? That’s the topic today. I know you recently started- How long have you been speaking for Great Plains? Now they’re Mosaic Diagnostics, I believe. You have been lecturing for them. How long of a focus have you had on mold issues? 

Evan: 

It started in 2017 or 2018. My wife and I built a house, and it was a on a cross base foundation, which is a terrible idea. Don’t do cross bases. Try to do a slab or even a walkout basement. A cross base is basically a basement that you can’t see. You’re not down there to check on it. 

We built this new house. I love trees, so I plant trees everywhere I move to. We had this water hose connected to the house. I was dumb. I was watering trees in the winter. I thought I needed to. I left the hose on, and it froze. That busted a sillcock valve in the crawl space. There was some water in there, and that evaporates up to the home and creates mold. 

I was having blood pressure issues and all sorts of problems. My friend Jack Wolfson, a cardiologist, I texted him, “I’m having these weird blood pressure issues. I’m dizzy when I wake up.” He texts me back in one word in all caps, “MOLD.” After that day, my life was never the same.

My wife and I were reminiscing and laughing about it. It’s not funny because it put me through hell, and we are still recovering. When I went to investigate, I got stung by a wasp at the same time. I found the water, and I got a wasp sting on my hand at the same time. It was a whole cascade of symptoms. 

I’d say 2018 is when it all started. Now, you and I are recording here in late summer 2023. I don’t think I’m 100%. I don’t know if you ever fully get 100% back from a mold incident. Your immune system gets affected. Your endocrine system gets affected. Your GI system gets affected. Your brain, specifically your limbic system, gets affected. Now, you’re stuck in fight or flight, whether you want to or not. You become more hypersensitive. I had debilitating chemical sensitivity to all sorts of fragrances, laundry, dryer sheets. If I’m around people, I don’t like it. I want people to be fragrance-free. It’s better for your health and others. I still react to it, but it’s far less, maybe 90% less than it used to be.

Dr. Eric: 

You’re a lot better, not quite where you used to be. You might not get to 100%, like you said. It’s also a lesson for those listening who might be dealing with mold toxicity. This isn’t a three-month process. It’s not a six-month process. Let me ask you: Can it be a three- or six-month process? Is it something where no matter the case, it will probably be a few years where you get to the point where you’re 95% or 98%? 

Evan: 

The fastest recovery was in a three-year-old little boy. We ran his organic acids test, and he was colonized. We also ran his mycotoxin profile. Do you post video, or do you just post audio for the podcast? 

Dr. Eric: 

The podcast portion is just audio, but I do post this on YouTube. If you want to share anything, we could do that.

Evan: 

Let’s do it. A picture is worth a thousand words. I will show you the case that answers the question of timeline. Many people are unrealistic with their expectations. As you know, I love the OAT test. It’s amazing. This is a first-morning urine sample that people run. You get it back to the lab. When you have yeast or mold issues, you’ll then spit off these organic acids. We can infer based on what we find in the urine what’s happening internally. 

You can see here in this poor boy—this is a three-year-old. The mother had five children and ended up working on the whole family, including the mom. They had tree roots that busted through the foundation in their home. They had water that came into the basement. They all had mold toxicity. You can see here this marker, 5-hydroxymethyl-2-furoic. For folks listening, we are looking at these long words that indicate that this boy was growing, and/or he was colonized for Aspergillus, probably in the gut, but also the sinuses. 

Arabinose was very high. We knew we had a candida problem. Bacterial overgrowth was a mess. He had some Clostridia, which we’ll often see in mold. Oftentimes, you will see mitochondrial issues, too. People with chronic fatigue, there is a massive link with mold there. 

In his case, neurotransmitters were okay, but a lot of times, you’ll see low dopamine. Ochratoxin, which is one of the most popular, common mycotoxins we find, that affects the part of the brain that makes dopamine. We will often see issues with energy, drive, focus, and concentration. In his case, he looked okay. Nutrient levels, we’ll often see those crash out quite a bit. 

This was in April 2021. We put together a protocol, and we retested in April 2022. Just less than a year. You can see we pretty much fixed everything. No more colonization. No more candida at all. Tiny bit of bacterial overgrowth on this one. The Clostridia was normalized. 

That’s about the fastest you can do it in my opinion, a year. It doesn’t mean it’s a year to feel better. It just means a year to really resolve it. That would be really fast, especially if you have been sick for 20, 30, 40 years. People have to know and remember that if you had mold exposure when you were a kid, and genetically you don’t detox it well, and now you’re listening to this at 52 years old, and you want to get better in a year, that’s unrealistic. You’ve had this stuff for five decades; you won’t get it out in a year. 

It’s important for the practitioner to set realistic expectations of the timeline. We are so used to that conventional medicine model. You take antibiotics for a week, and everything is better. That’s just not the case. You’re going to feel better gradually though, sometimes within just a couple of weeks or months, using the right protocol, the proper binders, antifungals up the nose and in the gut. You can make significant progress with depression, fatigue, sleep issues, gut problems, etc. 

Dr. Eric: 

I think you’d agree that probably all cases, you need to address the source of the mold. Either get rid of the mold or remediate. There are people who are not in a position to move. I’ve come across patients, and I’m sure you have, too, who for whatever reason, they couldn’t remediate. Maybe the spouse wasn’t on board, or whatever. If that’s the case, is there any hope of taking binders, doing things from a glutathione perspective? Do they really need to get rid of that source of the mold? 

Evan: 

Great question. It’s like a seesaw. If you have a fat guy on one side and a skinny guy on the other, the fat guy will always win. If you take that analogy and visualize that for the rate of detox as opposed to the rate of exposure. If you have this massive exposure, your bathroom or kitchen leaked or your basement flooded, you have exposure off the charts, and you’re doing a couple capsules of charcoal per day, you will lose the battle. 

But if you flip that, and you were able to remediate some of the issue—you can’t fix the whole house, but you fixed the wet wall or the cabinet that flooded—your rate of exposure is now lower than your rate of detox, then you win the game. 

You can implement fresh air into the home. If you have decent weather outside, and you can open your windows and flood the place with fresh air and dilute the mycotoxins, that’s obviously helpful. If you spend a lot of time outside, and away from it, maybe you work outside the home. Maybe you have the ability to work out in the garden during the day and air the house out if you truly can’t cut it out. 

Cost-wise, it shouldn’t be much. Some of these remediation companies will charge you $10,000+. You have to be careful about vetting these people. If they do mold testing and remediation, it’s probably not a good idea because they’re biased. Of course, they will say it’s a problem and need to remediate. I would try to find an independent tester that doesn’t do remediation. Sheet rock is not expensive. If there is wet drywall and baseboard, cut it out, pick a new piece in, patch it up, paint it up, put your new trim back on. You’re done. 

People get overwhelmed by this conversation because it’s their personal home. It’s their sacred space. It’s their sanctuary. People think that when they talk about mold, it means they’re dirty. No. My house was pristine. I had air filters in every room. I had a whole house water filtration system. This was a top-notch house. It was still moldy and still made me sick. Get rid of any brainwashing you have. Don’t feel that you’re dirty or a messy person or a nasty person if you have mold. This happens to the best of us. I’ve seen houses that are $2-3 million, and they’re moldy. I’ve had clients in these $1 million+ homes that are moldy. 

It’s the husband usually who is a skeptic, who’s this online guy. What does he know? Guess what? The wife continues to suffer, and then it affects their marriage because now she is exhausted, so she has no sex drive. The husband’s mad about that. Dude, look, if you want a good sex life, fix the mold. If you use that as the carrot in front of them, usually they’ll get motivated enough to fix it. If they can save their sex life and marriage, unfortunately, our hedonistic, human traits can’t be ignored. If you lean into that, usually you can get these people on board to fix the home.

Dr. Eric: 

You mentioned, which I agree, about hiring someone who maybe is not doing the remediation because they are more likely to find something that might not be there. What do you think about doing it on your own? There are companies like Mycometrics, where people can order the test and do it on their own without hiring a specialist. 

Evan: 

I love it. I think it’s a great place to start. I encourage almost every client I work with to do that. If you are going to do a HERTSMI or an ERMI, where you go around and grab a bunch of dust and send it back to the lab and see what shows up, you can do that. 

I prefer the petri dishes. They are these plates that have a gum resin on them, where mold can start to grow. These petri dishes, you put them on the floor in various rooms of the home for an hour. You put the lid on, mark them with the room they’re in. 

Also your car. A lot of cars are moldy. Mercedes did a recall on 2.5 million cars because mold was growing in the air conditioning system. Even if you have a luxury car, it could be moldy. If you drive somewhere, and by the time you get to work you have a headache, consider that it could be your car. 

These petri dishes are cheap. They’re like $3. If you do it with a lab analysis, it’s like $30 for a plate. You get a health score. 

Based on that score, we also like to see what’s in the home. Does that match up to what’s in the urine? 90% of the time, it does not match. This means that mold exposure was from years ago. That was the moldy college dorm. That was your previous house. That was your childhood home. That was your grandma’s house you hung out in. It’s rare that we find current exposure as the source. It still happens. We often find that this is a story that started long ago, but we’re just now getting the answers, just now getting the data.

Dr. Eric: 

Just to clarify, you’re saying that someone might do a home test for mold, or even have someone come to the house and test for mold, and it might be negative, yet they will show positive findings on either an OAT or a mycotoxin test? 

Evan: 

Exactly. They scratch their head and say, “Where the heck is this coming from?” It was probably a long time ago. Could be months, years, decades. Or it could be their office. If the office is in a commercial building with water damage, something like that. We try to find it. Sometimes, we don’t find the source, so we have to assume that it was from the past. 

It’s also been proven that mold toxin goes through the placenta. This could even happen from birth. I have been fortunate to test many young children. Almost half my practice is children these days. We see kids who are six months old off the charts with mycotoxins, even if they are living in a new house or apartment. Then we test the mom. The mom has the same mold toxins but way higher. Oh my god, look, we have just opened up the dam through the breast via the breast milk and/or the placental transfer. That’s how we see it. 

Same with flame retardants. Unfortunately, breast milk is highly contaminated with various toxins. It’s a bit thing, where we are seeing one and two-year-old children who have major gut issues, major skin issues. We are even seeing thyroid antibodies in young children. It’s very difficult to get blood on them. When some things are severe enough, we do. We are seeing Hashimoto’s in young kids. It’s nuts. 

Dr. Eric: 

When it comes to mold in children, do you treat them the same as far as using binders and glutathione? Obviously, you try to get rid of the exposure. But is the actual treatment similar? 

Evan: 

Yeah, the protocol is the same. We use more liquid protocols than capsules. Certain binders, you have to open up, but we can mix them in with juice or applesauce. I try to find alternatives to the capsule formulas. We use liquid antimicrobials instead. We do nasal sprays. It works great. 

Kids get better faster. Their immune systems are generally more robust than us adults. Their thymus is much bigger, so they have this big immune reserve if you will that we don’t. It’s a lot easier, and it definitely makes you look like a better practitioner when you’re working with a kid because you can get them better in half the time that it takes for an adult to get better generally. 

Dr. Eric: 

You brought up an example of a patient’s organic acids test, which showed mold. Let’s say everything was negative the first time you tested. Have you seen where the OAT is negative, yet the urinary mycotoxins test is positive? 

Evan: 

Yeah, that’s a great point. There are two things that can happen. You can be colonized for mold, meaning you’re a mold factory, so you’re growing it. Maybe you had a lot of exposure, or the exposure was long, or your immune system was weakened. For example, maybe you had COVID, so your immune system was weak, and you got exposed to mold and became colonized. That’s what we look at on the OAT. Are they growing it? Do we see on page one these yeast or fungal metabolites elevated, indicating they are currently growing mold? 

Or, if that’s all negative, but the mycotoxins are positive, then we assume they are just a mycotoxin reservoir. That’s the most accurate thing. Technically, it’s not a mold. It’s a mycotoxin they are holding in them. it’s a mold fart. That’s the mycotoxin. We see that all the time. Half the people are colonized, and half aren’t. 

But you still have to work on the client and not just the paper. If we see that there is gut issues and skin issues, maybe we run a stool test on them as well, and we see dysbiosis or other infections. As you know, a lot of these herbs are pretty broad spectrum. If I am working on parasites, let’s say, I might have some herbs in that formula that also kill yeast and/or fungus and/or mold anyway. Even if the OAT wasn’t a big smoking gun for mold colonization, we’re probably helping to fix it anyway. 

Dr. Eric: 

It sounds like you don’t test everybody for urinary mycotoxins. Is that correct? 

Evan: 

I do. If budget permits, I am going to tell them, at least initially for our first call together, I want everybody to have an OAT and a myco. I am seeing too many to ignore it. If budget doesn’t permit, or if this person says, “Hey, I know I feel better on binders. I’ve already done this in the past,” okay, fine. If you don’t care to see the numbers, these tests aren’t perfect. They’re good but not perfect. If you’re not wanting to spend the money or can’t spend the money, and/or you’re already feeling good on binders, just keep them up. I’m okay with that.

Dr. Eric:

I can’t say I test everyone for the urinary mycotoxin test, but when I do test for that, I typically use Great Plains, now known as Mosaic. Have you had Dr. Neil Nathan on your podcast? 

Evan: I haven’t. He’s not a fan of that. I know he likes RealTime. 

Dr. Eric: 

I think he uses both, right? I think it was him. Maybe it was someone else who uses RealTime and Great Plains/Mosaic because sometimes, I’ll find mycotoxins on one but not the other. 

Evan: Vibrant is another competitor as well. I’ve used them before. Vibrant showed mycotoxins in me personally that I didn’t see anywhere else. I don’t know what to make of it. 

If you talk with Neil, he basically says binders for life. I’m cool with that. These things that we’re using—zeolite, clay, silica, fulvic acid, chlorella, etc.—these are great for heavy metals and pesticides. We are all exposed to that, too, no matter how hard we try. I love the idea of keeping up with low dose binders. Maybe your test missed something. Maybe your mycotoxin test wasn’t perfect. I still do binders. 

It helps with die-off from gut infections or other issues we’re working on, like Lyme, bartonella, babesia. The die-off from that stuff can be intense, and the binders help mop that up. Zeolite can help with histamine issues. A lot of these people have histamine problems as well. 

I like to implement binders for everyone, even if the test says nothing is there. We will still use it and say what they report back. If I’m sleeping better, which is my story, I started experimenting with binders for bed. My wife and I both noticed we’re sleeping better. We started using it with our kids, and they slept better, too. Everyone needs binders at night. Done. 

Dr. Eric: 

Everybody in the household is taking low dose binders on a wellness basis then? 

Evan: 

Yeah, we are. My kids do. My wife and I do, too. I do a couple capsules a night. Sometimes, I’ll do them in the middle of the day as well if I feel out of it. I still sometimes experience brain fog from it. When you are colonized with mold and/or candida, a lot of people will have brain fog. You walk into the pantry and forget what you’re looking for. You forget your keys. Where’s your phone? You’re always losing something. That type of brain fog can happen a lot with candida, too. 

Mold is the bad guy that allows these other things to take place. If you have been working on candida and bacteria, and you’re struggling and not beating that, it’s like this relapsing phenomenon. Assume there is mold there. Candida rarely occurs in isolation. 

I did a summit on candida years ago in 2017. At the time, I didn’t know much about mold. Now that I look back, all these people that have all these candida problems, we were using herbal antimicrobials to hit those, herbal antifungals. The candida would come back. Let’s rotate herbs. Now I realize, crap, that was mold. Mold was allowing the candida to come back. Mold was giving candida the opportunity to thrive. Candida produces acetaldehyde, which is very similar to alcohol. People feel drunk and spacy with candida. That would get better temporarily, and then they’d relapse. Now, I go back and test those people, and they all have mold.

Dr. Eric: 

Wow, that’s something that is definitely overlooked. I don’t know if you can answer this, but if you had to put a number on it, what percentage of clients that you see would you say have the mold problem? I’m sure it’s high because a lot of people now know you as a mold expert and see you. Yours might be higher than the average person. If you had to guess the average household maybe that doesn’t see you, would you say it’s 50%, 60%, 80%? 

Evan: 

I’d say probably 90%. 

Dr. Eric: 

Wow.

Evan: 

It’s huge. I think it’s the biggest epidemic facing the country if not the world right now. I know you’ve seen this with your clinical work. Even in the last five years, the average person is sicker and more complex and more sensitive than ever before. There is a lot of things that go into that. Media and bioweapons and other things that play into this. Overall, I find the population to be getting sicker, more sensitive, more nutrient depleted, more depleted of vitamins and minerals. Therefore, this mold is the final dagger, if you will.

It’s probably 90%. It’s very rare these days that I test someone and don’t show up with something. You’re right. A lot of people are saying, “I heard you talk about this. I had this exposure. I have 50 symptoms. Can you help?” 

There are still average guys. I had a case in California. This is some real estate investor guy who said, “Hey, I feel pretty good, but I heard you, and I want to get a good functional medicine workup. I don’t have many complaints.” We looked at this guy’s lab, and he is colonized with mold. His mycotoxins were off the chart. “You’re sure you have no energy issues? You’re not depressed or anxious? You don’t have erectile dysfunction? Your blood pressure’s okay?” “Yep, I’m fine.” 

This is weird, but I don’t want to ignore this because mycotoxins are very carcinogenic. Ochratoxin affects the brain and kidneys. Things like aflatoxin can affect the liver and be a big driver of liver cancer. “Look, if we don’t want you to end up with some neurodegenerative disease as you get older, let’s get this stuff out now.” 

We got this guy on the protocol. Now, he is losing body fat. He was working with a personal trainer, and he couldn’t lose much body fat. Now he is leaning out. We are seeing some cool benefits, even though he didn’t have many complaints. Now, he is saying, “I am not as tired as the end of the day. I thought that was normal because I’m working hard.” But you shouldn’t be crashing at 3pm. You should be able to keep going. That’s fun, when you see a case where supposedly, they’re okay, but you fix them anyway, and now they’re better. That’s always rewarding. 

Dr. Eric: 

It is a lot of fun when you see someone, the life changes they make and their health.

Thyroid. As you know, this is the Save My Thyroid podcast. People want to know: How does mold affect the thyroid? Let’s dive into the mold-gut-thyroid connection.

Evan: 

Sure. I would say it’s a domino effect, like everything else. There is this perfect storm that happens. Do I think that Hashimoto’s and Graves’ and other thyroid issues can happen on their own with stress and that sort of thing? Maybe. The more I look at this, I really think of the thyroid issue as the effect, the end result. Here are the domino effects that I have seen. I’ll just lay it out to you the way I perceive it now. I’d love to hear your thoughts on it, too.

Step one is a trigger, if you will, like mold, for example. Let’s role play and say you had this mold exposure. That weakened your immune system. Now you develop candida overgrowth. While the backdoor was open, so to speak, now you have developed Klebsiella, which we know is a big bacterial trigger of any sort of thyroid issue, autoimmune thyroid. Now, you have Klebsiella and maybe Prevotella and Proteus. Now you have a diagnosis of RA and Hashimoto’s or Graves’. You have this multiple autoimmune thing happening. Now, we see you have gut inflammation. The nutrition’s off. You’re super stressed. You’re working too much. Your kids are crazy. Your marriage is on the rocks. All those things add up. Boom, you happen to test blood, and there is a big thyroid issue. I think there is probably other things predating you seeing that manifestation there. 

I’ve seen cases where we have seen TPO antibodies in the thousands, like 2- or 3,000. We have seen that drop thousands of points just by fixing what I’m describing to you: the candida, the bacteria, the mold piece. All of a sudden, antibodies go way, way, way down. I didn’t even give any “thyroid support” or thyroid protocol. Maybe I did basic stuff, like zinc, selenium, those things. 

It’s actually rare that I have to make a full thyroid protocol. It’s almost as if these other gut detox protocols are actually helping the thyroid. It’s almost like we are removing the roadblocks that allow the thyroid to be under attack in the first place.

Dr. Eric: 

I agree. In most cases, it’s not a thyroid problem. Graves’, Hashimoto’s, they are immune system conditions that affect the thyroid. All these things you just mentioned, the mold, the candida overgrowth, the Klebsiella, all these other factors can affect the gut, which you need a healthy gut to have a healthy immune system.

One thing I don’t think either one of us mentioned is mold can increase the permeability of the gut as well.

Evan: 

Good point. There is some good literature on that. If you put in PubMed “leaky gut” or “mycotoxin leaky gut,” you can find it. 

These people who are so clean with their diet, they’re confused. “How could I have some autoimmune issue? I’m off gluten, dairy, grains. I’m doing the perfect diet that everyone tells me to do,” this AIP diet. Yet their gut is still a mess. 

That’s right. Not only do the lipopolysaccharides and the endotoxins from bacteria affect the gut barrier, but mold toxin does as well. If you’re taking all these leaky gut protocols, leaky gut supplements, but you’re full of mold and mold toxin, you’re not going to get fully better.

Dr. Eric: 

What impacts will moldy foods have? We focus more on the indoor air. If someone is eating grains or nuts that are moldy on a regular basis, I would assume that also could prevent someone’s gut from healing.

Evan: 

Yeah. I think this is tough to prove. If I were to give you a pie chart of exposure, I would say the biggest piece of the pie is 90% inhalation. You breathe on average like 20,000 times a day. Versus you’re eating and snacking 3-5 times a day. Just your overall consumption is significantly less in the diet, I think. 

It is true that you can have moldy coffee, moldy chocolate, moldy grains. For example, there is one study out of Guatemala. Apparently, liver cancer is very high in Guatemala. It was connected to moldy corn tortillas, which are a huge staple in the diet down there. Corn can be highly contaminated with various mycotoxins. This also can affect fertility and create miscarriages and birth defects and other problems for females. 

Remember that we are talking gut-thyroid here, but there is this big endocrine system effect as well. A lot of mycotoxins are highly estrogenic, so if you’re having breast tenderness or other problems, female issues, hormone problems, PMS, and worse, that could also be a part of it. 

I would say the diet is a smaller piece. I will say this is probably why some people feel better on a grain-free or more paleo template. They have already eliminated some nuts, seeds, grains, so they got rid of the mold. 

You won’t have a moldy steak. Now, the cows, if they’re fed grain that’s moldy, moldy corn that is sprayed with glyphosate, and the GMO products are in the cow’s diet, could that impact the quality of the meat? I would say so. I would still prefer people to get pasture-raised meats if they can. 

Overall, if you had to choose your battles, and you had the option of living in a moldy home and eating clean, or living in a clean home and eating a McDonald’s hamburger patty with no bun and cheese, I would probably do that. The buildings will really wreck you far more.

Dr. Eric: 

That’s interesting. Obviously, you’re not recommending for people to eat McDonald’s hamburger patties. But if they had to choose between being in that moldy environment and not eating as clean as you would normally recommend, that does make sense.

I know you use natural binders. What are your thoughts on cholestyramine? I am asking you for a reason, not just for the mold. I don’t know if you know this, but cholestyramine can also bind to thyroid hormone. It’s actually used as a treatment for some people with hyperthyroidism. This is in the literature. I didn’t know this years ago. I found it in the research. 

Since then, I have had some patients get cholestyramine prescribed by their endocrinologist if they are unable to tolerate antithyroid medication. It’s not ideal, definitely not the first line of treatment. I wanted to get your opinion. What do you think of cholestyramine in general? In this situation, for the binding of mycotoxins.

Evan: 

That’s cool. I didn’t know that. It’s a pretty remarkable compound. Folks listening that might not be familiar with it, it was created sometime in the ‘60s or ‘70s. It was used as a cholesterol-lowering medication. Statins came out, and they work in a different mechanism than this. Cholestyramine fell off. Maybe there is not as much profit in it. I don’t know what the story was as to why it became this forgotten-about product or compound. You can get it compounded from compounding pharmacies, which I have, and I have personally taken it.

I’ll tell you this though. Nobody is talking about this. It’s frustrating. If I would have gotten more warning on this, I wouldn’t have messed with it. 1) It’s tough on the gut. I think it really exacerbated histamine problems for me. I don’t feel like I had many histamine issues until I started to use cholestyramine. I don’t know if it changed something with the gut barrier, if it was too harsh, if it was detoxing too strong, and that aggravated my mast cells, creating more histamine issues, or what the mechanism was. I definitely felt that it messed up my gut.

Secondly, there is an impact on the mitochondria from cholestyramine. I think it made my fatigue issues worse. Most people don’t mention that. If you’re a Ritchie Shoemaker-trained MD, a lot of these conventional mold doctors make fun of natural binders. Natural binders have saved hundreds and hundreds of cases in my situation. These people were at the end of their rope, and we got them better with natural binders. This idea that one is better than the other, or natural compounds can’t work, it’s simply not true.

Cholestyramine in the beginning though did get me out of the hole. I was in a dark place for a while. I had a lot of dizziness and vertigo. When I started it, I almost had instant relief. It’s a much stronger binder than something like charcoal. Stronger, meaning it’s a tighter bond to that toxin, whereas charcoal is a weaker bond. Think of it as a strong magnet versus a weaker magnet. 

When you’re using something like charcoal, it is true that some of the mycotoxins will essentially fall off and get reabsorbed back into the system. You can have a die-off or a Herxheimer reaction from binders. You would think binders are just this perfect, benign substance, and all it will do is pull bad things out of you. 

When I was taking 6-8 charcoal capsules per day, to experiment, I was messed up. I was not feeling well. That told me, “Hey, this is not a perfect product.” When I did cholestyramine, it was so strong that I almost felt more clear-headed with the natural binders. 

There are pros and cons to everything. Do I think it’s necessary to get better? No. But cholestyramine apparently is one of the only compounds on the planet to get out nonstick chemicals. Like the forever chemicals we hear about. It appears that cholestyramine can bind to those and pull those out. That’s cool. Maybe at a minimum, I at least pulled chemicals out of my body that natural compounds wouldn’t. 

Dr. Eric: 

That’s interesting. I didn’t know that. I can’t say I’ve had a lot of patients on cholestyramine. Typically, they’ll either be on the herbs, things like bugleweed or motherwort for those with hyperthyroidism, or they will be on antithyroid medication. If they can’t tolerate the medication, and the herbs aren’t effective, if it’s a choice between getting their thyroid removed or radioactive iodine or the cholestyramine, I will recommend the cholestyramine. 

Evan: 

Agreed. They probably have mold toxin anyway, so why not give them cholestyramine? Then you are helping them with thyroid and detoxing them. in your case, it would be a good strategy. 

I love that you use and implement motherwort. You are one of the few guys who know and talk about motherwort as much as I do. It’s one of my favorite herbs. I take it a few times a week, 5-10-15 drops sometimes. 

The stress and trauma and grief associated with this whole conversation is significant. We are talking uprooting people from their family homes. We are talking having to sell or remediate or renovate. You’re talking marriage stress, financial stress. There is a lot of other collateral damage that happens with this whole conversation. Motherwort is not only a great tool for the thyroid cases, but it’s amazing for emotional trauma and grief, heart palpitations, afib, atrial flutter, blood pressure irregularity. Motherwort is a really good ally throughout this process.

Dr. Eric: 

I agree. It also has some antimicrobial effects as well. It’s cool that you take it on a regular basis. I didn’t know that. 

I know there is so much more we could cover, but I know you have to run soon. Before we wrap it up, is there anything burning in you that you want to say? Did you want to give a summary? If someone is suspecting they might have a mold problem, what would be the next steps? 

Evan: 

If you haven’t done some good labs, test your home, and test your body. That would be a great investment. If you wait until you get the cancer diagnosis or the Alzheimer’s diagnosis or some other really scary thing that will have a lot of pharmaceutical interventions and potentially surgeries and all of that, you can save yourself from some of that if you get your body clean. You get these toxins out. 

This is not a rare situation. This is an extremely common situation. I bet a large amount of money that folks listening and/or their family members, their parents, their children, their grandchildren are probably walking around with mold toxin in them because the average person spends roughly 95% of their time indoors in the modern world. 

Versus just a short time ago, in the 1800s, when we were all farmers, we were all outside all day. Even if the old farmhouse was moldy, which it was probably less moldy because they used plaster and not drywall with paper backing, so the housing materials have changed. How tight our homes are have changed. There is a lot of things that have happened in a very short amount of time in terms of building technology that have made us more prone to having mold issues. 

I encourage people to remember that this is a multigenerational problem. I have tested grandma, daughter, granddaughter, and I have seen it through the family line. If you are one of those people who walks around saying, “Hey, mental illness runs in the family,” you’re maybe indicating there is mold illness running in the family. That’s why you’re all chronically fatigued, obese, depressed, anxious, etc. Of course, nutrition plays a role. 

But I have seen these families where they are all crazy. Mold causes rage. If the kid’s having behavioral issues, the mom is on an antidepressant, and the grandma had a nervous breakdown, these are the things you have to look for in people in a workup, to plot the dots here. “Grandma was nuts. Mom’s nuts. Kids are nuts. Okay, we have to figure this out.” 

If you dig deep enough, you’ll spend a couple thousand bucks to do a really good workup on yourself. If you do this, you will save yourself massive suffering. You’re potentially going to save your marriage if it’s not good. You will save the money from not having to send your kid to behavioral therapy and speech therapy and occupational therapy and interventions that you’ll try to do to mitigate the toxicity. 

The speech can be affected in children as well. That’s something that most practitioners don’t recognize. 

There is also a big link, and that’s why you and I love and have used Great Plains/Mosaic because of the link between autism spectrum issues and mold toxin. Any child who is on the spectrum at any level, any degree of severity, we are going to run chemicals and mold toxin. Guess what? We will find it 99/100 times in these kids. 

This is something I hope will become more popular and mainstream. At this time, there is very few people talking about this. Even less pediatricians talking about this. I know some really good functional pediatricians. Even they are not doing the work that I’m doing with this stuff. 

That’s why I have built up and had to become an expert in kids, mainly because I have three of my own, but also because who else is going to save the kids? 

At the current rate of toxicity that I’m seeing and the current rate of fatigue, behavioral issues, lack of motivation, I really don’t know how society will continue to function if we don’t start getting people healthier. Who is going to be the garbage man? If everyone is too tired to pick up a garbage can and throw it in the back of the truck and drive away, who is going to take care of society? How is society going to continue to run if our health is so chronically bad like this? We have a mess on our hands.

I hope people like you and I can put a dent in it. We need others out there. If you are a parent, and you need help, reach out. Let’s help your family. 

If you’re a practitioner, I would encourage you to learn about this stuff. If you’re interested, I have functional medicine training courses that people can take. I have over 1,200 students in there. A lot of them aren’t practitioners. It’s maybe an 80/20 split. 80% health seeker, 20% practitioner. 

The big flagship one I have is called Better Belly. This is a course where I have taken a lot of case studies and put them into an easy to understand and digest format. I’ll show you real quick. We could probably get a coupon code, too. If people want to get a better deal on it, they can. This is a fraction of the cost of one semester of college, and you will learn way more than you will in college, I promise. 

This course, I have a full curriculum. It’s over 53 lessons, anything from ulcerative colitis and Crohn’s, IBS, candida, candida protocols, stomach acid. We talk about SIBO and SIFO, H-pylori, Clostridia, heart issues, parasites. I have all these calls where I am on them with my clients, and you can listen to what the clients are saying. A histamine intolerance case study. We go into lab testing, supplements. I have some mold experts here. This is a professional mold inspector. This guy here owns a mold testing company. Here is a talk I gave on how mycotoxins create all these issues. I have a presentation on how to improve your home health. There is a lot of stuff. 

I am motivated and hungry to get this out. I am going to keep charging full speed ahead. I appreciate our time together. It’s been great. 

Dr. Eric: 

Same here, Evan. Can you verbally say the website? Where can people sign up for Better Belly? If they want to work with you one-on-one and check out your podcast? 

Evan: 

It’s EvanBrand.com. Everything is there. You can check out the podcast, too. We will get you on there as well. You will see Eric’s pretty face on the podcast soon. The podcast is free. The courses are paid. A consultation, I have me and another functional practitioner on my team. If you all need help, we’ll be here.

Dr. Eric: 

Awesome. Thanks, Evan. Great chatting with you. Definitely check out Evan’s podcast. Look into his Better Belly course. If you want to set up a consultation with Evan, contact him and his team. Thank you so much for this conversation. I learned a lot as well. 

Evan: 

Thanks for having me, man. 

Recently I interviewed Mira Dessy, and we talked about ingredients that can trigger thyroid autoimmunity. If you would prefer to listen to the interview you can access it by Clicking Here.

Dr. Eric Osansky:

I am super excited to chat with today’s guest on men’s health. We are going to be talking about men’s hormones, tying that into thyroid health. I have Dr. Tracy Gapin, who is a Board-certified urologist; a world-renowned men’s health and performance expert; and the founder of the Gapin Institute for High Performance Health.

Dr. Tracy is a thought leader, a professional speaker, and the author of the best-selling books Male 2.0 and Codes of Longevity. He has over 20 years of experience focusing on men’s health, human performance, and longevity. He has been featured in Entrepreneur Magazine, Dave Asprey’s Biohacking Conference, and NBC. Recognizing our healthcare system as broken, Dr. Gapin created the proprietary G1 program designed to help entrepreneurs optimize their mind and body to function at the highest level. Thank you so much for joining us, Dr. Gapin. 

Dr. Tracy Gapin: 

Thanks so much, Eric. Glad to be here with you today.

Dr. Eric: 

This will be fun. Before we get into men’s health and hormones, can you talk about what led you to taking more of a functional medicine approach? For years, you had a general urology practice, correct? 

Dr. Tracy:

Exactly. I like to say I am a recovering urologist. I spent 23 years in traditional allopathic medicine as a very busy clinical urologist, doing robotic surgery every day, treating prostate cancer, kidney stones, you name it. 

About halfway through my career in urology, through my own health issues, I came to realize that we were really failing men. I found that we were great at treating disease, symptoms, problems, but really bad when it comes to helping men with the common issues that they complain about. “I want to have more energy and focus. I want to lose weight. I want to have better sex. What do I have to do to live longer?” I found in traditional medicine, as a “men’s health expert,” as the urologist I was, we didn’t have the answers for them.

Selfishly, to overcome my own health issues, I went down rabbit holes. I started studying and getting certifications and going through courses and programs and research. I fell in love with precision medicine and epigenetics and functional medicine and wearable technology and peptides and all this world-renowned generative medicine and longevity. I put all these concepts together and created what is now the G1 program. I was able to transform my own health. When I shared this same approach with my patients, they had the same great results.

Many years ago, I made the decision that it was time to step forward and commit myself to doing this. I made the very massive decision to jump off a cliff a few years ago, and I stepped away from traditional medicine. I launched the Gapin Institute for High Performance Health, where I can now spend all of my time working with high performing individuals to help them with those challenges that I mentioned: I want to have more energy and focus. I want to lose weight. I want to have better sex. I just want to live longer. It’s fun. I love what I do now.

Dr. Eric: 

Wonderful. I know you’re in Florida. Is it Sarasota? 

Dr. Tracy: 

That’s right. 

Dr. Eric: 

Awesome. Let’s dive into the hormones. What are some of the main reasons why so many men have low male hormones, especially with an emphasis on testosterone? 

Dr. Tracy: 

Great question. We can look at things like our crummy diet, the standard American diet, with the high trans fats and pro-inflammatory Omega-6 fats and the high processed, refined carbs and sugars. We can look at the stress in our daily life and chronically elevated cortisol that we know are crushing our gut and putting us in a catabolic state. We can look at the poor sleep we’re experiencing. We can look at the lack of exercise and sedentary lifestyles. We can look at all of these factors that definitely come into play.

Without question, in my opinion, the single biggest factor when it comes to low testosterone is endocrine disruption. The toxins in our environment that are crushing our health. We can look at toxins in our food, in our water, in our personal care products, that are around us each and every day. Studies have clearly shown they are crushing endocrine function. They crush thyroid hormone function obviously and testosterone especially.

Dr. Eric: 

Any specific ones? There are obvious ones like drinking out of plastic water bottles and other sources of plastic with xenoestrogens.

Dr. Tracy: 

Exactly. BPA and phthalates are used to make plastic water bottles, food containers. They are used to line metal cans. They are ubiquitous. They are almost everywhere.

We can also look at things on our food, like our crops are sprayed with pesticides, herbicides like Atrazine. Atrazine is the second most commonly used herbicide behind glyphosate. Clearly shown to crush testosterone function in men. 

We can look at a lot of the chemicals in our personal care products, like laundry detergent especially. We are washing our clothes in these laundry detergents that we are bathing in our skin on a daily basis. These chemicals have been shown to crush hormone function. It’s about recognizing where these toxins are and making the little decisions every day to avoid them.

Dr. Eric: 

Of course, that’s a big reason to try to eat organic. Try to use natural cleaners, cosmetics.

Dr. Tracy: 

Absolutely. A big one is our water supply. A lot of people aren’t aware of this. Men in this country are on birth control. I say that jokingly, but our water supply is tainted with synthetic estradiol, which is from women’s birth control. The synthetic estrogen does not get filtered very well by our water treatment plants. What happens is we are drinking synthetic estrogen. What it’s doing is it acts like glue to an androgen receptor. It binds to the receptor and doesn’t let go. It switches on and never turns off. That disruptive estrogenic effect is what is crushing testosterone production and function.

Dr. Eric: 

I imagine it’s both the water that we drink and bathe in, or is it mainly just oral consumption? 

Dr. Tracy: 

Certainly, when you’re bathing, it comes into play as well. It’s a short contact time when you’re taking a shower, and you don’t tend to absorb it nearly as much through your skin. It’s much more a factor in the water you’re drinking.

You mentioned plastic water bottles. Any time you are drinking water, it’s going to be in your body longer. I carry a stainless-steel water bottle everywhere I go. I use a water filter at home for my water and ice. I think that’s one of the biggest sources of estrogenic stimulation in our body. 

Dr. Eric: 

We have chemicals from food, cosmetics, cleaners, and water. How about the impact of stress? How big is that when it comes to the low hormones? 

Dr. Tracy: 

It’s a big deal. I’m glad you brought it up. A lot of people don’t talk much about stress. Most of the high performing individuals I work with, they’re entrepreneurs. They’re uber-wealthy, super rich, young men who have already retired and are now busy building new businesses. They are professionals, lawyers, accountants, other doctors, and athletes. What a lot of men don’t recognize is the chronic stress in their life that is having a major effect. A lot of guys don’t realize this, but we can test for this. There are ways we can quantify this with cortisol testing.

Chronic stress, and we’re talking specifically about psychological stress here. Other stressors come into play here, like dietary, nutritional, sugar, food sensitivities, issues with dysbiosis in the gut, all these other things I look at as “stress” to our human operating system. 

Psychological stress, men tend to discount it. “It’s not affecting me much at all.” We can quantify it, and we do a lot of cortisol testing with our clients. We can see chronically elevated cortisol. 

You ask the question of what it does. It has a major impact. What cortisol does, and I know you’ve talked about this in the past, is the thyroid system gets affected. It affects TSH production and comes into play when we look at T4 conversion into T3. It certainly affects thyroid production and function.

With testosterone, what it’s doing is it’s going back to the brain and turning off the natural releasing hormone, luteinizing hormone (LH), and testosterone production. Cortisol in and of itself can be very significant and have a great impact on testosterone production and ultimately function.

Dr. Eric: 

With all of your patients, do you do adrenal testing and focus on stress management techniques? 

Dr. Tracy: 

Absolutely. We’ll talk about the big picture in a moment. It’s super important to look at adrenals, things like DHEA, which is coming from the adrenals; cortisol; and all the other key hormones that are coming into play. It’s like a symphony. Men don’t recognize we have over 50 hormones in our body. Testosterone gets all the attention, and it’s where we started the conversation here. It’s important to recognize there are a lot of hormones that come together and all influence each other to some extent. We start with testosterone but have to look at all the other hormones as well and understand how they all interplay.

Dr. Eric: 

How about insulin? Insulin resistance is a big factor, too. That also affects not just testosterone but other hormones.

Dr. Tracy: 

It becomes a vicious cycle. You mentioned cortisol. I will give you an example of how this is all connected together. I’ll work with men, and they’ll stay up until 1am working on a project, or maybe they’re just binge-watching Netflix. I don’t know. But they’re staying up late. Then they will fall asleep and wake up 2-3 hours later. They can’t fall back asleep again because their mind is racing. Classic elevated cortisol picture. 

What that’s doing is promoting inflammation by raising cortisol. That elevates blood sugar. That puts stress on the pancreas, trying to release insulin to control this blood sugar elevation. Over time, it can’t control it. Over time, the pancreas gets overburdened and stressed, and that is ultimately how rising fasting insulin and post-granulin levels rise. 

It gets to the point where your body can’t handle it anymore. You’re storing it as fat. What does all that do? It crushes testosterone production and function as well. That excess visceral fat you’re producing from the cortisol, inflammation, and insulin resistance is taking that testosterone and turning it into estradiol as well. Now, you’re tanking your good, healthy, optimal testosterone to estrogen ratio. You have that estrogen to testosterone ratio. 

That is a quick summary about how it all plays upon itself. Low testosterone, high estrogen in women will promote further chronic inflammation and insulin resistance, and it becomes a vicious cycle.

That’s metabolic syndrome. It’s about correcting that entire ugly process that happens. It’s ubiquitous in guys. Once they hit 40, 45, 50, it happens in almost every guy unless they’re aware of it and make the real decision to do something about it. 

Dr. Eric: 

It’s definitely widespread, and it is this vicious cycle. What I see is diet plays a big role, but usually depending on the severity, many times, just cleaning up your diet, it’s certainly often not sufficient alone to reverse this process.

Dr. Tracy: 

Exactly. This is why I really believe strongly- My philosophy is based on a systems model, understanding that we have all of these systems that come into play, and you can’t focus on any one of the hormones. We have over 50 we have to look at. You also have to look at your nutrition and your gut health, and get your microbiome cleaned up. You have to look at stress and how that’s affecting cortisol. There are various types of stress. You have to look at detoxification pathways. Are you optimally clearing those toxins from your body? You have to look at sleep. So many of these high performing individuals that we work with have crummy sleep, whether it’s intentional or not. Correcting sleep is a big part of breaking that cycle.

Dr. Eric: 

How about some of the common signs and symptoms of an androgen deficiency? 

Dr. Tracy: 

A lot of guys will notice decreased energy, fatigue. They may want to take a nap later in the afternoon. There’s something wrong if you’re taking a nap in the afternoon. You should not need a nap. That is typically a sign of endocrine problems.

These guys will have cognitive alterations, where they can’t think as quickly or clearly when they could before. They can’t make decisions. Mental acuity is off. They call it brain fog.

Sex drive will be one of the most common symptoms that men notice initially. Decreased libido. Impairment in sexual function can come into play. 

Guys will sometimes have difficulty sleeping. Testosterone will cause issues with sleep, which obviously will promote low testosterone as well. That is a cyclical issue.

Guys will start to put on belly fat. They have fat around their belly they can’t shake. So many guys will say, “I run on the treadmill every day. I’m eating perfectly clean. I can’t seem to lose weight.” When I hear that, it makes me think of hormone issues. It typically centers around testosterone as one of the first parts of that.

Dr. Eric: 

You mentioned earlier about thyroid. Can you talk about the impact of thyroid hormone on testosterone? 

Dr. Tracy: 

It’s interesting. So many people think that thyroid issues are solely a female problem, but they’re not. We see a lot of guys who have most commonly clinical hypothyroidism that is undiagnosed that they don’t realize is a problem. I’ve seen hundreds of men over the last 20 years now who come to see me and are on testosterone already but feel like crap. They have low energy, they can’t lose weight, they’re sluggish, and they end up having great testosterone levels but crummy T3 levels. A lot of these guys have issues with metabolism, energy, weight loss, poor sleep. A lot of it is associated, as you know, with microbiome issues, too. 

There is this common finding that almost every man that has low testosterone will have some element of at least subclinical hypothyroidism as well. We know that elevated TSH will suppress LH production from the brain. High TSH will suppress the natural releasing hormone effect on the pituitary. Therefore, low LH leads to low testosterone. There is a clear connection there. 

There are also common variables, where just like chronic inflammation and insulin resistance, microbiome issues, stress, can also affect thyroid. Those same underlying etiologies are affecting testosterone production as well. Very common to see guys with both testosterone and thyroid issues. 

Dr. Eric: 

One thing that caught my ear is you said T3. When we talk about testing, when it comes to testosterone, you focus more on free testosterone than total testosterone, not that total testosterone isn’t good to test, too. Same thing with the thyroid. The T3 is the free thyroid. Many doctors just look at TSH and T4 and neglect that T3.  

Dr. Tracy: 

Eric, it kills me. We have a couple of endocrinologists here in town that I’ve gone to war with. The fact that I’ve had patients who will come in, and they’re being told that their Synthroid is working great. Their TSH looks great. They have never had their free T3 checked. They check their free T3, and it’s 2.8. You fix that, and it is amazing how that can drastically impact their life and change their brain function, their energy. They’re alive again. This is a great example of how so often, it’s not testosterone; it’s some of the other hormones that definitely come into play as well. 

Dr. Eric: 

I agree. A number of people listening to this have hyperthyroidism. Typically, you get elevated sex hormone binding globulin (SHBG) here. With that pattern, you would expect to see lower free testosterone levels, correct? 

Dr. Tracy: 

Yes. High SHBG will bind to testosterone, so you’re right. Free T will be lower. In those cases, it’s tough to artificially lower SHBG. There are not a lot of great maneuvers that will do that. You need to go higher on testosterone therapy to get free testosterone to where it needs to be. 

Dr. Eric:

Let’s talk about testing. When someone comes in, what do you do as far as blood testing, adrenal testing, whatever you want to talk about? Lead the way. 

Dr. Tracy: 

I’m obsessed with advanced diagnostics. That’s the beginning when clients work with us. We do a lot of blood tests, saliva testing, stool testing, urine testing. 

Blood testing, we’re looking at all the major hormones. Testosterone, free T. We are looking at estradiol and DHEA sulfate, which is a common problem in these guys as well. It’s a fairly misunderstood hormone, but it’s very important when it comes to men’s health. It does help men with a lot of the same things that testosterone is responsible for: energy, mood, metabolism, etc. 

A lot of guys are deficient in DHEA. I’ll find also that if men are on testosterone therapy, their DHEA sulfate levels will typically be much lower than they need to be as well. It does suppress DHEA production very commonly.

In women, it tends to stimulate DHEA levels for whatever reason. I don’t think we clearly understand why. In men, DHEA levels are suppressed when on testosterone therapy.

We look at free T3, free T4, thyroid, TSH. We are looking at thyroid antibodies. 

We are looking at markers for growth hormone. IGF1 is not perfect, but it’s an easy serum test to assess growth hormone function. Understanding its limitations. 

Looking at insulin, fasting insulin, homeostatic assessment of insulin resistance, fasting blood sugar. Looking at micronutrient levels, advanced lipid markers, which can be closely correlated with insulin resistance for sure. 

For salivary testing, we look at cortisol in men, recognizing that they all tend to have some element of adrenal dysfunction, whether they are hypercortisolism or whether they have already crashed and need support. Somewhere in between is pretty common. 

We do a lot of microbiome testing, looking for dysbiosis, looking at gut integrity and permeability, looking at markers of food sensitivities that are pretty common in men. 

We do some urine testing, specifically organic acids testing. A lot of these guys have candida, mold, etc. 

Looking at markers of energy production, mitochondrial function, as well. A lot of lab testing.

I really believe that it all starts with getting hormones optimized. 

Dr. Eric: 

I really like organic acids testing. When it comes to the gut microbiome, do you do a GI Map or GI Effects? 

Dr. Tracy: 

We’re doing a GI Map right now. We seem to be getting great results with that.

Dr. Eric: 

For adrenals, I do a lot of saliva testing, too. I do some dried urine testing. Do you also do Dutch testing as well? 

Dr. Tracy: 

We do Dutch testing. You bring up a good point. I love Dutch testing when we’re looking at estrogen metabolism. The 2 4 and 16 hydroxy estrone, the metabolism of testosterone into estrogen. We’re looking at methylation, DHT. That third page is the money shot. You look at oxidative stress on the last page, the neurotransmitter markers.

The cortisol, I don’t use much at all. It’s interesting when you talk to the folks in Dutch. They concur with the research I’ve found. Urinary cortisol testing is not validated like salivary testing is. I really believe that saliva testing is where it’s at. Serum would be great, but you can’t do that nearly as easily. Salivary in my opinion is where it’s at for testing cortisol. 

Dr. Eric: 

Would you have them do a Dutch complete and a saliva test? Would you have them do the hormone portion of the Dutch and then the saliva test? 

Dr. Tracy: 

I can do Dutch+. It comes with the salivary test with it. I will look at the metabolized cortisol part of the urine, but I don’t personally put much stock in those numbers.

Dr. Eric: 

Okay. That’s good to know. With the testosterone in Dutch, I’m sure you’ve noticed this, that a lot of times, it’s low. Even in the report, it says it’s common to have false low results. They recommend testing it through the blood if it’s low. Do you also find a lot of low readings? 

Dr. Tracy: 

We do. I’ll use serum for testosterone typically rather than dried urine. 

Dr. Eric: 

With the blood, do you test for DHT or androstenedione? Is it free testosterone and total testosterone? 

Dr. Tracy: 

I tested DHT in the past. The issue is, what are you going to do about it? I don’t test it on every man. Some guys have hair loss issues; DHT is the culprit there. Stimulation of DHT receptors is what would cause me to be concerned there. I don’t check those on every guy. 

I don’t think I have intentionally checked androstenedione. Maybe I should, but I haven’t serum-wise. I know you see that in the Dutch and some of the organic acids tests. A test has it. I have never tested it. Do you test that? 

Dr. Eric: 

I don’t. I was asking you because you’re the expert. I want to make sure that I shouldn’t be testing that.

Dr. Tracy: 

I have never seen a value for it. When I have checked DHT, I don’t know what to do with it. Let’s say you check DHT, and it’s high. What are you going to do there? If the guy has no symptoms or major androgenic side effects, I won’t do anything about it. If he is having problems, like male pattern baldness, excessive acne, and we decide to block that, what are we going to do? It’s a 5-alpha reductase inhibitor like Finasteride. I know from the research out there with post-Finasteride syndrome, that it can be pretty devastating when you crush a guy’s sexual function permanently, irreversibly with that drug. I honestly try to avoid it if I can. 

Coming back to the beginning, that’s why I didn’t order it. What am I going to do if it’s high? Probably nothing. I only order a test if I am prepared to do something about the results. 

Dr. Eric: 

That’s a great response. Why do a test if you’re not going to take specific actions based on the test results? It’s wasting the patient’s money.  

Dr. Tracy: 

There you go. I’ll do DHT every now and then. It’s not on my standard lab panel. 

Dr. Eric:

Let’s talk about increasing testosterone. I’m sure you get a number of people, and I’m going to ask you here right now: What can someone do to increase it naturally? Can they increase it to a healthy level naturally? Maybe it depends on how low it is. 

Dr. Tracy: 

Wonderful question. Yes, for the listeners, there are ways you can naturally boost testosterone levels without question. One of the biggest ways is heavy strength training. We are talking about moving heavy weights, specifically leg muscles like quad and hamstring and core and back, these big muscles in your body, doing heavy lifting. You can definitely raise testosterone.

Perfecting your sleep can definitely improve testosterone for the reasons we talked about in relation to cortisol. 

Lowering stress also has a big impact, for the same reasons. 

Getting sufficient micronutrients, things like zinc, magnesium, B vitamins. Good healthy nutrition. Getting enough fats in your diet. It’s a misconception that if you have a low fat diet, it will crush your testosterone. It won’t have a major effect, but you want key macronutrient ratios.

Sunlight can help. Believe it or not, sunlight has been shown to help testosterone levels, especially on the scrotum. I know it sounds crazy, but going out nude first thing in the morning for half an hour with direct sunlight exposure to the scrotum has been shown to help. Those are the natural ways that you can raise testosterone.

Let’s talk about how much. The key question that you ended there with is how much can it raise it? is it enough? We’ll talk about lab numbers in a moment. I think this would be a good tie-in. In general, what I find most of the time is you cannot get your levels up to where they need to be with natural approaches, unless you’re just a little low. If you’re a little on the low side, which I almost never see in my practice. Never say never. “You’re almost there. Let’s do some natural stuff to boost it.” No. Guys need to be 20-30 with free T3. Most guys are at 4, 6, 7, 9. Nowhere close to where they need to be. Yes, natural can help them to some extent, but not enough to get them to where they need to be optimally.

I will recommend those things anyway in addition to giving them testosterone. 

Dr. Eric: 

Makes sense. You don’t want to just give testosterone. You want to try to address adrenal imbalances if they have them or endocrine disrupting chemicals. Makes sense. I know you focus more on the free testosterone, but is there an optimal range for total testosterone that you like to see? 

Dr. Tracy: 

Depends on the SHBG. Assuming that our target is 20-30, I have had guys where total testosterone of 800 meant a free T of 21. I have had other guys with a total T of 1,400, and their free is still 12. Purely based on the SHBG levels. Total testosterone can be a guide for men, where you know where their SHBGs are. In general, the free T is the critical number there.

Dr. Eric: 

Thanks for that example. You really do need to do free testosterone. 

Dr. Tracy: 

Yeah, across the board.

Dr. Eric: 

How about estrogen? Is looking at estrogen in men important? Do you do blood testing like estradiol or total estrogens? 

Dr. Tracy: 

We do. This gets into some fun controversial conversations. Estrogen is not the enemy. A lot of men think estrogen is the enemy, and we have to lower it and get it down as low as we can. That’s not accurate. Estrogen is incredibly beneficial. It’s helpful for men when it comes to sexual function and energy. We know that estrogen has massive benefit when it comes to cardiovascular health. This is why postmenopausal women are given estrogen, not only for symptoms and quality of life, but we know it has some protective benefits.

For men, estrogen is not the enemy. What’s important is the balance between estrogen and testosterone. A lot of men come in with insulin resistance, and they’re obese and have super low T and very high estrogen. We want to get estrogen down, not by blocking it, but by reducing visceral fat and improving testosterone levels. That will help with that ratio.

When working with men, I do assess estradiol in all of them. When it’s elevated, my main question is: Is there a problem? Are there any side effects? Is there a reason to lower it? The main side effects that men would get from elevated estrogen would be breast tenderness, breast enlargement. They’re moody, they’re crying over puppy movies, they’re excessively tearful and emotional. We had a guy this morning who had some rage issues, where he was angry and short-fused. That is typically not what you see from high estrogen. You’re more emotional and effusive and crying. 

When you do have those symptoms, then it’s worthwhile to look at bringing estradiol levels specifically down. If there is no symptoms involved, then nothing says we have to bring it down to any certain range. 

The key question there is: If a guy does not have symptoms, what is the threshold for when you should lower it? When should you get concerned? Some doctors will tell you if you get above 60, if you get above 80. This one doctor I know will say he gets concerned when estradiol gets above 1,000. He says that jokingly because he doesn’t measure it, he doesn’t test it, he doesn’t care. He has no concern. He doesn’t block estrogen ever because he doesn’t think it’s a problem unless a guy is having symptoms. 

I do think there is some rationale for having some threshold to lower it down to a reasonable level. It’s arbitrary. Interestingly, there is no clear science that shows estrogen in men is harmful. This was for me quite shocking when I heard this. I looked, and you cannot find anything that says estrogen is specifically harmful in men. It’s really more the ratio of your hormones all together.

Dr. Eric: 

When it comes to helping improve estrogen metabolism in men, is it a similar approach to women, as far as helping to support detoxification, including methylation, and the gut microbiome? 

Dr. Tracy: 

100%. We are looking for the same 2 hydroxy estrone pathway on the Dutch. We want to make sure they are having healthy estrogen metabolism for sure.

Dr. Eric: 

DHEA, since it’s a precursor to testosterone, can you increase testosterone by taking DHEA? 

Dr. Tracy: 

Typically, no. Can you get some marginal elevation? Yes. Not anything substantial. You can’t use DHEA as a way to support testosterone production unfortunately. 

Dr. Eric: 

We will get to bioidentical testosterone. With DHEA, if it is low, do you typically give DHEA? 

Dr. Tracy: 

I do, understanding that when DHEA sulfate is low, it’s from one of a couple reasons. It could be low substrate, low DHEA, in which case giving DHEA should help that. 

It could be chronic inflammation. Inflammation can affect the sulfation process, so DHEA does not get converted to the biologically active form of DHEA sulfate. If you have bio salt issues or gut issues, that can also affect the sulfation process as well.

Yes, I give DHEA. You put guys on 25mg once or twice a day of DHEA, and I will typically see massive changes in their DHEA sulfate levels. If I don’t, that’s when I will start looking deeper into the gut or other reasons why it is not coming up. 

Dr. Eric: 

Let’s move onto testosterone. Most people who you work with, their testosterone is so low that a natural approach won’t get it up by itself. You will do things to improve adrenals and reduce toxic burden, but it sounds like really, the best thing to do in addition to that is to give testosterone. 

Dr. Tracy: 

Absolutely. I feel very strongly of the benefits of testosterone therapy. Without question, it provides incredible improvements in quality of life, whether it’s energy, cognitive function, sex drive, ability to burn fat and build muscle, general sense of wellbeing and vitality and feeling like a man again. 

It has amazing benefits when it comes to cardiovascular risk. We know that men with low testosterone have a markedly increased risk of cardiovascular disease and about a 30% increased risk of a major adverse cardiac event. Dozens of studies have shown the same thing. About 30% reduction in a major adverse cardiac event when you optimize testosterone.

We know men with low testosterone very counterintuitively have an increased risk of clinically significant prostate cancer. Flies in the face of everything I was taught conventionally in urology for 20 years. Men with low T have a higher risk of prostate cancer. In my opinion, there is negligible risk but tremendous benefit to giving testosterone therapy. 

Dr. Eric: 

What form do you give it? Is it injection, orally, or topically? 

Dr. Tracy: 

There are a couple different options. You can do injectable. An injectable comes subcute or intramuscular (IM). You can do topical. Or you can do pellets. I generally tend to recommend them in that order as well. 

Dr. Eric: 

I don’t know the average age of the person who sees you. If someone is in their 50s, 60s, 70s, this is just me talking, but there may be a greater indication to take testosterone. You do have to factor in the age. It does decline as we get older. 

If someone comes in in their 30s, and they have really low testosterone. As you mentioned, a natural approach is unlikely to increase it. Even someone who is on the younger side, would you still recommend testosterone? 

Dr. Tracy: 

This is where it gets a little tricky. A natural approach will be a little more effective in those men, but not enough to get the free of 6 to a free of 20. 

In young men, you have to recognize there is still some fertility issues to consider. If a guy is 30 years old, and you give him testosterone, you are going to be shutting off fertility, sperm production through negative feedback. Testosterone is going to tell the hypothalamus and the pituitary gland, “We’re good here. We have enough hormone. We’re fine.” It will shut off production of both LH, which is what stimulates testosterone production, and FSH from the pituitary. FSH is what tells the testicles to make sperm. 

When you’re giving a 30-year-old man testosterone, you are turning off sperm production, which may not be what they’re looking for. A young guy, you need to have a conversation about fertility. Are you and your partner looking to have more children at some point in the future? If so, there are other ways that we can stimulate testosterone levels to get where we need them without giving testosterone directly. That would be things like ACG, Clomid, other medications that can help boost testosterone. There is even a peptide that is somewhat beneficial as well. 

Dr. Eric: 

That was my next question, the peptides, if those could help boost testosterone. 

Dr. Tracy: 

Yes, I have used Kisspeptin a number of times. I have been fairly disappointed each time. It’s not quite as robust an outcome as you get with ACG and Clomid. 

Dr. Eric: 

Yeah. Do you use other peptides in your practice? 

Dr. Tracy: 

Yeah, I love peptides. I use a ton of them. Kisspeptin is the one that specifically we consider for boosting testosterone. 

Dr. Eric: 

Can you go over some of your favorite peptides for other purposes? 

Dr. Tracy: 

We use a lot of peptides for boosting growth hormone production. You mentioned the average age of guys in their 50s and 60s. We see guys typically between 40-60 or so. We see women as well. I have a nurse practitioner who focuses on women. Same approach. My passion and focus is certainly on men. 

Those guys, once you hit 40, growth hormone production declines by about 1% a year or so. Growth hormone is an anaerobic hormone that is responsible for growth, for muscle, for burning fat. It’s responsible for energy, cognitive function. In some ways, maybe you consider the fountain of youth for longevity. There is a lot of debate around that that is questionable. A lot of benefits of having good healthy growth hormone levels.

Rather than giving growth hormone, which has some negative consequences, we would rather stimulate your body to produce more growth hormone on its own. That is where some of the peptides are great at telling the hypothalamus, the pituitary gland to make more growth hormone. 

I love growth hormone peptides. We use a CJC Ipamorelin combination, which comes at it through two different mechanisms of action. Growth hormone releasing hormone (GHRH) is the hormone from the hypothalamus. 

I want to make a brief point about this. GHRH comes from the hypothalamus and tells the pituitary to make growth hormone. It also has a lot of systemic benefits on its own that are important. When you give growth hormone through negative feedback, you are turning that off, which you don’t want. 

CJC 1295 is a growth hormone releasing hormone peptide that works very similarly to have those same benefits that you’re looking for. That’s why that one is so beneficial. Tesamorelin is another GHRH peptide as well. Ipamorelin is a ghrelin receptor peptide that is paired with CJC because it will, through the ghrelin receptor, turn off somatostatin, which is what is slowing down growth hormone production. If you turn off the blocker, a double negative becomes a positive. By turning off somatostatin, you’re turning on growth hormone. 

There are a bunch of growth hormone peptides out there. A CJC and Ipamorelin combination are the two we use most commonly, I would say.

BPC 157 is a great peptide. It comes from the stomach. It’s incredibly powerful for reducing inflammation, whether it’s in the gut or systemically or in joints. I love BPC.

Thymosin alpha is an amazing peptide that comes from the thymus gland. It shrivels up and involutes and goes away once you hit puberty. It’s really important for immune function, and it’s great for boosting T cell production and function. 

Thymosin beta is another thymus gland peptide that is great for musculoskeletal repair. You can give that one subcutaneously in the belly, or you can give it subcutaneously near the site of injury for repair. That’s a cool peptide. 

We love peptides that help with mitochondrial function, things like MOTS-c, a great peptide for mitochondrial biogenesis. 

Peptides for sexual function, like PT 141 or Melanotan 2. 

Epitalon is incredibly only two amino acids in length. It’s been shown in animal studies to extend longevity. Epitalon is a really cool one.

Semaglutide, by this point, everyone has heard of it, it seems. It’s a GLP-1 agonist. It’s technically a peptide as well. It’s used for weight loss specifically. It decreases appetite at brain level. It slows gastric emptying to make you full quicker. It works in the pancreas to increase insulin secretion to help reduce blood sugar levels. The three different mechanisms of action. It’s fantastic for weight loss.

Tirzepatide is another similar one that has another peptide combined with it, GLP-1 agonist. It’s probably a little more effective than semaglutide. Both of those have shown amazing benefits when you look at lipid numbers and cardiovascular disease as well. Intimal medial thickness data as well. Remarkable improvements with those peptides. 

That’s just a sampling. We use a lot of them. Those are the top ones we use.

Dr. Eric: 

Are they all injected? Are some of them oral? 

Dr. Tracy: 

A lot of them are injectable. I didn’t mention ones like Semax and Selank. Those are great nasal spray ones for anxiety and mood stuff. PT 141 is a nasal spray. BPC can be either oral or sublingual or injectable. Dihexa is a great topical peptide for cognitive function and memory. Different routes of administration. Probably 2/3 or 3/4 of them are injectable.

Dr. Eric: 

Cool. Are they safe to take long-term? Are they supposed to be taken short-term? Any side effects that people should be aware of? 

Dr. Tracy: 

Great questions. The answer is there is not a lot of data on taking them long-term, like years and years. There is just no data out there. You won’t get randomized control trials like you will with Big Pharma. You look at the basic science, understand the mechanisms of action, and go with that. Everything we prescribe has research and studies behind it to demonstrate efficacy and safety. There are typically minimal side effects. 

Everyone is different and unique with different physiology. I had a guy who had an allergic reaction to CJC, and he had a massive allergic reaction to Tesamorelin. We can’t use those with him. That’s one guy in hundreds of prescriptions I’ve given. There could be side effects, but most people typically tend to have none.

Dr. Eric: 

Even with herbs, most people will do fine with herbs, but you could be allergic to a certain herb. 

Dr. Tracy: 

You never know. In general, we don’t tend to find much in the way of side effects or complications. 

Dr. Eric: 

One last question with peptides: Do you personally take any on your own? 

Dr. Tracy: 

I love to experiment. I have probably tried them all at one point or another. For about three years, I struggled with tennis elbow in my left elbow. I went through all kinds of peptides for that. I have been through all the growth hormone ones. I have used a ton of them now. 

I will emphasize for the listener that there are a lot of sources out there that are direct to consumers for peptides. I would caution anyone against going anywhere where the general public can run a credit card to buy a peptide. Any place like that that is direct to the consumer, there is no oversight or quality assurance compared to a compounding pharmacy, where there is much more regulation, much more of a close eye on quality control and assurance and certificates of authenticity. 

There is a study that came out last year some time that found that after testing, one of these commercially peptide companies had nothing in it; it was like saline. You have to be careful about what you’re buying. If you’re injecting it in your body, I’d get that from a pharmacy. 

Dr. Eric: 

That’s really important. 

Dr. Tracy: 

I’ll also emphasize: I put out these YouTube videos on peptides. I get all these comments about, “Can I buy some peptides?” We’re not a pharmacy. We don’t sell them. We prescribe them for our clients who we serve. People get the wrong impression from a YouTube video I made talking about peptides. We are not a pharmacy ourselves. 

Dr. Eric: 

Tracy, you brought up one peptide that helps with sexual function. It made me think about how you probably deal with a lot of men who have erectile dysfunction. When it comes to that, it sounds like peptides could help. Also, increasing testosterone, I imagine it also could have a role. As far as ED, there is also a blood flow problem, too. Is it a multifactorial approach where you address different things? 

Dr. Tracy: 

When I talk about ED, I like to conceptualize it as four main buckets of causes of etiologies of ED. One is blood flow, as you mentioned. It’s arterial inflow, and it’s venous outflow. An erection is simply an engorgement of blood that gets trapped if you will. That arterial inflow is dependent on nitric oxide. That’s one of the other hormones we test. We can test it in my office. We know that things like insulin resistance crushes nitric oxide production. Chronic inflammation crushes nitric oxide production. We know that systemic issues like gut health and hormones and diet have a profound effect on blood flow. Blood flow is one. Arterial inflow comes in, and venous leak going out, that’s one.

The second cause would be hormones. As you mentioned, low testosterone can definitely be a cause. Sometimes it’s DHEA, insulin issues, or cortisol issues. Even growth hormone, thyroid, or other hormones can affect it. Testosterone is probably the biggest and most common culprit when looking at ED.

The third bucket would be nerve function. You need normal nervous function down there for an erection. Make sure there is no issue with neuropathy, especially if someone is diabetic. Looking at the history of pelvic trauma, pelvic surgery, prostate surgery, colon surgery, stuff like that. That is the least common of the categories.

The fourth is psychological. This is more common than you think. Issues with stress, with infidelity and marital strife. A big one is porn addiction. It’s such a rampant problem right now, where guys are having issues with porn addiction. They are not interested in their partner. All of these psychological issues come into play as well. 

Four buckets: blood flow, hormones, nerves, and psychology. 

Dr. Eric: 

We covered a lot. Is there anything that I didn’t ask you that I should have asked you or anything else that you’d like to discuss before we wrap it up? 

Dr. Tracy: 

My philosophy has become a three-pronged approach. The first is advanced diagnostics. Know your numbers. We talked a lot about testing. 

I believe in a very individualized approach, and that’s where functional testing comes in. We didn’t talk much about genetics, but genetics comes into play when it comes to understanding what’s right for our clients. What foods should they be eating or not? Detox pathways. Additional support? What exercise is right for you? It’s amazing how much genetics can really help us fine-tune things. 

The third is precision lifestyle. This is where I have functional coaches who work with my clients because as powerful as the molecules may be that we prescribe, if you’re not doing the right things at home, then you’re not going to have nearly the success that you would otherwise. 

Advanced diagnostics, individualized approach, and precision lifestyle is where it’s all at, putting all those pieces together. 

Dr. Eric: 

Wonderful. Thank you again, Tracy, for this conversation. Where can people find out more about you? 

Dr. Tracy: 

My website is GapinInstitute.com. If you text the word “Health” to 26786, we have a simple cheat sheet for 10 strategies to achieve high performance health today. 

Dr. Eric: 

Awesome. This was an awesome conversation. I learned a lot. I’m sure the listeners will learn a lot. Thank you so much. 

Dr. Tracy: 

Absolutely. A good time.