Recently I interviewed Dr. Ritamarie Loscalzo, as she discussed how to address insulin resistance and thyroid hormone resistance. If you would prefer to listen the interview you can access it by Clicking Here.

Dr. Eric:

Although I am always excited to do these interviews, I am especially excited today because I have the honor of interviewing Dr. Ritamarie Loscalzo, as we will be chatting about thyroid and insulin resistance.

Let me give Dr. Ritamarie’s bio: She is the founder of the Institute of Nutritional Endocrinology. She is passionately committed to transforming our current, broken, disease-focused system into a true healthcare system, where every practitioner is skilled at finding the root cause of health challenges, and uses the wisdom of nature combined with modern scientific research to restore balance. Dr. Ritamarie is also a licensed Doctor of Chiropractic with certifications in acupuncture, nutrition, herbal medicine, and HeartMath. She specializes in digestion, thyroid, adrenal, and insulin resistance. I know you didn’t include it in your bio here, but she also has a great deal of knowledge when it comes to genetics.

She is also a master at using palate-pleasing whole fresh food medicine and is a best-selling author, speaker, and internationally recognized nutrition and functional health authority with over 30 years of clinical experience. She also has a podcast called Reinvent Healthcare. This provides health and wellness practitioners around the globe to be part of the movement to provide root cause care to people in need. Thank you so much for joining us, Dr. Ritamarie.

Dr. Ritamarie:                                     

I’m so excited to be here. I love talking about this topic, and I’m honored to be on your podcast.

Dr. Eric:

It’s an honor having you as well. I normally ask my guests to begin by discussing their background. If you could please discuss how you got to where you are today, that’d be great.

Dr. Ritamarie:

Like a lot of people in functional health and wellness, I came through my own journey of illness. In my 20s, my health broke down, and nobody knew what was wrong with me. I went to all kinds of specialists, neurologists, gastroenterologists, ear/nose/throat docs because of the symptoms I was having. I wasn’t getting well.

I asked the fated question one day—I don’t know where it even came from—in the gastroenterologist’s office after they said, “Good news. You don’t have an ulcer.” I asked, “Great. What’s wrong with me? What do I do?” They said, “We don’t know. Just keep taking the ulcer medication.” A little bit of intelligence came up and said, “Huh? What do you mean? I’m 25. I’m supposed to keep taking ulcer medication? I don’t have an ulcer. What am I supposed to do? For the rest of my life?” They said, “Oh, maybe, until you don’t need it anymore.” The question popped up. “Could it be my diet?” They looked at me like I was crazy. They said, “No, of course not. Diet has nothing to do with your health.”

I set out to prove them wrong. This was back in 1984 when we didn’t have summits and podcasts and any of what we have now. People were in the dark about what we just freely talk about, and people get the information now. It wasn’t available then.

Long story short, went and did a lot of research. Discovered toxicity, food allergies, insulin resistance, hypoglycemia, and all kinds of things. Did some things to get myself better, but it took a long time. That’s when I decided to jump ship and leave my computer job, which prepared me eloquently for what I do now because I was a diagnostician. I was helping to fix breakdowns in software on the computer. Now I said, “I just changed the hardware and software,” and now I’m working on the body. That’s where it started. I have been passionate ever since to help people not to have to work so hard to figure it out.

Dr. Eric:

Wonderful. Thanks for sharing that. We’re going to dive into insulin resistance, tie it into thyroid resistance. I don’t know where you want to start. It’s probably best to start with insulin resistance. We can talk about what insulin is. If you want to mention metabolic flexibility as well.

Dr. Ritamarie:

Insulin is a hormone. A lot of people don’t even realize that. The hormones that people think about when we say “hormones” are progesterone, estrogen, testosterone, and a more educated person will say thyroid. Insulin is actually a hormone. Its job is to take the sugar from the food you eat, glucose, and put it into the cells, so the mitochondria in the cells can make energy.

What happens is because of the diet, lifestyle that we live, not me and you, but other people out there, our living is loaded with starches and sugars and processed foods and hydrogenated fats and things that are damaging to the body.

What happens is every cell has receptors, little places that hormones latch onto and get entrance into the cells. The receptors for insulin get damaged and tired and resistant, and they start to want to protect the inside of the cells from that hormone. There is so much of it because we have so much glucose and starch that is converted into glucose coming in. We develop something called insulin resistance. When we develop insulin resistance, all of that sugar stays in the blood. Doesn’t get into the cells. We have hyperglycemia, which eventually can lead to diabetes.

Long, long, long, long, and I emphasize, long, before it becomes diabetes, it’s a problem in the body. It’s a problem because of the damaging effects of insulin. We are going to talk a little bit more about the damaging effects of insulin on thyroid function in a bit.

Getting back to metabolic flexibility and what that is. We’re intended to burn carbohydrates, or we can burn fat as fuel. Most people are eating enough glucose all day long that they just look for glucose. When they are doing that all the time, the body is going, “I can burn glucose. Whoops. There’s no more glucose. I need glucose.” You have food cravings, low energy in between meals, etc.

When somebody is metabolically flexible, it means that they can switch between fat burning and glucose burning. But you can’t be metabolically flexible if you’re eating corn flakes, sugar toast with butter and jelly, that kind of stuff. You just can’t.

Recent research around 2018 was that 88% of the population is metabolically unwell, meaning that whole glucose/insulin/metabolism and the way it’s supposed to work doesn’t work properly. 88%! Think about that. That means 12% of the population is metabolically well and healthy. 12%! That’s tiny. This was pre-pandemic. My guess is it’s a much higher percentage of metabolically unwell people over the last few years.

Metabolic unwellness leads to all sorts of problems: cardiac problems, kidney problems, blood pressure problems, and imbalances in other hormones. Thyroid is a train wreck when insulin is out of balance. We can’t get the thyroid in balance if we continue with the process of too much insulin and insulin resistance. That’s in a nutshell insulin and the whole concept of metabolic health.

Dr. Eric:

It’s more of a cellular problem. Insulin resistance is too much insulin, but it’s not getting into the cell.

Dr. Ritamarie:

This is true of all hormone resistance. People know about insulin resistance.  We have kind of started to hear about leptin resistance. But you can develop resistance to all hormones. The way it manifests is the body shows signs of too little of that hormone, even though in the blood, there is either enough or too much of that hormone. The cells are smart. They know that too much thyroid in a cell causes somebody to be hyperthyroid and all kinds of complications that you talk about a lot.

Same thing with insulin. Too much insulin in the cell can cause lack of elasticity. It actually damages endothelial linings and cells. The body tries to protect itself from it, and it becomes resistant. You can get resistance to hormones by taking too much hormone. We think, Oh, hormones are not like drugs. It’s not like the chemical things that are foreign to the body; it’s natural to the body, so we should be able to take hormones safely. In reality, we have to take just the right amount to fill in what the body isn’t doing. Otherwise, you develop lots of complications of hyper hormone, but you also develop the resistance to that hormone.

Dr. Eric:

What are some of the common causes of insulin resistance? Why do so many people have insulin resistance these days?

Dr. Ritamarie:

Have you looked at what people are eating? That’s one reason. The garbage processed food.

Second is stress. Under stress, we release a lot of another hormone called cortisol. Cortisol is meant to help us run away from hungry animals. A tiger is chasing me, so I need cortisol to run away. One of the mechanisms by which cortisol works is to mobilize stored energy. That could be in the form of fat, protein, or glycogen carbohydrate, and create more sugar in the blood so we can run away from tigers. In that situation, it’s a good mechanism, and we don’t get in trouble unless we slow down and get eaten by the tiger. For the most part, it doesn’t get us in trouble to have that elevated sugar. It actually helps us.

In the day to day, modern life, I don’t know about you, but I haven’t had a tiger chase me recently. I’ve had deadlines chase me. I’ve had lots of anxieties perhaps. I don’t really get anxious, but people have lots of fear and anxiety around our current world: the economics, the crime, all that stuff. That causes that same stress response as if we have a hungry tiger chasing us, except we don’t get to run away from the tiger and burn that energy. It sits in the blood and causes that elevation of the sugar.

What the pancreas does when it sees the sugar so high, and it’s not getting into the cells, is it goes, “We just need more insulin.” It keeps producing more and more insulin. Then the cells become even more insulin resistant.

A lot of it is a modern lifestyle disease. We can change it, and I have seen people completely reverse even type two diabetes within two to three weeks of changing their diet, getting on a good stress regime, sleeping, moving, all the basic foundations of good health. That’s how we can reverse this and prevent it.

There are genetic factors that play in. I have a lot of the genes that predispose me to diabetes, so I have to be a little bit more careful than maybe somebody else who doesn’t have those genes. For the most part, the genes are a little bit of it, and the lifestyle is much more.

Dr. Eric:

Similar with autoimmunity. If someone has the genetics for Graves’ or Hashimoto’s or another autoimmune condition, that doesn’t mean they will necessarily develop the condition. Same thing. If someone has certain genetics, doesn’t mean they will certainly develop insulin resistance.

Dr. Ritamarie:

Just because they don’t have the genetics doesn’t mean they won’t develop it. You can outsmart your genetics with good diet and lifestyle, but you can also defy your good genetics and get diseases if you mistreat the body. It’s like a car. We don’t put jellybeans in the gas tank. “It must be tired because of that high octane fuel. I’m going to try something else.” Doesn’t work that way. Gums up the mechanism. Same here.

Dr. Eric:

I’m glad you expanded beyond diet because diet plays a role, but you mentioned stress and sleep. If someone is only getting four or five hours of sleep consistently, that could also be a factor.

Dr. Ritamarie:

Huge factor.

Dr. Eric:

What testing do you recommend? As you know, most conventional medical doctors just look at a fasting glucose, and that’s what they go off of when it comes to insulin resistance and diabetes.

Dr. Ritamarie:

The fasting glucose is actually the last thing to change. You can have this problem going on for decades. That’s why I said a long, long, long time. You can have it go on for decades because the fasting glucose goes too high. Plus their ranges for fasting glucose are a little too wide and not narrow enough.

The other tests I recommend is insulin. Test your insulin. We can see kids in their teens with hyperinsulinemia. You can tell by some of their behaviors. The point is you can test the insulin. You can test the fasting insulin.

You can test something called hemoglobin A1C. It’s not quite as accurate as it could be sometimes in somebody who is extremely anemic or an intense athlete, but you get a general range. Hemoglobin A1C is how much of your red blood cells are sugar-coated. We all have some percentage of them that are sugar-coated because they’re bathing in this glucose in the serum.

Around 5 is a good amount. A little bit less, a little bit more. The conventional medicine looks at 5.6. By the time somebody gets to a 5.6 in hemoglobin A1C, their average glucose is around 119. As it starts to go up, we are getting all of the complications of diabetes in somebody who has never been diagnosed. I have worked with patients who have had complications that are typically diabetic: diabetic nephropathy, diabetic neuropathy, diabetic retinopathy, but they are not diabetic. Doctors say, “Your glucose is 95. You’re just fine.” They missed the boat. This poor person, because of the swings up and down over the years, make a difference.

I remember one person having that situation. He went and got his A1C checked, and it was 10. More than double what it should have been. No wonder he was having these things. Because of his big, wide variations in swings, by the time he made it to morning, he was okay. It was “normal.” Probably because he was producing so much insulin, and his insulin was high as well, that it got his sugars down when he had the eight-hour sleeping window.

Most of them are not recommending what I recommend: postprandial glucose. You get yourself a little glucose meter, poke your fingers, and see what your meals are doing, what your stress level is doing. What happens when you don’t have a good night’s sleep? What happens when you exercise versus when you don’t? You can see all of this.

I have been talking about these forever. I have been having people test their glucose that was prandial for the last 20 years. But more recently, there is these things called continuous glucose meters. You can actually wear it. I have one underneath. A bright blue patch. It’s got a little filament, not even as thick as an acupuncture needle, that is under the skin. It’s detecting the glucose. You know at any moment what the glucose is. “Oh, I just ate a donut. My glucose is 192. I just had a nice salad with avocado and tomato and lettuce. My glucose is 98. Wow, what a difference.” There are all kinds of ways that people can be empowered to take charge of their own health. I know that’s what you and I are all about.

Dr. Eric:

Definitely. When it comes to the levels, you mentioned with hemoglobin A1C, around 5, so a little bit higher, a little bit lower. If someone is a 5.4/5.5, you’re suggesting-

Dr. Ritamarie:

I’m suggesting let’s get you really taught and educated about how you get it lower, how you get it down to 5/5.1/4.9. It’s an early warning sign.

Dr. Eric:

Are there concerns if it gets too low?

Dr. Ritamarie:

Sure. If it gets too low, probably someone is in a hypoglycemic state most of the time. You talk about hyperglycemia and hypoglycemia. Hypoglycemia is “The blood sugar is low. We have to eat something to bring it up.” Most of the symptoms that people are having when they feel like they are hypoglycemic is actually hyperglycemia. The blood sugar is too high, but it’s not getting into the cells, so the cellular sugar is too low.

If the A1C goes down to 4.5, maybe your average glucose is in the 70s, but that means there may be times where it’s lower. You just have to watch. Is the person symptomatic? What’s happening overnight? What’s happening with their meals? They may just have very tight control. Their body keeps it in a very tight range. We investigate further if it goes too low. You need sugar in your system to get cellular function.

Dr. Eric:

When it comes to insulin, some functional practitioners like to see that fasting insulin below 5. Would you agree with that?

Dr. Ritamarie:

Absolutely. Between 2-5 would be the “ideal” range. Between 2-3 is even more ideal. That’s the range I like to see it. If someone has a fasting insulin between 2-3, it could be perfect, or it could be a sign that they actually have been very high, but they are heading into a pancreatic failure or have antibodies that are attacking their pancreas. I always investigate that. I look at their symptoms. What are the other factors playing in?

If they have a fasting insulin of 1.5, hemoglobin A1C of 5.1, a fasting glucose of 79, they feel good, they have good energy, then it’s perfect.

But if they are complaining of some other things, then I would want to do what’s called a postprandial insulin. I have them eat their highest carbohydrate meal that they typically would eat and then check it to see if the pancreas responds, to see if that insulin level goes up. It shouldn’t go up a lot, but it should respond. If not, it might mean they have some pancreatic failure going on.

Dr. Eric:

How soon after eating would you recommend that?

Dr. Ritamarie:

Usually 45 minutes to an hour. When you look at studies, it shows the insulin and glucose peak right around 45 minutes.

Dr. Eric:

With regular fasting insulin, or even postprandial, I haven’t done postprandial insulin testing, but I do regular insulin testing all the time. Do you get concerned if it’s a 6 or 7, or do you not really get concerned until it’s in double digits?

Dr. Ritamarie:

I get concerned as soon as it’s above 5. When I say “concerned,” that means I’m educating somebody. There is an indication you are producing too much insulin. Here are the downsides of too much insulin. Oh, you have a history of cardiovascular disease? Too much insulin stiffens your blood vessel lining, so you are more prone to have a heart attack if you go to run for the bus because your blood vessels can’t expand. High blood pressure, thyroid resistance, and other cellular hormonal resistance. At that point, I’m investigating, and I’m helping them to bring it down within the 2-5 range.

Dr. Eric:

Thyroid resistance. Let’s talk about how that relates to insulin resistance and also how that presents on a thyroid panel.

Dr. Ritamarie:

It doesn’t present on a thyroid panel. Here’s the deal. It can present as a perfectly normal thyroid panel. Normal TSH, normal T3, T4, free T3, free T4. But the person has clear symptoms of thyroid problems. We go, “Wait a minute.” The typical Western approach is you have constipation, here’s a laxative. If you have depression, here’s an antidepressant. If you have dry skin, put some moisturizer on it. They are not addressing it as a combination. Those are low thyroid symptoms. I always say if it looks like a thyroid problem, and it sounds like a thyroid problem, it’s a thyroid problem. But it’s not with the thyroid itself.

Those numbers look good, yet the person presents with thyroid symptoms. It’s usually because the receptors have become resistant. There are some really common imbalances that affect the thyroid receptors that cause them to underwork.

We have homocysteine. How many people do you test homocysteine? I listened to your podcast episode on your favorite tests. You test homocysteine on people. Elevated homocysteine can damage the thyroid receptors. We’re looking at that. What is elevated homocysteine caused by? Usually a deficiency of Vitamin B6, B12, folate. There are a number of other things that are less important, but those are your majors. We look at that.

Deficiency of Vitamin A can affect the thyroid receptors. If somebody is not getting enough Vitamin A, or they are getting enough Vitamin A in their diet but have a problem with fat digestion and fat-soluble vitamins, those are two very important things.

But the most important one that I think most people suffer from is either excess cortisol or not enough cortisol. In order for those thyroid receptors to work properly, we need the right amount of cortisol. Stress can respond. Cytokines, we all have heard of cytokines over the last few years in terms of cytokine storm. Cytokines are inflammatory mediators in the body. Excess inflammation, excess cytokines damage the thyroid receptors.

Last but not least, our good old friend, insulin. Insulin not only causes receptor resistance for insulin, but it causes receptor resistance for thyroid and other hormones as well.

Dr. Eric:

On a thyroid panel, it might very well be normal, so you can’t always pay attention. In some situations of thyroid hormone resistance, you will actually see thyroid hormone levels look on the higher side. In the case of hyperthyroidism, that would result in depressed TSH, but in the case of thyroid hormone resistance, sometimes you will see it elevated on a thyroid panel. TSH will actually be elevated as well, which shouldn’t be the case when you have too high.

Dr. Ritamarie:

Yes. In fact, that’s why it said it can look normal. There is no classic way it presents. I always tell people when they’re looking to solve their thyroid problems, and I give people a document that shows different kinds of imbalances, if the T4 is low and the T3 is good, or vice versa, what to do, so we can address those imbalances. If you don’t address that there might be thyroid resistance, you can address all those other things that are out of balance, get them in perfect balance, have the panel look perfect, yet there is still a problem. They are still symptomatic. I always say to address that.

Right from the start, assume thyroid resistance. If you’re wrong, great. Check the homocysteine, Vitamin A status. Address the stress levels. Address the insulin. That’s super important.

Yeah, excess of any hormone can cause resistance to that. It’s a clue: When that hormone is high, it’s turning off those receptors.

Dr. Eric:

Thanks for clarifying. As far as fixing the problem, diet, stress management, getting proper sleep, all these diet and lifestyle factors. The homocysteine, which could oftentimes relate to nutrient deficiencies, specifically some of the B vitamins and other nutrient deficiencies like Vitamin A. Trying to address all these imbalances.

Dr. Ritamarie:

Absolutely. What I find, and you may find this in your patients as well, is people want quick fixes because that’s what they have grown accustomed to throughout their lives. If you have a headache, pop Motrin. If you have heartburn, pop some antacids. That’s not the way the body really works. There is no quick fix. We have to address the underlying causes.

We have to look at what’s the gut function like? A lot of thyroid issues, especially the autoimmune, we have some sort of leaky gut usually. Hyperpermeability of the gut lining. We have some inflammation, some dysbiosis. We have to address that.

We have to address all the different stressors on the body, not just the mental and emotional stressors, but heavy metal stress, mold, all kinds of things like that. Chronic low-grade infections that aren’t resolved. There are all sorts of things we need to look at in the big picture.

Dr. Eric:

You’re right. A lot of people will focus on the diet, the stress, and the exercise, but they still might see elevated hemoglobin A1C and/or fasting insulin, but they might have disruption in the gut microbiome. They might have a higher toxin load. They might have stealth infections. Sounds like there are a lot of things that could at least be a contributing factor when it comes to insulin resistance and thyroid resistance issues.

Dr. Ritamarie:

A few years ago, I did an all-day workshop on hormone resistance. Nobody is teaching this. People need to know how to address it.

Dr. Eric:

I know you kind of answered this, but if they have cortisol resistance, they’re thinking cortisol/adrenal stress. But they can’t just block out time for mind/body medicine. They should do that, but if that’s all they do, it’s probably not going to address the cortisol resistance.

Dr. Ritamarie:

We have to do it all. We can’t just pick and choose. The yogis want to do the stress piece. The foodies want to do the food piece. The marathoners want to do the exercise piece. There is such a thing as overexercise, which we can talk about another time. We can’t just address the pieces that we like, that resonate. We have to address all of it. The sleep is huge. I don’t know about you, but people come in and tell me, “I can’t fall asleep. I can’t stay asleep. I can’t sleep more than six hours.” That’s putting a huge stress on the body and the hormone balance.

Dr. Eric:

I definitely agree. Sleep is a priority. You can’t negotiate the sleep.

Dr. Ritamarie:

I tried. That’s when I developed insulin resistance.

Dr. Eric:

Most of us notice a difference, even if it’s not reflecting right away in the blood sugar. Like you said, it can take years for that to develop. But it can affect the body in many other ways.

How about exercise? You mentioned exercise. Everyone is different. Some people listening to this might not be able to engage in certain types of exercise. On average, do you recommend more resistance training, cardio, high intensity interval training (HIIT)?

Dr. Ritamarie:

All of the above. It depends on the person. Ideally, do all of that stuff. But not everybody can. People have injuries in certain parts of their body, and they can’t move that particular area.

For blood sugar balance, the HIIT works really well, burst training, 30 seconds to a minute of all out, rest for 2-3 minutes, and do it again. Or do it throughout the day. You go for a walk, and then you run or climb a hill for 30 seconds to a minute, get your heart rate going, and then continue to walk. Other people do separate times throughout the day, 30-60 seconds of exercise. People find that easy to incorporate.

There is such a thing as overexercising, especially if there has been a lot of stress, and the adrenals have been going. Too much exercise for your constitution right now creates a cortisol release. That cortisol release puts you into stress mode. We have to watch it. If you are someone who says, “I want to exercise,” and you go out and do all out, weights, interval training, and then come back and can’t exercise again for 3-4 days because you’re exhausted. That’s a sign that you overdid it.

The hardest thing is when athletes burn out. They just want to keep doing it, and they can’t. The couch isn’t a bad idea right now. Just walk around the block a couple of times. Keep it light. Keep your heart rate going. Keep the oxygen flowing.

But I find that it’s harder to get people who are avid exercisers, who are burned out, to slow down. That’s even harder than some people who have been couch potatoes and don’t want to start it. But it’s super important to get the right balance of exercise for you.

Dr. Eric:

Agreed. I mentioned in past episodes where I was guilty of overtraining, and I’m pretty sure that was a contributing factor to the development of my Graves’ condition years ago. You don’t want to be a couch potato. You want movement to be a regular part of your daily routine, but you don’t want to overdo it in the gym or at home.

Dr. Ritamarie:

Even at home, there are so many little things you can do. If you have a staircase, running up and down the stairs 2-3 times can get your heart rate up. If you have a knee problem, you won’t do that. Work with your body and the limitations to find things.

There are these little exercise things you can put on the table. They’re like a bicycle. You can put it for your feet, but you can use it for your shoulders. If you have knee problems or hip problems, put it on the table, and you can work your heart rate up by using them as an arm exercise. There are a lot of options.

Dr. Eric:

The last thing I want to briefly chat with you about is intermittent fasting. We chatted a little bit before the recording started, but to remind you that some of the listeners have hyperthyroidism and might be losing a lot of weight. It’s not a perfect fit for everyone. On average, would you say if someone is dealing with insulin resistance, and let’s say they are gaining a lot of weight, is that something you usually address?

Dr. Ritamarie:

Intermittent fasting, I have been talking about it since before it became popular. I have been teaching it since like 2008 in my programs. We didn’t call it intermittent fasting; I don’t remember what we called it.

Meal spacing, let’s space your meals out. No more than three meals a day. 12 hours between the last meal and the first meal, minimally. If you can go longer, great. Finding your fasting window. Some people do great by skipping breakfast and starting to eat later in the afternoon. Some people do horribly with that, but they are really good at eating first thing in the morning, having another meal, and a light dinner. 2-3 meals a day.

Some people are doing one meal a day, but some of the research I have seen on that is it actually backfires. You gorge yourself, and you are putting all of these calories in at one time. I have a continuous blood sugar meter, so I find if I overeat at a meal, even if it’s all low glycemic stuff that I normally would eat, my blood sugar will go up. It’s just too much of a load all at once.

I’m a real big fan of intermittent fasting. I have seen amazing results with it to help people get past the plateaus of weight loss. I’ve seen it work really well for folks who have mitochondrial disruption, so their energy is low. People think, “Oh my god, I can’t not eat to get energy.” Yeah, you can. It can work really well. There is a lot of research to that effect.

It works well for brain stuff. That’s where a lot of the ketogenic diets came from. When you have intermittent fasting, you’re going longer periods of time. You have more of an opportunity to get into a ketogenic state, especially if you do a 16-hour, overnight, or from bedtime to whatever. That will help you to get into a state called autophagy, which helps your body do cleaning out. There are so many benefits to intermittent fasting.

But it’s not for everybody. You do need to be careful if you’re a menstruating woman. Don’t do it the week before your period because it can disrupt your hormones. If you find you start doing it, and your periods stop, it’s probably not the right thing for you. Like everything, it’s not for everyone.

It’s certainly not for someone with hyperthyroidism or who is underweight and has a high metabolic rate even if they’re not hyperthyroid. While everybody else is told to eat two meals a day, space your meals 4-6 hours, I say, “Eat every 2-3 hours,” because otherwise they will just burn away to nothing.

Dr. Eric:

Is there anything I didn’t ask you about insulin resistance or thyroid resistance that I should have asked you? I know there is a lot we could talk about.

Dr. Ritamarie:

There is so much. Here is the thing. If you are working on a thyroid problem, and you are ignoring your blood sugar, you won’t get very far with healing your thyroid. You must address both.

Dr. Eric:

Just a final summary as far as action steps, if someone is looking at their blood test report now and are seeing high A1C and/or fasting insulin, would you say to start with diet, cleaning up, whole healthy food, minimizing refined foods and sugars as a good place to start?

Dr. Ritamarie:

That’s a great place to start. Watch your sleep. Some people don’t sleep, not because they can’t sleep, but because they don’t get to bed. That was my situation. “I have plenty of energy. I can push it. I can stay up.” You do that and get a second wind. Just go to bed.

Make it a point to move your bedtime back so that it’s before midnight at least. Some experts would say by 11. I haven’t done that one yet, so I can’t recommend it yet. I have moved mine back to before midnight.

I’m really focused on getting 7-8, even nine hours of sleep. Some studies show that the closer you get to nine hours, the more rapidly the results and the shifts happen with healing insulin resistance.

Dr. Eric:

I can’t say I’m there yet. I usually strive for 7-8 hours, not that I wouldn’t love to get nine hours. Most nights, it’s 7-8.

Dr. Ritamarie:

Exactly.

Dr. Eric:

How can people find out more about you?

Dr. Ritamarie:

You can find me on Facebook. We post a lot there. It’s @DrRitamarie, I think. Same thing on Instagram. We are reviving our YouTube channel. Same thing. We are starting to do weekly lives and putting more content on there. If you’re a practitioner, we have a new website opening up soon. The URL is INEMethod.com. We have a lot of great resources for practitioners. I can’t wait to share those. My podcast is Reinvent Healthcare. Those are all great ways to reach me.

Dr. Eric:

Definitely check out the podcast. I mentioned I have listened to some of the episodes. Excellent information. Thank you so much. Thanks again for sharing your knowledge with us.

Dr. Ritamarie:

Thank you for having me. It’s my pleasure to do so.

Recently I interviewed Sarah Clark, as she discussed how to overcome infertility. If you would prefer to listen the interview you can access it by Clicking Here.

Dr. Eric Osansky: With me, I have Sarah Clark, and we are going to chat about fertility. When Sarah was 28 years old, she received a diagnosis of premature ovarian failure. She had both of her children through IVF (in vitro fertilization). Years later, she realized the root cause of her infertility was a food sensitivity and later a gut infection.

Sarah is a certified life coach with accreditation from the International Coaches Federation and a health coach with training from the Institute of Integrative Nutrition. She is the author of Fabulously Fertile: Supercharge Your Fertility Naturally. Her fertility coaching program, which includes functional lab testing, supports couples to make diet and lifestyle changes that dramatically improve the chances of a healthy pregnancy and baby. On her Get Pregnant Naturally podcast, she shares with functional medicine and natural fertility solutions, we can eventually reverse infertility. For more information, you can visit her website, FabFertile.com. Thank you so much for joining us, Sarah.

Sarah Clark: Thanks for having me, Eric.

Dr. Eric: You’re welcome. Let’s dive into your background. Let’s talk about how you started helping coaches with infertility.

Sarah: In my early 20s, I had irregular cycles. During my teen years, I had great skin, and all of a sudden, I got acne in my early 20s. I had a weird fungal rash. With irregular cycles and acne, I went to see my conventional medical doctor. They put me on hormonal birth control. That obviously regulated the cycle, but falsely, and helped the acne a little bit, but not a lot.

I’m a big planner, so I had a life plan of getting married at 25 and having kids at 28. I got married at 25. Shortly before I was 28, I knew I needed to get off the pill and figure out what’s going on here. I went off the pill. That is when I had the diagnosis of premature ovarian insufficiency or failure as it was known, which is a loss of function of ovaries before the age of 40. I was told the only way I would ever have children was through donor eggs. I remember the OB-GYN reaching up on her shelf, grabbing the brochure for IVF, and saying, “Here you go.” I was completely shocked, devastated. That wasn’t my plan of how to have my children.

But I didn’t take any time to grieve. I went straight into action. I got on a list for a donor egg. Back then, the donor egg profile came in the mailbox. I waited for the maternal and the paternal info. I got the profile. We were lucky enough on our first transfer to have our daughter. She is about to turn 21.

When I said “donor egg” back then, people didn’t know what that was. Now, we have more couples going through IVF. We have embryo adoption and embryo donation. I had a guest recently who did embryo adoption. She adopted an embryo that was frozen for 13 years. The natural siblings are 13 years to her little children, who are now two and four. Science can do some cool stuff.

We had a couple embryos left over. We wanted the kids close together. I was super stressed about having them close together. I went back in after a year. That first transfer did not work. I went on another list for a separate donor egg. We were lucky enough after three years to have our son. He is about to turn 18. I don’t know where the time has gone.

After I had my daughter, I had nine colds. Every cold turned into a sinus infection. I thought it was a good idea to take tons of antibiotics for all those sinus infections. I had chronic bladder infections, sinus infections, yeast infections, toenail infections, dandruff. My immune system was low. I caught every cold and flu that went by. I still wouldn’t have said I was unhealthy.

I was working in a corporate environment. I was in HR for years. I decided I wanted to bring a life coaching course into HR.When I did that, I had my own personal wakeup call. It’s always health and wellness I have loved. I took a health coaching course. That is when I discovered all these food sensitivities: dairy, gluten, and later, corn. I had gut infections, bacteria, and parasites.

The thing I discovered that took me forever was chronic stress. I actually thought I wasn’t stressed. When I got that diagnosis, I wouldn’t have said I was stressed. I am the kind of person who likes a lot of energy. Let’s go. That was stress all along. I was disconnected from my body. I didn’t discover this until years later.

Now I help people who have been told donor eggs are their only option. Most people have gone through multiple failed IVF cycles. We are helping them get pregnant naturally, or if they go to IVF, they get pregnant with their own eggs.

Dr. Eric: You said that with your daughter, it was successful the first time. With your son, you had to do two rounds?

Sarah: We had embryos left over from my daughter’s donor. That didn’t work. We went on another list for a separate donor. I had to wait for that. Then I had my son. Both times, it was on the first transfer of the fresh embryos, when they used to do fresh transfers. They do fresh and frozen now.

Dr. Eric: Is it common for everything to go okay with the fresh transfer?

Sarah: Usually with IVF, it takes three rounds at a cost of $60,000. The fact that it worked for me on the first fresh transfer, I had my daughter at 31 and my son at 34. The donor eggs were in their late 20s. That may have helped. Many people we see, that’s not the case. It’s been failed cycle after failed cycle.

Dr. Eric: Like you said, even if it does work on the first try, it’s very expensive. Ideally, you want to try to get to the root cause of the problem, so you can hopefully avoid IVF.

Sarah: Exactly.

Dr. Eric: Speaking of causes, can you talk about some of the common reasons why more and more women are dealing with infertility?

Sarah: We are coaching couples, even though we are primarily dealing with low AMH (anti-malaria hormone) or high FSH (follicle stimulating hormone). Typically, people are being told that donor eggs are their only option. 50% of fertility can still be a male factor. Even though males are being told their sperm is fine, they haven’t looked at it through functional reference ranges.

Typically, we are seeing all these missed healing opportunities. Obviously, thyroid issues. We see more hypothyroid issues, Hashimoto’s or subclinical thyroid issues. Especially with the high FSH, we see blood sugar irregularities and insulin resistance. We are seeing a lot of autoimmune disease in conjunction with low AMH and high FSH. Typically, Hashimoto’s and Celiac. They go do IVF and have an autoimmune disease, and no one does anything. No one has targeted changes.

We see food sensitivities, non-Celiac gluten sensitivity, gluten off the charts. People may have gotten gluten-light or 80% gluten-free. If you have a sensitivity, even a crumb will cause reaction in your body.

We see the chronic stress piece. Doesn’t matter how old you are. Whenever you decided you want to expand your family, there is a lot of stress in that when it’s not working. Especially if you have gone through failed IVF, thought that was your solution, spent a lot of time and money in there, and it hasn’t worked, fertility can impact all aspects of your life: your social life, seeing families at church, going out in public and seeing families and children and pregnant bellies. You may lock yourself off from some of your friends and family because it’s too painful. The chronic stress of this.

We see alot of trauma, either childhood trauma or trauma from the infertility diagnosis that needs to be addressed. We believe in a mind/body/spirit approach. We look at the biochemical stuff. It’s important to look at mindset and the spiritual side of it, really believing that the spirit of your baby is waiting for you. It’s ready to come down. Here she is. Many people feel that diagnosis from the reproductive endocrinologist can get embedded in their subconscious. “You will struggle. It’s not going to work. You can only use donor eggs.” People start to believe that. It’s really important to believe that you’re not broken. You’re fertile. You can conceive.

Dr. Eric: It sounds like you take a whole-body approach. You mentioned diet and the importance of gluten. Also stress and past traumas could have a big impact, of course. Sleep. You look at the whole picture.

Sarah: Yeah, sleep, for sure. We see a lot of people with dysregulated sleep. Tired and wired when they wake up. Unable to fall asleep. It could be gut bugs or gut infections. Nutrient deficiencies. We see a lot of sleep in both partners. People have struggled for years and can’t sleep at all. After making the changes, they are able to finally get their eight hours.

Dr. Eric: Let’s talk again about diet. You mentioned gluten, which a lot of people listening to this are familiar with the concerns with gluten and gluten sensitivities. You also mentioned Celiac. Even if you don’t have Celiac, you could have a gluten sensitivity. I’m sure there are some people who say, “How can eating gluten prevent myself from getting pregnant?” Either the impact on the female or male. Can you expand on food sensitivities and talk about the relationship between gut health and infertility?

Sarah: Yeah. A lot of people like me were put on hormonal birth control. That can predispose you to food insensitivities, gut infections, and nutrient imbalances. We see that a lot. With the food sensitivities, if you have a food that you’re eating, and it’s coming in every day, it’s causing inflammation in your body, then your body wants to survive, not procreate. It’s causing all this inflammation.

We have our couples start off with an elimination diet, taking out those top allergens, like dairy, gluten, soy, corn, peanuts, eggs, processed sugar, and alcohol for 10 days. Then we systematically reintroduce over the course of 30. You can really see how each food impacts your body. Most people who come to see us, it’s not a sick population, but they don’t know how unwell they are until they feel amazing. They could have niggling bloating, eczema, post-nasal drip, digestive issues. They don’t know how great they can feel when all those common but not normal complaints go away. The food piece is huge. We see people’s energy and all areas of their life improve by eating the right diet. Taking out those top inflammatory foods, reintroducing them.

We have them tweak it with food sensitivity testing. You may take out foods for 60-90 days. If it’s read on some of the testing, you take it out then. Most of the food, not gluten, you can bring back in, once you’re healing the gut.

We are doing gut testing, looking at the DNA of your stool. We see a lot of people with bacterial infections, fungal infections, multiple parasites. We see H-pylori. You won’t be able to absorb all your nutrients. Passing back and forth to partners. Once you heal the gut and work on gut repair, alot of those food sensitivities you may have, especially if you have leaky gut, your body is mounting that immune response to your favorite foods. People take the food sensitivity test, and lo and behold, you realize you are intolerant toall the foods you are eating on a regular basis. We see that a lot with our clients.

As you heal the gut and eradicate the infections and repair the gut and take out those inflammatory foods, then the body starts to come back alive. We just had someone here who has .02 AMH. She is very young, like 26/27. Within six weeks of working with us, her period is already back, and she hasn’t had it in years. We have had people get pregnant naturally when their AMH is .04. Conventional medicine turns their back on those people.

Dr. Eric: That’s awesome. Do you use the GI Map?

Sarah: Yes.

Dr. Eric: For food sensitivity, you said you start them off with an elimination diet and do food sensitivity testing.

Sarah: Yes, we start the elimination diet protocol that they follow. We use the Vibrant Gut Zoomer depending on where they are in the country.

Dr. Eric: Okay. Before doing these interviews, I always do my research and try to listen to an episode or two of the person guesting on other podcasts. I heard you did Dutch testing as well, yes?

Sarah: Yes. We may do an adrenal test to start with. A lot of times, it’s a type A, busy, ambitious person who in the past, they have done a whole bunch of stuff. Now they are throwing everything at this. Maybe their adrenals are completely fried, and their cortisol is flatlined. It’s important for them to see what is happening with their cortisol levels, so they can pull back and work on self-care.

We do the Dutch adrenal or a full Dutch complete, looking at your sex hormones, which pathways are going down, your melatonin. People in the fertility sphere will read It Starts with the Egg, a popular book by Rebecca Fett. There is some good information in there, but some of it is geared toward IVF. Taking melatonin can be helpful, but let’s figure out why it’s low in the first place. It may be necessary. People aren’t even taking magnesium. We use a Dutch test.

We do genetic testing. We do a female hormone panel. It will give us what’s happening with your blood sugar, your thyroid. It looks at the FSH number and more. Female hormone panel. Then it will tell us specific diet and lifestyle and supplement recommendations to support those genetic SNPs. It’s not just, “Here’s your genes. You’re doomed.” It’s, “We can support those with these targeted steps.”

We also do a blood chemistry view. We do a semen analysis, looking through functional reference ranges. We don’t do all these tests at once. They can be overwhelming. We could do a hair tissue analysis testing. Check to see if there are heavy metals or nutrient imbalances. Those can be helpful, too.

Dr. Eric: Quite comprehensive, it sounds like. As far as the semen analysis, a few questions. Do you require the couple to be present? Do you always also evaluate the male, or do you focus more on the female? How does it work in your practice?

Sarah: We will exclusively coach couples unless they are single by choice. By just coaching women, we are missing the whole other piece of the equation. Even if he doesn’t have any issues with his semen, there could be issues in the relationship. This infertility will impact all other aspects of your life. It will either pull you together or tear you apart.

Even when his semen analysis is fine previously, or they have gone through years of treatment- Typically, they have gone through IVF, so they have had a semen analysis. Sometimes, they have tried naturally for two years, and no one has checked the man’s semen analysis. We work with Legacy, a digital semen analysis at-home testing kit for men. They get their testing done. It will give you the count, DNA fragmentation, fertility, and more. We will look at that through the lens of functional reference ranges. We look at the male’s blood chemistry as well.

He has his own health goals. She will have her own health goals. Then they come together as a couple to discuss them all.

Dr. Eric: I’m guessing you have them both follow maybe not the exact same diet because it depends on the testing, it sounds like. It’s up to the person obviously. You would ask them to both follow a strict diet.

Sarah: Yes.

Dr. Eric: And make other lifestyle changes, too.

Sarah: Yes. If they are living together, cooking together, eating together, we wouldn’t want the woman over here making all her changes, and he is over there eating Big Macs and pizza. No. They are doing this elimination diet together. At the end of it, she will get more tweaking with food sensitivity testing. We will look at his semen analysis and blood to see if that’s necessary for him, if he presents with any kind of fertility issue. He has his own goals.

Sometimes, in the partnership, the woman ends up nagging the man to take his supplements, change his diet, get rid of alcohol and caffeine, but she needs to focus on herself. He will come over when he is ready. That’s why it’s important to have a coach here. We never recommend coaching your partner. It’s disastrous. Focus on yourself. We will coach the male partner. 99% of the guys are ready to make the changes. They are open-minded and ready to go. If they’re not, it’s not a good fit for the program.

Dr. Eric: I’m sure you screen them before, just to make sure they are both on the same page, and you can coach both of them.

Can you talk about environmental toxins in fertility? Obviously, that has been a huge issue overall, over the last few decades. It seems like it’s getting worse as far as our toxic world, the impact that that has.

Sarah: We always ask our couples to check all their products against the Environmental Working Group. You want to get lower than 3. You want to ditch the plastics. You want to slowly move up the personal care. You don’t want to throw it all in the garbage; as each one expires, you would get a new product that is non-toxic. All of these are endocrine disruptors. There are the Dirty Dozen in the EWG.

Make sure that you have filtered water, that you’re not drinking out of a plastic water bottle. All of these things can leach into the body and disrupt the endocrine system. If it’s freaking you out, and you want to go around the house with a garbage bag, we say to slowly do it as each one expires.

I interviewed Dr. Shanna Swan, who wrote the book Count Down. She had a study that just came out talking about how in the last 40 years, male fertility has dropped by 50%. A lot of it is due to some of the environmental toxins, like glyphosate spread on food crops. Make sure you go organic. Stuff that’s in our water, over 85,000 chemicals we’re exposed to. Looking at that stuff is really important as a first step. Go organic. Cheap food is not good. Good food is not cheap. You can do the clean 15 or the dirty dozen. Make sure the dirty dozen foods are organic. The environmental toxin piece is key. Slowly do it.

Dr. Eric: Organic food, filtered water, cleaning products, cosmetics. A lot will be in their own home because once you step outside, there is only so much you can do. Do you recommend air purification systems or supplementation to help the detoxification process?

Sarah: You can get an air filter and do that. Blue light impacts the body, too, from the tablets and screens. We recommend blue light blocking glasses.

From a supplement perspective, we are recommending a whole protocol based on the testing, your health history. We have binders and things to mock up if we see exposure. With detox symptoms, we look at doing rebounding and dry skin brushing. We always recommend a castor oil pack over the liver to help move the sludge out of there. We have some teas, like milk thistle tea

Drink lots of water. Many people come to us, “I am drinking 1-2 glasses of water a day.” Make sure you have a good filter, like a Berkey water filter. A Brita is okay; it’s not our favorite. Get a glass or stainless-steel water bottle to drink out of.

Dr. Eric: I’m not a big fan of Brita, but it’s better than just drinking tap water.

Sarah: People do the fridge or the tap.

Dr. Eric: Fridge is not much different. I would agree with that. Do you ever recommend infrared sauna?

Sarah: Yes, we can recommend that, too. It can be good.

Dr. Eric: Earlier, you said you see mostly hypothyroidism, which is a lot more common than hyperthyroidism, which is what I and a lot of my patients deal with. We also get listeners who have Hashimoto’s. Most people who have hypothyroidism have Hashimoto’s. When you see someone who has lower thyroid hormone levels, and part of the testing is to see if they have Hashimoto’s, if they haven’t been diagnosed, you test for the auto antibodies and maybe recommend for them to see a practitioner with prescribing rights to be on thyroid hormone. How do you handle your hypothyroid patients?

Sarah: 99% of the people we work with, there is something going on with the thyroid. They have been told their TSH is normal, and it’s 3 or 4. Typically in the reproductive endocrinology world, for fertility treatments, they like to have it under 2 or 1.5. They may be taking a T4 supplement, a Synthroid or levothyroxine. Maybe they are already taking that. No one has looked at the full panel or the antibodies.

We are not diagnosing, but we see things out of alignment. The physician on our team is licensed in about 27 states, so she can do a prescription with a consult with her. Practitioners in other states can then get a prescription. Sometimes people are like the idea is to be off the thyroid medication. For us, bioidenticals may be necessary. Thyroid medication may be necessary. It’s also important to do the targeted diet and lifestyle changes with them because medication alone is just a Band-Aid.

We have had people with antibodies at 900 and making these changes come down under 100. People who have Hashimoto’s and are trying to get pregnant before they come to see us with repeat miscarriage, failed IVF cycles, and it hasn’t worked. No one addressed the Hashimoto’s or the high antibodies.

There is lots to do from a thyroid perspective. I do a masterclass and ask the question, “How many people here have a normal TSH?” All these people are struggling with low AMH and high FSH. No one has looked at the full panel, the T3 or T4. There is no due diligence. The doctor can’t run it because of insurance issues and stuff like that. So dig deeper.

Dr. Eric: Sometimes, what we’ll see is they will say it’s normal, and it is normal according to the lab reference range, but it is outside of the optimal range. TSH is maybe 3.8, which is within the lab range, but definitely above optimal. Same thing with the T3 and/or T4. It’s on the lower side but still within the lab range but outside the optimal range.

Sarah: Yeah, that was me. My TSH was 3.5. My hair was falling out. My skin was dry. Everyone is like, “Your thyroid is normal. There’s no problem.” But there was a problem.

Dr. Eric: Before we started the interview, I mentioned that years ago I wrote a blog post on infertility. There are a few statistics. I wish I could say I remember it all, but I have it right here. One of the studies show that the prevalence of infertility was 47% in those with Hashimoto’s and 52.3% in Graves’. Either way, whether you have Graves’ or Hashimoto’s, much higher incidence, prevalence of infertility.

Also, you mentioned the TPO antibodies. I did come across some studies that show that in female infertility, there is a higher prevalence of positive TPO antibodies when compared to controls. A few other studies have shown increased risk of miscarriage with thyroid autoimmunity. There was one more here that showed that during the first trimester, the pregnant woman with autoimmune thyroid conditions carries a significantly increased risk for miscarriage. Actually, even when they had normal thyroid hormone levels, so when they were euthyroid. Obviously, the low thyroid hormone levels are a concern. Or high if you have hyperthyroidism.

Most of the evidence I presented was related to the autoimmunity. Whether you have Graves’ or Hashimoto’s, definitely get the thyroid hormone levels balanced, but you also want to do things to improve the health of the immune system.

Sarah: Going to IVF when you haven’t addressed these things, you’re at a higher risk for miscarriage and the devastating effects of that.

Dr. Eric: If a couple has problems conceiving before looking into IVF, they should seek someone with experience like you. When would you say that IVF is necessary?

Sarah: It’s a very personal choice. IVF can be necessary if there are structural issues. We think most people are fertile, but there are other healing opportunities that haven’t been addressed. IVF is there to push it. If we address the chronic stress, food sensitivities, mindset, all of this is how we get you out of the fight or flight, down to the parasympathetic, reduce inflammation, and get you in that receiving stage. Then you can get pregnant naturally.

IVF can be there. It’s typically in the patience piece. We find more of an average of 12-18 months. We have a six-month program, but then it goes into our monthly piece. It’s 12-18 months before you can get pregnant. People want to push it. It’s a personal choice. Obviously, the older you get, you may feel your window is closing in, so you have to do it. To me, there is never any negative side effects of you working on your health. Either you get pregnant naturally, or IVF will actually work.

Your RE won’t tell you any of this stuff. I heard an RE say the other day, “You should go gluten-free and dairy-free.” That’s good. Some of this stuff is permeating into the conventional side of things. Typically, it’s pushing you over there.

It’s a personal decision. You have to do what feels right for you. They are selling packages of IVF. Buy a three-cycle package. A lot of insurance and egg freezing. There is a Wild West of fertility industry, which is billions. The stuff that’s going on in the world right now, infertility, 1/8 mistakes and 1/8 couples are trying. Most people know someone who is struggling. It’s only going to get worse because of all these environmental toxins and things that are coming at us.

To me, working on your health first, either pregnant naturally or doing IVF, when you’re ready, if necessary, then you can make that decision.

Dr. Eric: Are there a lot of side effects associated with IVF?

Sarah: I have done an episode on that. Some of them can be at higher risk of ovarian cancer and other things from these drugs. There is not a lot of research around some of these things. If you are pushing your body to do something that it’s trying to say, “Hey, I’m not ready right now,” because the reproductive system will be deprioritized, and it wants you to keep walking and moving. You’re pushing it. We don’t really know.

Even with IVF children, both my kids, I didn’t figure any of this out. Both of them have food sensitivities. Both of them have mood imbalances. I didn’t work on my stuff beforehand, so they got that? Maybe. I think so. Epigenetics, they are saying you can pass infertility on to your children. We want it done yesterday is the culture we’re in. Taking the time to prepare your body instead of rushing, it just makes more sense.

Dr. Eric: Yeah, I definitely agree. I also speak with many women who I’m working with on their thyroid conditions or autoimmune thyroid conditions. Many of them want to get pregnant, too. They are at the age. They are telling me, “Can I start trying within three months or six months?” They are putting a timetable on it. I definitely understand.

I agree that you want to try your best to avoid the IVF, but even if you end up doing the IVF, you want to try to do things prior to that to improve your health, not just jump into the IVF. It makes sense that you wouldn’t want to give it just three months or six months. Maybe in some cases, it depends on the person. If six months isn’t enough, 12 months might be the answer for you. It would be a shame for someone listening to give up after six months and get the IVF when they maybe just needed another three to six months.

Sarah: Just to dig a little bit deeper on some of these things. If you have a targeted plan with testing and someone looking at it to see how we can optimize it. Many times, people are finding generalized guidelines of fertility diets and superfoods. These things may work for someone else and not you. If you take a targeted, functional approach, and have a team to help you dig in and work on a lot of these limiting beliefs or dealing with stress, this can be helpful, too.

Dr. Eric: If couples have been struggling with infertility and really want to try to avoid IVF, what are some action steps they could take?

Sarah: If you are ready to go hardcore, do the elimination diet. I have an episode on my podcast about how and why to do the diet. If that’s too hardcore, at least go organic. Really work on the diet piece with your partner together.

Second would be focus on sleep. The most restorative sleep is between 10pm-12am. Go to bed before 10 if you can. Really prioritize sleep. Get the full amount.

Work on your intimacy. It’s not just about baby making; it’s lovemaking. Date nights. There is often a lot of strain on the relationship. Reconnecting with your partner. Don’t put joy on hold until the baby comes. Focus now on what makes you happy.

That whole self-care piece. It’s a buzz word, but it’s important to mother yourself and parent yourself now before your future child comes.

Work on diet, sleep, and dig into that self-care to get yourself out of the fight or flight. If you are feeling panicked, and you feel your eggs are too old, dig into that piece. You are fertile. You are a parent now, the moment you start trying. Dig into that intuition that you know your body better than someone else who may have labeled you with this diagnosis. It’s important to know that and be empowered by that.

Dr. Eric: Wonderful. Is there anything we missed? There is a lot of information on your podcast. Anything else, or did we cover at least the basics?

Sarah: The basics are covered. It is this mindset piece of if you have the diagnosis, you are not the label. To dig deep or get a second opinion. Don’t let the medical gaslighting of you, thinking “I should get my full panel,” and your doctor won’t run it. Know your numbers. Dig deeper. Take charge.

Dr. Eric: Definitely check out Sarah’s podcast, Get Pregnant Naturally, as well as her book Fabulously Fertile. Also, you have a fertility challenge opt-in. The website is FertilityDietFreebie.com.

Sarah: There are summer recipes available there. There is a meal plan and grocery shopping list. It helps you dig your toe into the fertility diet. It takes out those top allergens. There is some awesome food in there. It’s not about you starving.

As the seasons change, if you’re listening to this later on, there will be fall recipes, winter, and spring. Right now, we’re doing summer.

Dr. Eric: Thank you again, Sarah. Appreciate you sharing your experience and knowledge with everyone. Look forward to maybe having you back in the future.

Sarah: Thanks for having me, Eric.

www.ThyroidChallenge2022.com

Recently I interviewed Dr. Aimee Duffy, as she discussed how to optimize the health of your adrenals. If you would prefer to listen the interview you can access it by Clicking Here.

Dr. Eric Osansky:

With me, I have Dr. Aimee Duffy. We are going to be chatting about the adrenals. I am going to give Dr. Duffy’s bio, and then we will chat about adrenal health, tying it into thyroid health. Dr. Duffy is the #1 bestselling author of Normal Doesn’t Have Side Effects. She is an award-winning speaker of Harvard Club in Boston, CNN, NASDAQ, New York City Bar Association, and the Philadelphia College of Physicians. Dr. Duffy has shared the stage with Martha Stewart, Suzanne Somers, Ice-T, and Dr. Oz. She is a frequent podcast guest and expert guest on ABC, NBC, CBS, and FOX Network TV shows. Thank you so much for joining us, Dr. Duffy.

Dr. Aimee Duffy:

Absolutely. I’m so excited to be here. Thanks.

Dr. Eric:                        

So excited to have you. Why don’t we go ahead and start off by discussing your background? How did you get into functional medicine?

Dr. Aimee:

Sure. I love to tell stories. That’s the best way people like to hear information as well. When I was younger, I absolutely loved babies. They were my favorite thing in the whole world. I had all the Cabbage Patch Kids with all their clothes and accessories. I became a babysitter at the early age of 11. I wasn’t allowed to stay alone with the babies, but I would go over to neighbors’ houses and play with the babies while moms were doing their thing.

Over the course of the next several years, I developed a great relationship with one of the families that I babysat for. They invited me when I was 17, a senior in high school, to be in the delivery room when their next baby was due to be born. That was really my first experience. I had never dealt with anything like that before. I was there. I got to see the whole thing. When that baby came out and was put on Mama’s chest, I thought this is the coolest thing ever. I want to be a doctor and do this. I am going to deliver babies. That was in high school.

I went through college and med school. I became the doctor that delivered babies. Over the course of my years, I have delivered over 1,000 babies. It’s been an amazing experience. What I found though was that when you’re not delivering babies, in that line of care, you’re doing a lot of women’s health and GYN-type stuff.

Early in my career in medical school residency, there was a lot of talk about hormones. The Women’s Health Initiative came out. There was lots of scary information about the concerns associated with hormone replacement. I found myself in these conversations with women. “What should I do about these hormones? Do I need to get off what I’m taking? I feel horrible. You have to fix me.” “Well, we have these hormones, but we’re hearing they have a lot of negative things. My job is to do you no harm, so I don’t know that’s the best option for you.” We didn’t have a good solution for that. Get stuck between a rock and a hard place of having horrible symptoms or risk the negative side effects. I didn’t think that was a good place for anybody to be, myself in trying to help these patients, or them having to make that decision on their own.

I started doing a lot more research and reading about hormone therapies. I came across this idea of bioidentical hormone therapy that I had never heard of in medical school or residency. That was like Alice in Wonderland, where she goes into the tiny door, and it opens up, and it’s this amazing world of beauty and knowledge. Where did this come from? Why aren’t we talking about this more?

When people first think about bioidentical hormones, they are thinking about estrogen, progesterone, and testosterone. Really, this is where we’re rolling into adrenals. Cortisol is a hormone. Thyroid is a hormone. Are there ways we can test, understand what’s going on with a patient, and then evaluate it in a better way to help them get back to normal again? Ultimately, that’s what our goal is.

I started with these patients who were really feeling miserable, whether they were having classic hormone symptoms, but they are also fatigued, they can’t lose weight, their hair is falling out, their libido is horrible, or they’re having painful intercourse. Their gut is a mess. They didn’t even think that was something they needed to talk to the doctor about because they are so used to having gut issues. That is where I started to really find the results: when we could test those patients, see what their issues were, and respond more naturally. That is where my book Normal Doesn’t Have Side Effects comes from.

When we are getting things back to normal in terms of hormone levels, be it the sex hormones or thyroid, people really start to feel better. You don’t have to worry about all those side effects. We are doing it in a more natural way. That’s really what started my process: going through the steps to get to those types of patients. Now, that’s the type of patient that I see in my practice for the most part. That’s where we get started.

Dr. Eric:

Always want to try to address the root cause of the problem, which of course we both do. There is a time and place for hormone therapy as well. Now that we have some of your background, why are the adrenals important to our health?

Dr. Aimee:

If people hear about adrenals, they don’t really know what that means, but there is a lot of chatter in advertisements for supplements about cortisol and stress. I must have high cortisol levels because I’m so stressed out all the time. What I have found over the course of my 15+ years doing this in practice is the adrenals are your stress hormone, but they are also really important for other things, like your immune system. They’re anti-inflammatory.

When we talk about the pandemic that we have been living in, and everyone being so stressed out, their cortisol levels are not normal. That could be affecting their ability to fight off infection and immunity. Not having the appropriate stress response, it starts to mess with your brain. You have to think about what the adrenals are supposed to do in the first place, so you can understand why if they are not working right, what the consequences could be.

When you wake up in the morning, your cortisol levels are high. It’s time to wake up. The sun comes up. You’re ready to go. Over the course of the day, your cortisol levels go down. Let’s imagine that at 1pm, you get chased by a saber-toothed tiger. You would have a fight or flight response. Your cortisol and adrenaline go way up. You’re able to outrun the tiger. Run fast, jump high, lift heavy things. You won’t stop and go to the bathroom and eat a snack. If you sprain your ankle, your body is smart. It doesn’t want to let you feel that pain, so you can keep running. Otherwise, if you stop, you won’t make it. That adrenaline is really important for our survival.

In that scenario, maybe you find a cave. You outrun the tiger. You catch your breath for 20 minutes. You go back to your home, and everything’s fine. You rest a little bit that afternoon, and you go back to normal.

What happens where we are now, fast forwarding from caveman days to here, is we have so much stimulation, starting with setting an alarm clock and turning on lights before the sun comes up in the morning to getting in the car to dealing with your schedule. Especially now with our smart phones, we have constant notifications all the time interrupting us. It may not necessarily be stress although everybody knows what stress is. That stimulation constantly throughout the day. Driving in your car, it’s not relaxing. You have to be on alert all the time. Your cortisol levels are always a little bit higher. You get home and turn lights on. Even though the sun is going down, we are not calming down. We have screens in front of us. We are not sleeping well. We call that “tired and wired” when you’re exhausted throughout the day but are not getting adequate sleep.

What I tend to see more in my practice is low cortisol. We have really used up all the reserves. What the adrenals are supposed to be doing, we have asked them to work so hard over time. We are running a marathon uphill without ever taking any breaks. That starts to lead to what we call adrenal dysfunction. It used to be called adrenal fatigue, and a lot of people understand that. It’s an imbalance in that pattern of high in the morning, low at nighttime. The signals from your brain start getting confusing. The brain is telling you, “I am being chased by a tiger, but you are not responding.” That gets really confusing. When there is really something stressful going on, like you get sick, or you do have an injury, then the signals are all messed up, and you are not able to recover appropriately.

What happens more so indirectly from cortisol dysfunction and adrenal fatigue is that it doesn’t allow us to do the things that we know we need to be doing to maintain our health. When you’re tired all the time, you are less likely to exercise appropriately. You’re not getting adequate sleep when your cortisol levels are cattywampus.

One of the most common symptoms that I see is carbohydrate cravings. You tend to crave salt and sugar because your brain is saying we need energy from somewhere, especially later in the day. We tend to go back and forth between this salty snack, this sweet snack. Margaritas are a favorite because they are both salty and sweet. Then we are frustrated. “I want to eat healthier, but I tend to crave these things.” Then we start rationalizing, “I have a busy day. I’m tired. I am just going to order pizza tonight.” We are not able to get over that hump and do the adequate lifestyle management things that we need to do. These people become overweight.

It starts to affect other hormones. There is definitely a connection between the adrenals and thyroid. There is also a connection between adrenals and progesterone; that’s a big one. Other hormones, too. Everything starts to fast forward. I see women who are going through menopause or feeling menopausal earlier, late 30s, early 40s because their cortisol levels are tanking, and it’s messing up the whole hormone connection there. There is some direct correlation with adrenal dysfunction and health, but it’s more indirectly because it’s not allowing us to maintain healthy habits. We start to get overweight diabetes. We are going to have blood pressure issues. More high cholesterol. It just goes on and on from there.

Dr. Eric:

We mentioned low cortisol. When I dealt with Graves’, I did a salivary test, and that definitely showed my cortisol levels were in the tank. My DHEA was low. I don’t know if you commonly see that, too.

Dr. Aimee:

Absolutely.

Dr. Eric:

For those listening, DHEA is also an adrenal hormone. It sounds like it’s not just emotional stressors, but also you mentioned the importance of diet when it comes to adrenals.

Dr. Aimee:

Right. The other thing that I talk about with adrenals, and I mentioned the stressors from the outside in terms of either work stress, home stress, finances, time management, we have all these stressors. A lot of people are taking care of elderly family members who are sick, and that’s a big stressor on life, those sorts of things. Everybody understands what stress means from the outside.

What a lot of people don’t understand is the stressors that are happening on the inside. That is where we deal with diet and gut. If we are eating and ingesting or being exposed to things that your body looks at as foreign or a threat, so any kind of chemical, all of our standard American die that is full of chemicals right now; medications you might be taking. We can’t control 100% the air we breathe and the water we are drinking. Now our insides are being exposed to these threats. It really sends the exact same signal to your adrenals. The brain is not delineating between that tiger chasing me and I just ate something like gluten. That is a very popular one. I just ate the McDonald’s McMuffin or something like that (I don’t know what it’s called now). If you eat that, your body goes, “What is this thing? It looks like a threat.” It will send all those same signals as if we are being chased by that tiger.

Those internal stressors are affecting your adrenals just as much as the outside stressors. You may not recognize that. People go, “Man, I ate that, and now I don’t feel good.” Maybe they don’t notice it at all, but later, they feel really tired, or they are having some aches and pains in their joints because of the reaction they had to the food they ate earlier that day or in previous days.

When you think about diet, what do I need to do to support my adrenals? There really isn’t an adrenal diet if you want to think about it that way. You need to think about what are the foods I am going to put in my body that are going to help heal and fuel my body and restore it as opposed to the foods that will be a threat? When you are ready to sit down and eat something, you are holding it in your hand, is this going to be fuel and restorative for me, or is it going to cause more stress to my body?

Dr. Eric:

Most people know what foods they should eat and what they shouldn’t eat, to some extent. Some people classify whole wheat pasta as being healthy. Like you said, there is gluten in that. There are other foods people might think of as being healthy. We know refined foods and sugars are not good for us. Unhealthy oils, like canola oil and seed oils like sunflower seed oil and peanut oil. Definitely agree most functional practitioners (hopefully all…) agree that people should be eating whole healthy foods, plenty of vegetables, and avoiding those refined sugars, unhealthy oils. There is no specific adrenal diet. There are books on adrenals that talk about diet. Everybody is different.

You mentioned adrenals can have an effect on thyroid health as well as the sex hormones, especially progesterone. Can you get deeper into how that has an impact?

Dr. Aimee:

In both scenarios, there are different things that happen. Sometimes it’s hard as practitioners even to figure out which one is driving the bus. People come to see me all the time,” I was diagnosed with hyperthyroid. I am on Synthroid. Maybe I felt better for the first month, or never really felt better although they told me my labs were better, but I still have all these symptoms.” Ok, what’s going on there?

For me, that’s a great place to look at other things, like hormones and adrenal function. Even though their labs say their thyroid levels are okay, they still have all the same symptoms. There is definitely a communication between the adrenals and the thyroid. It’s not really easily defined in my opinion as a direct, if you have low cortisol, you will have hypothyroid. It doesn’t always work that way.

I’m sure you’ve talked about this in your podcast before, but to take the inactive thyroid hormone and convert it to the active thyroid hormone. There is an ability to take the inactive thyroid hormone, which we call T4, and convert it to active thyroid hormone, which is T3, that hits your receptors and does the work. It takes an appropriate amount of cortisol to do that. There is a lot of other factors that go into that. It’s not a direct thing. If you don’t have enough cortisol, if your body is under stress, it won’t be able to make that conversion. In your blood work, your thyroid may look okay, but if your thyroid hormone is not getting to your tissues, then you won’t feel the response to those symptoms. There is definitely a connection there between adrenal and thyroid.

In the hormone section, if you look at the steroid hormone pathway, they all start with cholesterol. There are different signals that move it down. This is biochemistry 101 that I was awful in in medical school. Now I use it every day, which is crazy. You have progesterone. Right below that, you have cortisol.

What I typically see in my practice is women who are pre-menopausal, so they are under 50. Let’s just make it easy that way. If they start to have hormone-related symptoms, like night sweats, more irritability, irregular periods, weight issues, “Something is up with my hormones. Can I be in menopause already? It’s too early.” They’re 41. Usually, what happens is it’s the adrenal dysfunction, the low cortisol that starts to pull progesterone down because our body’s #1 job is to keep us alive. We are all about survival first. If you can’t run from that tiger, then you won’t make it. It doesn’t matter if you have the progesterone there to procreate because progesterone is important for helping you ovulate and prepare the uterine lining for baby and pregnancy. That’s where libido comes from, too. If your cortisol levels are low, it starts to pull your progesterone down, and you start to have hormone-related symptoms. That is really coming from the adrenal dysfunction.

In other women, we see them when they are 53/55, and they are like, “Man, I was feeling great until I hit menopause. Boom, all these symptoms showed up.” That is probably more the hormone changes that turned around and affected their cortisol levels. You can see it in two different places, but there is definitely a connection between those hormones.

One of my favorite things to talk about, and I’m going off on a tangent a little bit, is the connection between thyroid issues and estrogen. In post-menopausal women, why do women get thyroid disease more than men? It’s more rare in men. Oftentimes, we are seeing it in this older group. I have heard patients tell me all the time, “My doctor told me it’s normal for women to have low thyroid. They put me on my medicine. They didn’t talk about why or where that’s coming from.”

Estrogen is really important to help regulate the little protein called thyroid hormone binding globulin that carries the thyroid hormone around in your blood and delivers it to where it’s supposed to go. If you have low estrogen, it’s counterintuitive, but it increases that thyroid hormone binding globulin. It increases the carrier. All your thyroid hormone gets stuck to that, and it’s stuck to this protein and not being delivered to the tissues.

When women start to go through menopause, and their estrogen levels go down, they have less available thyroid hormone. Even if maybe their thyroid is actually producing what it’s supposed to produce, it’s not getting to where it needs to go. When people are frustrated, “I still have thyroid symptoms even though I’m taking this medication every day. Do I need a higher dose?” you need to look at that bigger picture and think, “Are we out of balance from a hormone perspective, whether it’s progesterone or estrogen affecting the thyroid and adrenals?” They all communicate together beautifully.

That’s why I love doing saliva testing. You get a really nice picture of what your cortisol levels are, estrogen, progesterone, DHEA, testosterone. It’s like putting music notes on a page. You can see how they all dance and work together and start to create a better balance there. Of course, thyroid normally is tested in blood. We don’t do saliva testing for thyroid. But you have that side by side. You can start to see the connection there in how all the hormones work together. In my opinion, you really can’t put blinders on and say we are going to deal with your thyroid and not look at the other parts of that hormone cascade picture.

Dr. Eric:

Just to repeat what you said: If you have low estrogen, that will increase the thyroid binding globulin. You will have less free thyroid hormones in the bloodstream. You need healthy adrenals to have healthy estrogen. If you have low adrenals, it’s common to see low estrogen and low progesterone. Like you said, there is an interrelationship, but that is where the adrenals tie in as well. There are other things that relate to having healthy estrogen levels as well. I’m glad you brought up that thyroid/estrogen relationship. Thank you for doing that.

A couple of questions I have. How about high cortisol? You see mostly low cortisol, but I’m sure you see some high cortisol. I know I do when I do saliva testing for example. Obviously, with an acute stress situation, we’ll see cortisol rise. But then there is that middle stage. I’m sure you’re familiar with the three stages of adrenals.

Dr. Aimee:

Definitely. I can see some high cortisol. Because I see so many people with cortisol levels that are low, I’m not saying that you can’t have high cortisol, but I’m usually questioning my interpreting of that. There is some triage there. What was going on that day? Did you have any surgery lately? Have you been on any kind of steroids? Do you do a Flonase for allergies every day? It’s so rare to see high cortisol that I want to make sure that’s actually real. Sometimes I will repeat the test again because if it doesn’t fit their clinical picture, that may not make sense.

The reason it’s so important to connect those two and determine if it’s real is our treatment approach is very different. They may have similar symptoms. For people with high cortisol, they are going 120 miles an hour, so they will be tired from that. They may still have fatigue and difficulty sleeping and things like that. You want to be able to make sure that is really what is going on because our treatment for high cortisol is going to be more telling the brain, “I’m not being chased by that tiger.” We use more calming herbs. L-theanine is a great one for that. Things that will help your brain turn off. My goal there is definitely supporting a symptom, but it’s more trying as much as we can to prevent them from getting worse and going into that low cortisol/adrenal fatigue stage.

Just like I made the connection from low cortisol, you need cortisol. Too much cortisol is also not good. It overwhelms the system. You will still probably see some dysfunction from a thyroid perspective as well. Again, it’s not a direct, if somebody has high cortisol, they will have high thyroid. If they have low cortisol, they have low thyroid. But they do talk to each other and connect.

Dr. Eric:

I agree with you in that if cortisol is very high, it’s a good idea to ask the patient on that day of collection if anything crazy was going on. I remember once, I had a specific patient, where their morning cortisol looked good, but in the afternoon, there was a spike. The last two cortisol levels on the saliva test looked okay. I asked her if anything was going on that day. She said she was studying for a test around lunchtime, which coincided with the saliva sample she took around that time. That makes sense.

Dr. Aimee:

I had a story like that real early on. When you’re first learning about this stuff, you have to learn from somebody else. I would do all these saliva tests and call the lab to ask about this particular person. It took some time to learn it. This person, I remember it was the same thing. It was a 2pm spike or something like that. Everything else looked normal or what I expected. After several questions and conversations, I found out that she was putting some sort of steroid spray or cream on her dog every day. It was that time of day. “I always put it on at lunchtime.” She didn’t connect that when she is putting this steroid cream on her dog, that would affect her saliva test. Once we figured that out, we did it the right way without exposure to that, and it came out okay.

The other thing that’s really important, and we should do this with all of our tests, is if the clinical picture doesn’t fit with what you expect the pattern to be, then that’s another reason for questioning. Again, I’m expecting somebody, when they fill out their intake form, or we’re having conversations, that their adrenals are going to be tanked. Then it’s not. Whether it’s high or even when cortisol is normal or appears normal, the way they are describing their symptoms, I would have expected them to be flatlined. Even then, I might say, “Tell me about that day. Was it a super stressful day?” In some patients, their norm may be really low, but the stress of that day increases their cortisol enough to make it go into the normal range.

That becomes the art of this medicine: Even though this test looks normal, this doesn’t fit the clinical picture. That happens in thyroid, too. This person has every single symptom of thyroid dysfunction, yet their thyroid levels look totally normal. That’s a little bit different. It’s not a direct relationship to what was going on that day, but it makes you start thinking, what else is creating those symptoms or the inability of the thyroid hormone to get where it needs to go? That should prompt you to look more directly into adrenals and gut health, too. If your gut is not happy, then you’re not absorbing that thyroid hormone that you’re popping into your mouth every day, and it’s not doing its job.

Dr. Eric:

Good point. You want to look at the whole picture and take into consideration the test. That’s also why we do a health history to get other information. Sometimes we need to dig deeper. Maybe do a comprehensive stool panel or other tests. Thanks for pointing that out.

Getting back to the adrenal testing. You do saliva testing. I’ve done saliva testing for years. Why do you do saliva testing over blood tests? I know the answer to that, but for those listening who figure, “Why can’t I just go to a LabCorp or Quest or somewhere else and get a morning cortisol?”

Dr. Aimee:

Specific to adrenals, there are two parts to that question. The first part is we talk about an adrenal pattern. I mentioned it earlier, but your cortisol goes high in the morning when the sun comes up. Over the course of the day, they go down. The sun goes down, and it’s helpful. I see a lot of patients where their morning cortisol may be pretty normal, but by the time they get to noon, they’re tanked. It’s bedtime for them. That’s why they’re complaining of all this afternoon fatigue. “I can’t stay awake at my desk. My kids drive me crazy when they get home at 5pm. I’m trying to make dinner, and they’re screaming. I feel crazy. I think I need some antidepressant or antianxiety medication” when their cortisol levels are low.

If all you do is go into a lab and get a one-time cortisol test, that’s not giving you an adequate picture of what the whole day looks like. Especially if someone is having trouble sleeping, it’s very common to see a little rise in cortisol at nighttime as you are getting ready for bed. If they are not sleeping well, rather than, again, us going down the traditional path of needing Ambien or some other prescriptive medication for sleep, if we see that their cortisol level is going up, there are certain supplements we can do to help stop that. You can get better sleep.

It’s really important in my opinion to get that full four cortisol test throughout the day to adequately see what that pattern looks like. That is step #1.

Step #2, sort of what I mentioned earlier about the stress. Let me go backwards for a second. Ideally, we want to collect the cortisol sample 30 minutes after you wake up. That’s when it should be at its peak. There are plenty of studies that show us that your peak cortisol level is going to be 30 minutes after you wake up and are ready to get out of bed. Imagine trying to wake up, get dressed, get in the car, find LabCorp, get a needle stuck in your arm, and have that test all done in 30 minutes. That’s unrealistic, but that will also be stressful. You will end up with a high or even a normal morning cortisol level that then doesn’t tell us the actual clinical picture of what’s happening throughout your day.

That’s my interpretation of why I do saliva testing for cortisol specifically. Yes, you can measure cortisol through blood. It’s accurate from the perspective of what your cortisol level is in your blood at that moment. But it’s not accurate of your personal clinical picture of what’s going on with you.

Dr. Eric:

The only way to look at the Circadian rhythm of cortisol is the saliva test or the dried urine test. I don’t know if you use Dutch testing in your practice.

Dr. Aimee:

I have a little bit. I like the saliva test better, but I do find the Dutch test helpful. That’s one of those things when you are starting to troubleshoot, and that clinical picture doesn’t fit. I have had times, and this can be a little bit confusing. This gets advanced. When somebody’s cortisol level is really low, so I’m treating them as such. I’m giving them lots of cortisol herbs or even hydrocortisone. That’s another conversation we can have. They are responding as if their cortisol level was high. They are saying, “This is really stimulating me. I can’t take this.” It’s not doing what we expect it to do.

There is a phenomenon where people make cortisol and get through it really fast. It doesn’t show up as readily in the saliva test because it’s already gone. The Dutch test, doing a urine analysis, gives us the cortisol metabolites that have been through. There are some cases where you can have low cortisol on a saliva test, but it will appear high in the Dutch test. That is somebody who actually has high cortisol; they are just super fast metabolizers and getting rid of it quickly. That’s rare. I have heard of that at conferences and things. I have had probably less than a handful of patients who fit that picture. That’s where I have found Dutch testing to be helpful.

Dr. Eric:

As far as the metabolism itself, those metabolites, it’s very common with hyperthyroidism, which a lot of people listening to this have. You prefer saliva testing, and you also use saliva testing for the hormones, too. You don’t test hormones in the blood, like progesterone or estradiol?

Dr. Aimee:

What I have learned and trained in my saliva testing courses, which I now teach to other providers, there are a few parts to that. One of the parts is hormone levels change throughout the day. That has been tested in bloodwork. I have seen the studies several times, where they took two women and tested their estrogen levels every 10 minutes. It looks like an EKG machine. It’s all over the place. Collecting four samples throughout the day, taking a pooled sample and getting one number that is more accurate of what your overall day hormone levels look like, especially if you are on hormone replacement.

Whatever your hormone replacement regimen is, you want to catch a nice balance. What does the average look like rather than a one-time blood test in the morning, and you took your hormone replacement that morning before you showed up? That level will be high. Or vice versa. If you took it yesterday, and now is a sample where it might be low, so that’s confusing. Having that test throughout the day can give us a nice average level. I do like doing saliva testing for that. It’s not impossible, but it is quite difficult to be able to go to a lab four times a day and get those tests done and then average those numbers. That’s not realistic. That helps.

The second part is we talked about thyroid hormone binding globulin, which is a protein that the thyroid hormone sticks to. You have the same kind of protein for your other hormones as well. Hormones don’t usually just hang out in the bloodstream. They have to be attached to those proteins, which carry them to the receptor sites on the tissues, whether that’s your hair, skin, breast, ovaries, etc. Blood testing misses those hormones that are stuck to that protein, so you don’t get accurate levels of what hormone is actually being presented and what the tissues are being exposed to. Oftentimes, in the bloodstream, you are getting the leftovers. It wouldn’t be unusual for it to be low. That could be inaccurate. By the time it’s high in bloodwork, then it’s really high in the rest of your body. That is going to cause side effects and things we don’t want to deal with. I find saliva testing to be more accurate in terms of actual physiologic. Where are these hormones going? What is your body being exposed to?

Dr. Eric:

If someone is cycling, do you have them do one of those cycling saliva panels?

Dr. Aimee:

We can get into a topic of irregular cycles. If they can test somewhere between 18-21 days, which is basically a week before their period is supposed to start, that is when the progesterone level is going to be at its peak. After you ovulate, progesterone levels start to go up. If you get pregnant, it will keep going up. If you’re not pregnant, it starts to go back down again.

18-20 is when it should be at its peak. If somebody is low then, then it’s very likely they will be low the rest of the time, too. That is where we are focused for progesterone in particular. Estrogen does change. It peaks a little bit earlier, but we can have a nice level of what we expect it to be during that time as well.

When somebody is cycling, estrogen is probably not the issue because they are cycling, which means they still have adequate levels of estrogen. It’s looking at progesterone and the balance in their cortisol levels. I haven’t found it to be helpful. I did it in the beginning when I was first learning. There are some labs that have you do eight days throughout your cycle or 11 days. That’s just a pain in the butt for the patient to do, and it’s not very exciting for me to interpret all of those numbers and results. I try to simplify things with getting the best information. That’s what I have found to work really well. Do that test about a week before their period is supposed to start.

Dr. Eric:

Let’s talk about treatment. I know you mentioned high cortisol, you don’t see a lot of those cases, but you mentioned L-theanine. When it comes to low cortisol, you mentioned hydrocortisone. Some practitioners will give licorice root or adrenal glandulars. What approach do you take? Does it vary depending on the person?

Dr. Aimee:

Absolutely, it varies, depending on what their levels are. I have various adrenal supplements. There are so many out there that can be overwhelming and hard for me to choose sometimes. Either I have another practitioner who says, “This is working really well for me,” or a little bit of trial and error.

As a physician and a mom of four, my cortisol levels were not very good for a long time. I have tried every single adrenal supplement out there. Even treated myself for a couple years with hydrocortisone. I have personal experience on that level as well.

I have adrenal supplements that I call mild, medium, and hot. Kind of like salsas. If you have that cortisol pattern that is a rollercoaster, you may be high, then low, then high, then low. It’s hard. Do I give them a more stimulating adrenal supplement or a shut down the adrenal supplement?

There are some supplements out there that are more adaptogenic. More mild, let’s just try to balance things out a little bit. That’s where coming to the brain, having some L-theanine or something calming that way can be helpful.

The medium one is that cortisol is okay in the morning but tanks later in the day. I call that the Gatorade of the adrenals. Those herbs we commonly see, like ashwagandha rhodiola. We see some other herbs there. Lots of B vitamins. The P5P.

The hot one is in addition to some of those herbs, we add some adrenal glandulars to that. There is a lot of supplements that have mixtures of adrenal glandulars as well as other herbs. Siberian ginseng is found in a lot of those supplements to get the brain working a little bit.

I play around with those. Which one depending on which the patient’s symptoms are in terms of what sort of support we can give to the adrenals. Hydrocortisone, I have used a lot in my practice. I think it’s a great tool, especially for that flatlined person.

Let me go backwards for a second. Remember when I said earlier that when you are sprinting this marathon uphill all the time, that is wearing out your adrenals. We can give you Gatorade throughout that process so you can keep sprinting. Ultimately, one of our goals in long-term treatment of adrenal dysfunction is to lower the slope. We have to start working on that stress. We have to make that hill less steep. That comes from working on outside stressors. I can’t manage your stress for you. I can’t go to your job and help you figure that out. What are some things we can do with meditation and breathing and getting you back into parasympathetic mode? There is a lot of conversation we have about that.

Also, those internal stressors. That will go back to the dietary stuff. Let’s start eating to minimize that stress on the side.

Treatment of adrenals is not just pop that new supplement, and you will feel like a million bucks. Ultimately, that is what I started doing. I had great results with that. Patients would come back six months or a year later and wonder how long they have to be on these adrenal things. It felt good at the beginning, but some of those symptoms are coming back. This should be a magic pill. If you don’t support the adrenals to heal, then those supplements are just the Gatorade that is keeping you going on that hill.

Now, hydrocortisone fits very nicely in that when somebody is literally, “I cannot get out of bed. You’re telling me that I need to eat healthy. I can’t even process that. I can’t even think about going to the grocery store. I don’t care about eating. I don’t even eat anything, and I’m still overweight. Everyone thinks I should be a skinny mini because I hardly eat. I can’t sleep. I can’t do anything. My brain is a mess.” You see a flatline cortisol. We may need to use hydrocortisone for a while. That could be anywhere from three months to two years in some patients until they can really start to recover. If they aren’t in a place where they are going to be able to do the things they need to do to start healing, we have to get them feeling better.

Hydrocortisone is bioidentical cortisol. We use it in physiologic dosing, which means that your own body normally, in a perfect world, makes about 30mg of cortisol a day. I might start with 5-10mg in the morning and another 5mg in the afternoon trying to create that normal high and low curve. It just supports the process. Then they are starting to feel better. It takes them about a week or so to notice it. It’s not like you’re popping an Adderall and running around cleaning out closets. It’s not stimulating. But they start to notice they’re less tired, and they need less of a nap or didn’t need a nap at all today. They are going through the motions of regular life.

Now we can start introducing the supplements to support the adrenals to do their job. If the brain is not sending the signal, those supplements won’t do anything. You have to get the brain back.

I tell them hydrocortisone will do three things. Help you feel better and control some of those symptoms. Let your adrenals rest a little bit. Here they are on this hamster wheel trying to run this marathon of life, and they never get a break. We have to let them rest. We are not suppressing them. That’s what prednisone does. Hydrocortisone is let’s stay on this hike, but I will carry your backpack for you for a while, so you don’t have to work so hard.

The third thing it does is it resets the brain to say, “This is what’s normal.” High cortisol in the morning. Low at night. We will do that over and over every day for 30 days, 60 days. When you take it away, the brain is like, “I need cortisol.” Send the signal. Your adrenals have rested. You have some Gatorade in there. Now everything starts to work the way it’s supposed to.

Dr. Eric:

If you were to give a summary or action steps people can take if they feel like they are experiencing problems with adrenals. You can’t always go by symptoms. Can you give them some action steps? I’m sure there are things they can do on their own with stress management and diet.

Dr. Aimee:

What I have experienced is the more knowledge people have, the more they will have power to support their own health. They will be empowered as opposed to depending on others. Of course, you might need to depend on a doctor like me or you to help you get started in that path.

Yes, there are steps you can take on your own. If you think you have adrenal fatigue, look at a list of symptoms. It’s very easy to Google this. If you look up the symptoms that you have, and it feels like adrenal fatigue, you can look at some of those supplements and say, “Maybe I need some Gatorade.” They won’t hurt you. They are pretty safe supplements to take for the most part. If our goal is to get you to feel normal again, and you don’t feel normal, then you stop taking it. If you’re feeling overstimulated, or it’s upsetting your stomach, you can stop taking it. It’s not super dangerous to take an adrenal supplement necessarily.

But if you have so many symptoms, it’s hard to be subjective. “I feel this way. I took a pill for a week, two weeks. Didn’t work. How do I feel now?” Having objective measures of what is your cortisol now? How intense is it? We talked about the different phases of adrenal fatigue. If you are so low on that spectrum, those supplements won’t do anything for you. That doesn’t mean you don’t have adrenal fatigue, and the supplement didn’t work. Your brain is not sending the signal, so it doesn’t matter what you have there.

There is some trial and error with supplements out there. You can experiment. If it makes you feel better, that gets you one step ahead of the game. Again, we have talked throughout our conversation about the importance of everything working together. You might have adrenal fatigue symptoms. Is it because your hormones are out of balance? Your thyroid’s not working?

Finding a practitioner that is like me or you that can do some more objective testing and help you understand what is going on, where is that balance. If that is overwhelming for you, you can start with the basics. Let’s get us back into parasympathetic mode. I tell my patients all the time to Google how to be parasympathetic. There is a lot of good information out there about the things I can do to get out of that fight or flight mode, out of that stress mode. It’s easier said than done.

I have been doing a lot of talking on cold water plunging. There are a lot of studies on that. If you don’t have a tank where you can throw a bunch of ice water and get into a cold water plunge, you can turn your shower cold at the end of your shower. I think that’s fascinating. Even if you don’t have adrenal fatigue, it will be helpful for you.

At the end of your shower, turn it to as cold as you can possibly manage. The colder, the better. Count to 30. Your first response will be to hold your breath. “If I have to be here for 30 seconds, I can’t hold my breath that long,” so it forces you to start breathing and exhale. You have to do that calm, big, deep breath to help your body relax while you are in that water. The more you do that, that’s a great way to force yourself into that parasympathetic mode, that calm mode. If you can mimic that throughout your day, you don’t always have to be in the shower, but you can start help managing your stress a little bit better.

Back to the diet. Whatever you want to term it, whole food diet, I tell patients all the time: The closest you can get to nature in the least steps possible, that is the diet you want to be on. Pick an apple. Hopefully it’s organic. Pick an apple, and eat it. There are no steps to prepare that apple. Protein in meat is different. You want the minimum amount of steps. Nothing added to it. Get that raw meat. Cook it however you want to cook it, and eat it. Your veggies, as much as you can, raw veggies. One step. Steam them, sauté them, roast them, whatever. Minimal steps.

When you start thinking about something like whole wheat pasta, like you were talking about, or what we think is healthy grains and carbs, we didn’t go out and pick a stalk of wheat and chew on it. Even then, when you take the wheat and grind it up into flour after drying it out, we don’t sit there and eat spoonfuls of flour. That all has to be mixed with something else. These preservatives get in there to prevent it from getting moldy and hard. There are 52 steps to get from where it came from to your mouth. That’s an easy tool to let patients start looking at foods. How many steps? Three or less, that’s your diet you need to be on. You can start there. That will make some big changes before you find a practitioner like myself or another integrative functional practitioner that does more in-depth testing.

Dr. Eric:

I do take my cold showers. Not fully cold. I alternate. I do hot, cold, hot, and then finish up with cold. I recommend those. I can’t say I do it every single time, but most of the time, I do it.

Where can people learn more about you, Dr. Aimee?

Dr. Aimee:

My own personal website is AimeeDuffyMD.com. You can find links there to my book, Normal Doesn’t Have Side Effects. Also, if you click Learn More, you can flip over to my website for Carolina Integrative Medicine, which is my practice. You can also go to CarolinaIntegrativeMedicine.com. We have lots of info about what we talked about today, maybe not in quite so much detail. Adrenals, hormones, gut health.

There is a place where you can click Work with Me, which will get you to schedule a free discovery call with my team. We will chat with you for about 15-20 minutes. What is going on with you? What are your health issues or goals? If we’re a good fit to work together, that will get you set up on our schedule to go through the labs and the consult. That’s how people find me.

Dr. Eric:

Wonderful. Thank you so much for sharing this wonderful information with the audience. I’m sure they learned a lot about adrenals and sex hormones. Appreciate you taking the time for this interview.

Dr. Aimee:

You’re welcome. I enjoyed it.

Recently I interviewed Julie Michelson, as she discussed AIP diet tips and troubleshooting. If you would prefer to listen the interview you can access it by Clicking Here.

Dr. Eric Osansky:

With me, I have Julie Michelson, who is a national board-certified functional medicine health coach, bestselling author, international speaker, and the host of the Inspired Living with Autoimmunity podcast. Through her journey of overcoming more than a decade of decline with rheumatoid arthritis, Julie became passionate about functional medicine and using lifestyle to create healing. Julie is an expert in supporting others achieve the changes necessary to experience true healing. Thank you so much for joining us, Julie.

Julie Michelson:

I’m excited to be here.  Thanks for having me.

Dr. Eric:

You are welcome. I am excited to have you as well. We are going to be discussing diet with a focus on autoimmune paleo (AIP) diet, giving some tips and troubleshooting. Before we dive into this, I would like to have you talk a little bit about your background, how you became an AIP-certified health coach and how you got into what you do now, helping people with autoimmune conditions. Of course, we said a little bit in the intro because you had rheumatoid arthritis, which I’m sure ties into that.

Julie:

It does. It is just one of the diagnoses I had. When I was in my early 30s, newly single mom with three little kiddos, I was diagnosed first with rheumatoid arthritis. I was told when I was diagnosed to expect to decline. There was nothing I could do except take the medications they gave me. On their end, what they would try to do was slow my decline as much as they could and keep me as comfortable as possible. Unfortunately for me at the time, I believed that. I had great doctors. Everyone seemed to agree. When you are diagnosed with something like that, that’s your fate.

I of course did decline for over a decade because that’s what I was expected to do. I kept piling on the prescriptions. I was on 10 prescriptions at the end of 11 years at once. I was taking 10 at a time. It wasn’t working. I was unable to work. I was resting while the kids were at school, so I could handle that afterschool to bedtime window. I had severe brain fog. I was in severe pain. They were trying to get me to put a handicapped placard on my car to save energy and steps. That was the current conversation at the time that I luckily had my aha moment, my dark moment, my light moment, whatever you want to call it.

My youngest daughter begged me, “Please don’t die and leave us.” Obviously, I couldn’t promise her that. What I said that changed my life, and hopefully a lot of people’s lives because this is why I do what I do. I promised her, “I would try everything.” In that moment, I realized I hadn’t tried everything. I tried every medication they had me try, thinking that was everything.

Luckily, I had the history of a little bit of improvement with diet change that I had done on my own. That was where I started with diet. At the point I made that decision, I was already gluten-free. My son had been diagnosed with Celiac a few years before that. To support him, I went gluten-free with him. We would do it together. I noticed my joint pain had gotten a little bit better by going gluten-free. Come to find out, I had Celiac.

I remember even back then, asking my doctor, “Wow, if this helped a little bit, what do you think about dairy? I’ve read that nightshades can be a problem.” “No, nightshades is one in a million. It’s not really a thing.” Back then, I believed her. It was enough. It was stuck in my head, and that’s where I decided to start on my own.

It took me years. AIP wasn’t around yet. I was uneducated. I thought I was eating Paleo at that point. I was still eating corn. I didn’t know corn was a grain. I was eating loads of sugar. I was still avoiding fats, even healthy fats, because I still had that mindset of fat is bad. It took a long time. It was a process.

I am really fortunate that without even managing my other underlying causes, just over the years, by continuing to tweak diet and learn, I was able to get well enough to reduce the brain fog, so I could learn more and continue down the journey. It has become my life’s calling not only to help people but also to shout from the rooftops, as you do all the time, that we can heal. People need to know that autoimmunity is not a death sentence; it can be turned around.

Dr. Eric:

Well said. I definitely agree. Your rheumatoid arthritis is under control?

Julie:

I have no symptoms. I have been symptom-free for about six years, maybe longer now. Time keeps marching on quickly.

Dr. Eric:

True. You mentioned AIP wasn’t around. Same thing when I was diagnosed with Graves’ in 2008. There was no AIP then. I started out with more of a modified Paleo diet, you could say. I was still eating nuts, which I had to eliminate later on because I was having some issues. I wasn’t 100% certain it was due to nuts, but when I cut them out, I progressed further.

Why don’t we talk about AIP? Could you give a brief overview of what the diet entails?

Julie:

Absolutely. I want to start right away by saying when people hear AIP, they think diet. We are going to focus on food today, but AIP is a lifestyle. It’s important for people to understand that they may dial in their diet perfectly, but if they are not actively managing their stress, not sleeping well, not in community and connected with others, not handling toxins, not moving properly at the level for their body. If one thing is perfect without the rest, I can guarantee you it won’t get you the results you’re looking for. To me, diet is a low-hanging fruit and such a big driver. It’s not just a diet.

What AIP is, as far as the food plan, it contains a comprehensive elimination diet, where we are eliminating all of the most common drivers to autoimmunity. I say “most common” because usually by the time most of us are diagnosed with an autoimmune condition, we know we have leaky gut. When we have leaky gut, we have food sensitivities. A lot of them can be to really healthy, nutrient-dense foods that aren’t on an autoimmune list, things like spinach. I try to stop saying kale because people are tired of hearing about kale. There is no one written plan that is going to be optimal for everybody. But AIP is so comprehensive that we now have great scientific studies behind it.

As you mentioned, it’s a Paleo diet. It’s just beyond that. The key, and the part I think gets the most misunderstood, is yes, the elimination phase is very restrictive. It’s supposed to be a phase. It’s not supposed to be a lifelong thing unless someone really needs to be avoiding all of those foods long-term. You mentioned Paleo. It’s completely grain-free. Yes, even oatmeal. These are the things people like to negotiate all the time. I know we will get into that later. It’s sugar-free. It’s sweetener-free. No legumes, nuts, seeds, eggs, nightshades, alcohol. What else am I missing?

Dr. Eric:

Paleo allows eggs, nuts, and seeds. You mentioned those are not allowed.

Julie:

No dairy.

Dr. Eric:

No nightshades, grains, legumes, alcohol. Of course, it goes without saying: no unhealthy oils.

Julie:

No processed foods. All of those additives and chemicals, we’re talking about a whole real food eating plan.

Dr. Eric:

Even certain spices are not allowed, correct?

Julie:

The ones that aren’t allowed are either nightshades or seeds.

Dr. Eric:

Speaking of coffee, would you say that falls under the legume category?

Julie:

It is a bean. Coffee may technically actually be a seed. I can’t remember which category it’s in. Full confession: I have coffee right here. It’s earlier here than it is where you are. I have done my reintroductions, and I am okay with coffee although I am not okay with other legumes. I don’t eat legumes.

Dr. Eric:

In your situation-

Julie:

Where we start is not where we end up ideally. That restrictive phase is a phase.

Dr. Eric:

I agree. I look at AIP as more of a starting point. It’s a phase. When I have someone start on an AIP diet, and I can’t say I have every single one of my autoimmune patients start there, but for those who do start there, I usually will try to encourage them to go at least three months. Even 30 days is better than nothing. But a minimum of three months. What do you have to say as far as duration of that phase?

Julie:

It’s individualized. It’s going to depend on response. I’ve had the rare occasion where we’re working toward a full AIP elimination, and someone feels phenomenal. If someone is feeling amazing, then I will say, “Okay. I don’t need to get more restrictive.”

I agree. It depends on where they are. What are their symptoms like? How long have they been struggling? It usually takes at least a good 60 days. Here’s the thing I find. I will start with an at least. I don’t say 90 days to anybody because I don’t want to scare them off. I do say, “This will depend on you.” Nobody believes me when I tell them this, but I always tell them, “I promise, I will be encouraging you to do reintroductions. You are not going to want to.” At the beginning, it sounds really hard and overwhelming. When it is the right thing, and you feel amazing, nobody wants to put those things back in because they don’t want to feel crummy again.

For me, the whole purpose of AIP is information and power. It’s not about the elimination. It’s about the reintroductions and really learning what each of those foods is doing. People don’t understand. I have people ask me all the time, “Are we creating a food sensitivity? I have been eating tomatoes my whole life, and now they bother me.” I liken it to because I am over 50, that fuzzy TV screen, those of us in my age group remember when the antenna wasn’t just right. You have so many little sources driving your inflammation that you can’t feel what just one is doing. That is the beauty of this protocol.

I know we may touch on some other eating plans. The thing I love, I am working on my Bredesen certification, and I have worked with a Bredesen-certified physician. That’s an Alzheimer’s plan. Anyone familiar with the Wahls protocol. All of these things come down to the same thing. They are all grain-free, dairy-free, nutrient-dense, loads of veggies, lots of good healthy fats, and no sugars. All of the higher-level diets have some level of ketosis involved. There is a crossover. I study all of them and see these are the things that must be important no matter what your diagnosis or symptoms are.

Dr. Eric:

I agree. I want to talk about grains. Toward the beginning, you picked a little bit on oatmeal. Before the interview, we were chatting a bit. That is one of the things patients like to introduce. Oatmeal, rice is common. As you mentioned, a lot of these diets avoid grains. Why are grains not part of AIP or a Paleo diet or a ketogenic diet? Keto might be different. You are trying to get into ketosis, so there are different reasons.

Julie:

I think that’s still part of it. There is more than one answer, and there is overlap. We will start with the easy part. Grains are going to increase your carbs. At some point, for everyone, carbs become inflammatory. Just that alone, without the other reasons, is why someone who is dealing with chronic inflammation needs to be careful of their carbs.

I have gentled as I have aged and coached more and more. I did pick on oatmeal. The reason I picked on oatmeal is most people think oatmeal is really good for them. It’s marketed really well. I had a client recently who was a type one diabetic who was eating oatmeal every morning for breakfast. She had no idea that was bumping her blood sugar. Easy reason #1 that carbs can be a problem for people.

Also, certain gluten-free grains, because gluten is another thing- Everyone who works in the autoimmune world will agree that gluten is a problem, especially for those with autoimmunity. One problem with other grains is molecular mimicry is a thing. They can send similar signals and trip similar immune responses. Some of those proteins are similar. That’s another piece of the problem.

I go by what I see. When I first started coaching elimination diets, we would introduce gluten-free grains all lumped together. We would do oats, rice, and corn. I don’t do that anymore. We need to know exactly what each particular driver is doing. I do have clients that are okay with rice when all is said and done. Even those clients can’t eat rice every day, or they will bump their inflammation back up. My kids would tease me, “Not all grains are evil.” I did used to be so, “No, grains are bad!” The ones I think sometimes people can eventually handle in moderation are rice (cook it, cool it completely, then it becomes a resistance starch, and you can eat it) and oats here and there. I don’t eat oats. I will occasionally have sushi if I pour MCT oil on it. It really does depend.

Through coaching hundreds of people through this process, corn is a big problem for people. They typically have no idea. That is another reason why I think the gluten-free movement is not that great. I thought it was great with my son before I knew better, but that food is just loaded with junk and high-sugar stuff and corn.

Dr. Eric:

Some people might say it’s organic, so it’s GMO-free. It’s not just the GMOs. It’s the corn itself. Even if you have organic corn, it’s something you still want to avoid, arguably not just when trying to restore your health, but generally. It’s difficult because so many products, especially if it’s packaged and gluten-free, will usually have corn.

Julie:

Humans were not designed to be able to process grains, from the way we chew. There are a lot of reasons when we look back. If we think of paleo, that’s this approach. How did we eat in Paleolithic times? What are we designed for? We weren’t sitting around eating carbs all day. We weren’t sitting around all day either. When you think of what that mindset means, that’s what it means.

Dr. Eric:

They didn’t sit around eating popcorn, speaking of corn.

Julie:

My daughter was just teasing me about that. When I said I was doing Paleo all wrong. I thought I was eating Paleo, and I was having popcorn almost every night, when I had that treat mentality still. No, they weren’t watching movies and eating popcorn.

Dr. Eric:

Some people might be able to get away with some gluten-free grains, possibly rice and maybe oats. The thing is you never know how someone is going to respond. When someone is trying to negotiate, it’s up to the person. We can’t force people to follow any type of diet. We just give recommendations. What I always say is if you deviate, it’s ultimately up to you. You might progress fine. But we just don’t know. If that’s a risk you want to take, if you go 30 days or a few months, then you hit a road block. If you hit a road block, we don’t know for sure that you’re eating bad food. If you’re eating rice, we don’t know for sure that’s why you’re not progressing. If you’re eating strict AIP, we can’t blame it on certain foods. If you’re eating that food, then we don’t know.

Julie:

It’s the scientific approach. That is why I believe wholeheartedly the proper reintroductions are the most important part. Then you’re not guessing what does rice do to me? I don’t always coach AIP straight as it’s written. We use it as a framework. If you ask Sarah Ballantyne, that’s what it was designed for. In order to be a resource for people, you have to give them the framework.

I just had a potential client come to me until she told me she was vegan. I said, and I know you have a question about that, that I was not the right coach to help her heal unless she was willing to incorporate some animal protein into her diet. Luckily for both of us, she said, “I will do whatever you tell me to do. Let’s get started.” As a vegan, some of her really high sensitivities were things like soy and a bunch of the wonderfully nutrient-dense vegetables she was eating.

Here is where I love the food sensitivity panel not only as a backup but how to get a vegan not to eat soy. You show them data that their body is having a problem. For me, it made that part of my job so much easier. She just reintroduced kale last week. She did a full elimination diet and has been very slow to reintroduce. “Please, can we do kale now?” “Sure.” She can’t eat kale; it’s not her friend. And she loves kale. It doesn’t even have to be an evil food, like my kids think I think, on that list of things. Now, her body has told her that. If she had been eating that the whole time, she wouldn’t have gotten the results she got on her elimination phase because she would have had inflammation the whole time.

Like you said, it’s so important to take it out, and then to really feel. I’m one of those. I get it. I was eating gluten my whole life. I didn’t have gut issues. I thought it was fine. When they wanted to test me for Celiac, they told me, “You have to eat two pieces of wheat bread a day for a week or 10 days” in order to get an accurate read before the biopsy. That’s where I learned that. It didn’t happen. I couldn’t. I was that sick. That’s that sense of your body can tell you. Had a health coach told me however many years ago that was, 15 years ago, I shouldn’t eat gluten, I probably would have still dabbled in gluten. Feeling what it does to my body, it’s a never ever food for me.

Dr. Eric:

Definitely listen to your body. One thing I want to say about soy. You do a food sensitivity panel, and soy comes back positive. The one flaw with that, in my opinion, is if it comes back negative, you’re not just avoiding soy because you’re sensitive to it.

Julie:

Which is why it’s on AIP.

Dr. Eric:

Exactly.

Julie:

I run into that all the time. I try to explain I’m doing that panel for extra data. I’m looking for things like kale on that panel.

Dr. Eric:

You’re looking for foods that are allowed on AIP.

Julie:

That are nutrient-dense that I would normally encourage you to keep eating. To clarify, I take soy away from everybody all the time. That’s not usually one they argue with me a lot about. It’s usually dairy. “I only eat cheese.” I will offer to everyone contemplating, whether it’s AIP or any eating plan, to take a week and become truly educated about what you are eating. I have had so many people say, “I avoid dairy,” and there is dairy in the products they are using even if they are not eating straight dairy. I’m not picking on dairy. My family was in the dairy business, so I love cows. It’s not about that.

Dr. Eric:

Even dark chocolate. That is also not allowed on AIP. Some people might think they are eating dark chocolate, but it will have milk chocolate in there without saying. If you look at the label, it will say so.

Julie:

But they will have casein added, which is a dairy protein. I had that recently with someone, “I am eating these dark chocolate keto things.” “What’s in them?” “Oh, there’s milk in here.” If you have one takeaway from this conversation today, the starting point for everybody is really being truly aware of what you are eating because often we think we’re avoiding stuff, and we’re not.

Dr. Eric:

Quick question about food sensitivity testing. I personally don’t do a lot of it. Do you do IgG testing?

Julie:

I do IgA and IgG testing. I do the combo.

Dr. Eric:

You have them do the blood draw first without doing any type of elimination diet.

Julie:

The panel I use, they will send a kit right to the house. It’s a finger prick test. There is plenty to eliminate just on AIP. Most of the time, unless somebody is, “No, I want to go all in right away,” we’re stepping toward that, whether it’s slowly or rapidly, anyway. We get started right away while we are waiting for those results to come back.

Dr. Eric:

Let’s talk about constipation. That’s a common problem, where people are used to eating whatever they eat, whether it’s fast food, or maybe not eating a lot of unhealthy foods, but are eating grains and legumes, etc. Not necessarily a vegan/vegetarian, but a person in general who gives up all these foods. All of a sudden, they are experiencing constipation. What tips do you have for them?

Julie:

I’m going to go way back. I just had this conversation with a physician I work with. Sometimes we forget to start at the beginning. Are you drinking enough water? We jump to, “What can I take to help me with constipation?” There is often an adjustment period. It is interesting. I don’t experience that very often with the clients I walk through AIP. It could just be the way we handle that transition into the full elimination. It’s very rare actually for me. I know it is a big problem in the AIP community in general. #1 is how much water are you drinking? We have to be flushing things out. Look at that first. It sounds so basic, but it is so important. This could be why I don’t see a lot of it in my practice. AIP, we focus on the elimination phase and what you’re avoiding.

The other important piece is what you’re including. We’re including a lot of nutrient-dense vegetables. Here’s that crossover with AIP and Wahls and the Bredesen recode. Lots of vegetables and a variety: leafy greens, colors, cruciferous veggies. Those all have fiber. That could be a good reason why we don’t see a lot of it. I am not going to say my clients within a week are eating nine cups of veggies. That’s not true. But it is important, and it does help. “I need my oatmeal so I can poop.” We’ll find another way.

I’m not a physician. I work with a physician. Typically, if there is an adjustment period, we encourage people to make sure they are getting magnesium. They may have to increase that intake for a little bit to keep themselves regular. Typically, then they can back off. Most of us are deficient in magnesium, and there isn’t a part of your body that doesn’t love it. Tell me what you do for constipation.

Dr. Eric:

Similar to what you said. Make sure they’re hydrated. Make sure they’re eating plenty of vegetables. Like you said, it can sometimes be challenging because they are not used to eating a lot of vegetables at first. They are not making the transition to eight or nine cups a day initially. They might only be eating two or three servings a day. That can be helpful to increase the vegetable intake. Magnesium, I agree. If you’re constipated, citrate-

Julie:

Or a blend if you don’t want to go overboard. I’m guessing you would do the same, but for those listening who don’t know how much magnesium to take, it’s a brief, maybe unpleasant experience. You want to keep increasing your dose until you have too much motility, and then you back off. If you’re taking capsules, you drop it down one. That’s usually how we do it. You can do it gently. Then the beauty is once you get the veggie intake up, and the body is adjusted, you can drop down. It’s a really important supplement. We all need magnesium. I personally love blended forms. Different parts of the body like different forms of magnesium.

Dr. Eric:

I don’t recommend citrate for most of my patients. It’s just for-

Julie:

Motility, yeah. Absolutely.

Dr. Eric:

I like glycinate and other forms of magnesium, like malate. Just focusing on constipation, I would say citrate. You could also take a blend. Nothing wrong with that.

I will also say movement. I had this conversation recently with someone who experienced constipation after following AIP. She wasn’t moving around enough. I told her my experience. I was really sluggish when I was in my early 20s. I would have a bowel movement almost once or twice a week. My diet was horrible growing up. These days, I have regular bowel movements. Sometimes it’s on the sluggish side. But if I am sitting too much, which I try not to do—I have a treadmill desk, so I can walk and work at the same time—if I start moving, it’s usually not a problem. But if I do everything else, and I’m not moving, that can be a problem when it comes to constipation.

Julie:

I’m so glad I asked you. It’s like the water. These are things our body needs to be doing. When we were talking about Paleo, they were moving all the time. Whatever that level looks like for you, it doesn’t mean you have to go out and do a HIIT workout. Get up.

Dr. Eric:

Exactly. I don’t know how many patients you see with Hashimoto’s or Graves’. Hashimoto’s is more common.

Julie:

Yes, more common. It’s such a common crossover, I find, whether it’s a secondary or primary diagnosis in autoimmunity. Definitely ¾ of someone sharing a different diagnosis also has Hashimoto’s. Not as much with Graves’.

Dr. Eric:

I’m bringing that up because there is controversy in the world of thyroid health with iodine. I wanted to get your thoughts about sea vegetables, which are really high in iodine. Do you recommend sea vegetables to your patients with Hashimoto’s?

Julie:

I do. I know everybody takes a different path. They are nutrient-dense. We do need iodine. Most of us aren’t getting iodine in our diets elsewhere. They are not hopefully eating iodized salt anymore by the time we are getting going. We are looking for other good sources to support them.

We also use labs a lot. I work with a functional medicine physician. Whether it’s in my program or with the patients at the clinic, we are always doing labs as well. Working with the women I work with, one of the things that we see a lot, women who have cystic breasts need iodine. Sometimes supporting iodine in them will clear something. We look for signs and test as well.

Sea vegetables, people aren’t usually coming in and saying, “I eat a ton of these. Is that okay?” That won’t be the bulk of somebody’s diet. I think it’s really good to incorporate.

Dr. Eric:

Just to confirm, you are not really seeing problems with your Hashimoto’s patients as far as sea vegetables go?

Julie:

We don’t. A lot of it comes down to how many are they eating? I’ll qualify that. He doesn’t have Hashimoto’s, but I have a client right now who is an avid podcast listener and reader and learner and loves wellness. For the people who think they should be eating a ton of sea vegetables and are intentionally trying to do something good, that can be a problem. Everything in balance is what I will say. I don’t have people that really need to be avoiding sea vegetables.

Dr. Eric:

In the last few minutes, I want to do something I haven’t done before.

Julie:

Oh boy.

Dr. Eric:

I want to do a rapid-fire round, where I bring up a topic and have you give your opinion for 30 seconds.

Julie:

Let’s do it!

Dr. Eric:

Ashwagandha and AIP?

Julie:

I say no.

Dr. Eric:

Because it’s a nightshade?

Julie:

Yep.

Dr. Eric:

Pea protein powder and AIP?

Julie:

No, it’s a legume.

Dr. Eric:

Bone broth powder and AIP?

Julie:

Bone broth and AIP, yes.

Dr. Eric:

I knew you’d say yes to bone broth. I am purposefully bringing up the powders because there are so many. I’m sure you get, “I don’t have time to make bone broth, but I will add this bone broth powder to my smoothie.”

Julie:

I will ask what is in your bone broth powder? It’s the trick answer to the trick question. It’s about becoming a label reading master. There are AIP-prepared bone broths. I understand not everybody wants to make their own bone broth. Going back to my formerly vegan client—who still identifies as vegan. I said, “You can’t say you’re vegan when you eat salmon four days a week and drink bone broth and eat eggs. You’re no longer a vegan.” If you can’t handle chicken feet, there are reasons. I would never ask her to make her own bone broth. She hasn’t jumped to the beef world yet. You have to read your ingredients and know what’s in there.

Dr. Eric:

What’s your favorite cooking oil?

Julie:

Depends on what I’m cooking and how. I love avocado oil. To me, it’s a middle of the road oil in the sense that it doesn’t taste like coconut. It doesn’t have an intense flavor. It’s very mild, and it can handle a higher heat than olive oil. I don’t like cooking with olive oil; I like dressing with olive oil. Coconut oil as well, we use.

Dr. Eric:

Chlorella and spirulina in AIP?

Julie:

Again, it’s going to be a non-answer. It’s an individual thing. I’m a fan of chlorella. I mentioned I occasionally take sushi. I will take chlorella when I eat sushi to try to bind some of those nasty things. It’s going to depend on your autoimmune pathways as to whether you can handle certain things or not. Those are not typically a problem for people. It’s almost like the sea vegetable thing. There is such good stuff in both of those things. For the most part, people can handle it, but I would be aware. I would take them as an introduction. I would take them when you’re feeling well and eating clean, and you see how your body feels about it.

Dr. Eric:

I bring it up because I’m pretty sure Sarah Ballantyne says not to eat it. It’s a No on that list.

How about AIP and ghee? Which I asked you about when you interviewed me on your podcast.

Julie:

You must get this question a lot. The answer is yes, we allow ghee. If you know you have a dairy allergy, don’t do ghee. The proteins are gone, so it’s one of the ways to make AIP more successful for people is to allow them to have ghee. I almost added it in my list of cooking oils. I don’t know if it’s an oil oil.

Dr. Eric:

Last rapid-fire question. Reintroducing gluten and dairy if remission has been achieved.

Julie:

Yes. I believe everybody should reintroduce everything. Gluten and dairy are absolutely the last two on the list. When I have people reintroduce dairy, I have them do different dairies at different times. I will have them do goat separate from cow. Goat might be an occasional food for someone, and cow may be a never. I want people to feel what it does so that six months later, they don’t end up at a birthday party where they accidentally had the birthday cake. It was loaded with gluten and sugar and dairy, and now they are in a flare with no idea what it was. I do believe everybody should reintroduce everything. I will reiterate because I have to: I believe they should avoid gluten for the rest of their lives.

Dr. Eric:

I didn’t expect that response. How about if they reintroduce gluten, and they feel perfectly fine?

Julie:

I cry. It has happened to me literally twice out of hundreds of people. It’s very rare, and I cry. Then I explain. We review leaky gut and autoimmunity and how this all happened to begin with. I still remember you talking about the occasional pizza. For them, I say have a little gluten in Italy. It seems to be less of a problem there. Don’t make it a part of your regular diet.

Dr. Eric:

Thanks for that. I know we are just about out of time. Anything I didn’t ask that I should have asked? Any last words you want to give to someone who is thinking about following AIP and isn’t sure they will be able to stick with it?

Julie:

I can say it can sound overwhelming, and it will be way easier than you think once we get into it. I think we may have talked about this on my podcast, but as you make changes, you will start to feel better. You will have more energy to make more changes, which is why ripping off the Band-Aid and just jumping in from a standard American diet to a full AIP elimination is probably not going to work.

Look for support, whether it’s someone doing it with you. Find a coach. This is why there are coaches. You want to really be supported through that process.

I would say if you’re thinking of it, but it seems overwhelming, and you’re still eating gluten, then go gluten-free. Take one step. Look at the elimination plan. I always tell people to start with the easiest thing. What is the easiest thing they think they can eliminate successfully, so they can start to build some momentum?

Dr. Eric:

Thanks for that. How can people learn more about you and your services, Julie?

Julie:

The easiest place to find me is JM.Coach. That can then take you to my free mini course, my website, my social handles, my podcast. It’s my gateway to anything you might want to know. JulieMichelson.com is my website.

Dr. Eric:

The name of your podcast is Inspired Living with Autoimmunity.

Julie:

Come check it out. If you need more Dr. Eric, we did a great episode there.

Dr. Eric:

That was fun. This was fun, too. Thanks so much for taking the time to share your thoughts on AIP and other diet aspects.

Julie:

Thank you so much for having me. I always enjoy chatting with you.