 Hi, this is Dr. Ruscio and let's discuss the connection between your gut and your thyroid, which is a fairly profound connection, but is oftentimes overlooked. And the main point I'm hoping to impress upon you with these a few data points is that if you're floundering with thyroid symptoms or an ambiguous thyroid diagnosis, or you've been unable to find the ideal dose of medication, either to rectify embalances in TSH or G4 or in your symptoms, then an examination of your gut health is a very good idea because it may be your gut health that's actually causing this litany of symptoms. But let's look at what the data shows so we can make a more confident decision to investigate our gut health. I'll start with some association data which associates your gut as implicated in causing problems with the thyroid. And up here in the screen I will list a study from Poland. And in this study, and what you're seeing in this chart is essentially the TSH levels, free T3 and free T4 levels of a healthy group of controls as compared to those with SIBO and diarrhea or SIBO and constipation. And what I've highlighted here for you in orange is a real main thrust of this paper, which is the TPO antibody levels or the thyroid antibody levels, which assesses the degree of autoimmunity. And the controls was normal at 6.3 in the SIBO diarrhea group was abnormal or high just above the cutoff of about 35 at 39 and even higher yet still in the SIBO constipation group. So what we're seeing here is an association between a elevation of thyroid antibodies or thyroid autoimmunity and small intestinal bacterial growth. Now we should also be careful to point out that this elevation is not drastic. And so one of the things that I think patients have a hard time adjudicating is, well, I have varying levels of TPO antibodies. I know I may have positive antibodies. When do I know if my antibodies are in an acceptable range? Or when should I be worried about them? And while the data to answer this question is a bit sparse, it does seem that 500 for the TPO antibodies seems to be a reasonable cutoff value. So if you have thyroid autoimmunity and your TPO antibodies are below 500, that seems to be, in most cases, a clinical end context there is important. But that's just one guiding post to provide you as you're trying to piece all this together. So continuing with the gut thyroid association, another paper published in the World Journal of Gastroenterology looked at 1,800 patients and they were looking for what was most associated with SIBO. And they examine gastrectomy, PPI therapy, any essentially gastrointestinal surgery, stenosis or a narrowing of the gut lumen or the the hose that is your gut, gastroparesis or essentially paralysis of the stomach muscles, neuropathy, nerve damage, immunosuppressive drug therapy, being hypothyroid or hypothyroid and on levothyroxin and or type 2 diabetes. And what was shocking about this analysis was the most associated with SIBO, not surgery, not stenosis, not immunosuppressive drug use, but actually being hypothyroid or being on levothyroxin. Now don't stop taking levothyroxin, that would be a mistake. This association tells us that there seems to be something about aberrances in the gut that may be driving these problems with the thyroid. Now as an aside, excuse me, what may be driving this is we know that roughly 30% of hypothyroid patients have an impairment in their ability to release hydrochloric acid. And what may happen in these cases, and this has been posited by Dr. Richard McCallum who's done some very elegant research in this area, bacteria from the oral cavity may be getting down into the small intestine and overgrowing. And because acid secretion in the stomach is not adequate, those bacteria make it through the stomach into the small intestine can take up resonance and start to colonize you. So that hasn't been firmly bore out, but that may explain the association that we're seeing here where those who have hypothyroidism have a decreased ability to release stomach acid that open as the door for SIBO. And that may be why in this study of over 1800 patients shockingly out of all these factors examined being hypothyroid or on levothyroxin were the most associated with small intestinal bacteria overgrowth. What about H. pylori? You may have heard that there's some association between various autoimmune conditions and H. pylori. So let's look. Well, a meta-analysis published in the journal Thyroid in 2018, I'm sorry 2013. And again, a meta-analysis will summarize the available data. So in this case, seven studies involving a total of 862 patients were summarized in this meta-analysis. And overall, according here, overall H. pylori infection was associated with autoimmune thyroid disease. So that's very interesting and that reinforces this posit that there's a connection between the gut and the thyroid. But there's one important caveat here, because as a countervailing perspective here, we don't want to run rampant and become heretical in how much blame we place on the gut as causing problems with the thyroid. So as a countervailing point here, the association was significant for Graves disease, which causes hyperthyroidism. It did not seem to be significant for hypothyroidism or Hashimoto's. So still more here to learn. And I don't want to represent this connection as being 100% definitive, but certainly the totality of the data suggests there is an association between the gut and the thyroid as well. So one promising study from Italy, actually, found treating H. pylori can improve thyroid autoimmunity. And this was published in the clinical journal of endocrinology. And this table is a bit busy. I'll just point you to the two yellow boxes. What you're seeing here, the green group and the red group, the green group was a group that had H. pylori and Hashimoto's and was treated. The red group had Hashimoto's and H. pylori and was not treated. And what the researchers tracked pre-deposed was changes in the TPO antibody levels. And the green group averaged out to a change of about 2,000 units changed in their antibodies, whereas the non-treatment group saw about 500 units of change. So that was considered non-significant, the non-treatment group. But in the treatment group, the change in antibodies was significant. Now that's only one study. And again, we don't want to over-represent the connection here. But some promising data is showing that in a reasonable fashion, if you have problems with your gut, if you can investigate those and take care of those, you may yield benefits from a thyroid perspective. And also, one promising case studies from the Journal of Infection and Developing Countries, a patient who had an intestinal infection was Blasocis hominins, specifically, was treated with metronidazole for two weeks in antibiotics. And Blasocis hominins was eradicated. Their urticaria or chronic hives and angioedema or redness disappeared. And at a four-year follow-up, there were no symptoms. The thyroid hormones normalized, and the thyroid antibodies declined. So definitely some interesting data published there. And I'll share one case study from my office, Laura, who presented with fatigue, insomnia, weight gain, fuzzy thinking, or brain fog. And in her case, we changed her diet. As soon as you put her on an elimination diet, similar to a paleo diet, but wouldn't have to be a paleo diet per se, and also put her on probiotics. And over the course of a couple months, she saw improvements in her fatigue, her insomnia, lost weight, and was more clear-headed while she required half the amount of levothyroxine. Now, you may be saying, how could someone go on half the dose of thyroid medication and feel better? Well, we know that the intestinal tract, the small intestine specifically, is where your thyroid hormone is absorbed. So if someone has impairment in their gastrointestinal function, they may not be ideally absorbing their medication. So the issue in the gut may be causing malabsorption of medication on the one hand and some of these symptoms on the other. And this is how we can see by treating the gut with diet and probiotics in this case, a halving of the levothyroxine dose and also an improvement in all of these symptoms, including weight. So in summary here, thyroid conditions may be highly associated to the gut and preliminary data suggests GI treatment can improve thyroid conditions and associated symptoms. Now, we'll do a part two where we'll outline in more detail some of the treatment options, but I want to put a pin in this here so as not to overwhelm with too much data in one kind of dump here. So more to follow, we'll link to part two in this video. But as a reminder, please, if you are not feeling well, if you're struggling with thyroid nonresponsive labs or symptoms, then definitely give your gut health a look, because this is one area that does seem to elude patients and I think would really benefit people if there was a broader awareness of this gut thyroid connection.