 Being hypothyroid increases your risk of small intestinal bacterial overgrowth, the stomach acid connection. Hi, this is Dr. Ruscio and being hypothyroid has been associated with increased risk of small intestinal bacterial overgrowth through the causative mechanism of low stomach acid production. But there's good news. This mess, this causative mess that can frustrate patients because they can't figure out where their symptoms are coming from actually has a solution. And if you understand this domino rally of causative events that can cascade, it's actually not too difficult to clean up the mess. But there's one important factor that must be included in how we look at a patient with hypothyroidism, especially one who's still suffering from and describing symptoms. And that is the gut connection. And here's the simple kind of causal cascade I'd like to lay out for you. We'll include all of the references that support this in a moment. One thing I want to be always very careful to do whenever we are discussing hypothyroidism is use high quality references because unfortunately I have been appalled on the internet the amount of fictitious and erroneous claims that are made regarding hypothyroidism and it's very disheartening to see what in my estimation it's also been reinforced in the published literature is a high number of patients who are looking for the thyroid to be the cause of their symptoms and there actually may be another layer, their gut that's totally overlooked. And when that layer is finally addressed, the symptoms improve. It's not to say the thyroid's not involved but oftentimes adequate care and attention to the thyroid has been given. This other causative issue, the gut, which is causing these symptoms, including things like fatigue and brain fog and constipation or what have you, has been unaddressed and this needs to be really included in a care plan to make sure that you're seeing the optimal improvements in your health that you're looking to see. So here's the flow chart. Hypothyroidism increases risk of low stomach acid. There have been a number of studies showing this and they average out at a finding of about 30%. So 30% of those with hypothyroidism appear to have low stomach acid. And there's enough data there to say that that's not really a refutable statement. Leading to two, low stomach acid increases the risk of SIBO. There have also been a number of reports that have documented this. Now we can't say because hypothyroidism leads to low stomach acid and low stomach acid is associated with SIBO that there's definitely this connection between hypothyroid and SIBO. That's an inference, but thankfully we have other data connecting this circle all the way back showing that those who have hypothyroidism actually do have an increased prevalence of small intestinal bacterial overgrowth. We've discussed in the past one study in over 1,800 patients that looked at a number of factors associated with being hypothyroid. The chief factor associated was actually small intestinal bacterial overgrowth shocking the researchers in this study. So every point in this causal domino rally, if you will, does have evidence to support it. So this is really important to understand. Now the next question we should be asking is, well, what can we do about it? Well, first we want to address SIBO or small intestinal bacterial overgrowth. And in my experience, going to a doctor and being tested, it's not really a point you need to start with. Now, why? Well, that's because we have a number of clinical trials to date five. And this has been so far as to be summarized in a minute analysis showing that probiotics can clean small intestinal bacterial overgrowth out of the small intestine. And certainly you don't need to see a doctor in order to use a probiotic. Certainly there's a time and a place for seeing a doctor. And if you have any concerns, you should go see a doctor. But if you're, let's say, hypothyroid and you're not feeling great and your doctors told you that your thyroid levels are normal, then you may just want to go on a probiotic protocol for a few months and then reassess. Because if you do have small intestinal bacterial overgrowth, this will help. And there's a good chance based upon the data that a good probiotic protocol will be able to decontaminate the small bowel of small intestinal bacterial overgrowth. So that's a good starting point. And it doesn't really matter if you do or don't have SIBO, small intestinal bacterial overgrowth, you can still go on a probiotic protocol. There's no reason why you couldn't run a probiotic protocol if you did not have SIBO. So you can start there. And really you can go through a good probiotic protocol at the same cost for one doctor's office visit. Again, if you have concerns, always check in with your doctor, keep your doctor in a loop, but this may be a way to mitigate unnecessary doctor's office visits. So first, we try to rebalance what's going on in the gut. That's a probiotic protocol. Then second, you can try a supplemental hydrochloric acid to see if you notice any further symptomatic improvement. The reason why I recommend doing this after the probiotic protocol is so that you don't have the confounding symptoms that can come from the SIBO. So first, we should try to clean out this small intestinal bacterial overgrowth. You'll likely say, okay, I'm feeling better. Then you can try the supplemental acid, the betaine hydrochloride or betaine HDL, and see if your symptoms improve even more. Perhaps your digestion feels better, you feel less bloated, you feel like you digest your food better. Now, alternatively, you may notice that when taking hydrochloric acid supplementally, you notice some reflux or a warmness or a burning sensation, and that will tell you that you don't need to supplement with digestive acid. And there are a few factors that you can look at in your own history that will tell you, I have an increased probability of being low in stomach acid, therefore needing to supplement with it, or I do not. And here are the factors I'll put up here on the screen that will tell you if you're at an increased risk for having low stomach acid, therefore needing to supplement with it. These are, if you've had a history of anemia. If you have a autoimmune condition, of course, if you have diagnosed Hashimoto's, which is one of the underlying causes, the main underlying cause of hypothyroidism, or any other type of autoimmune condition, this increases your probability. If you have the chronic use of painkillers or NSAIDs, and or if you are over the age of 65, all of these can lead up to about a 50% prevalence of low stomach acid. But no, that's 50%, that's one in two, that's not everyone. So just because this association exists doesn't mean that you should blindly use supplemental stomach acid, unless you have some subjective sense that you feel better when using the stomach acid, hence my one-two approach of start with the probiotic protocol, attempt to get the gut as balanced as possible, then you have a more kind of consistent baseline from which to try the hydrochloric acid supplement to see if you notice any improvement or any regression in how you feel. The improvements indicate continuing with the supplement, the regressions and the negative reactions like that warm burning sensation indicates that you should not use the acid. So this is a great way to get started. Now just briefly regarding the evidence, we will put all the references in the transcript associated with this post and I would encourage you, if you're at all skeptical to look at those, I try to be very cautious in the statements that I make. Everything that we've covered here is supported by a good level of evidence. And so this is important for the hypothyroid patient who is suffering with symptoms, mainly to consider taking some work to improve your gut health before going further down the road of trying to optimize your thyroid hormone levels. And this is the real proverbial fork in the row that I think needs to be changed in care today. It seems that many patients are being pushed to run these elaborate thyroid assays and try to tweak and change their medication prematurely instead of going to cleaning up a problem in the gut first. There's a time and a place for both but if we want to have the most logical sequence of interventions, first start on a thyroid hormone medication and attempt to get your thyroid hormone levels in the normal lab range, not the functional medicine ranges that are very, very narrow, but in the normal lab ranges. This gets you in the ballpark. If you're not feeling well there, then do some work to improve your gut health. And if your symptoms clear, it tells you the symptoms were not because of this need for fine tuning your hormones, but rather your symptoms were coming from the inflammation and other imbalances in your gut. But if after taking some steps to improve your gut health, you're not feeling better, then move to try to fine tune the levels of your thyroid hormone medication. Of course, all along the while here, keep your doctor in the loop, but also be cautious not to be too quickly pushed into going down this what I found to be oftentimes unfruitful road of really dialing in your thyroid hormone levels, doing a free T3 or a reverse T3 considering adding in with, let's say, Li-Both-Iroxin, Cytomel, or just going from Synthroid to a combination therapy like Armour. So that's important to really understand that because I've seen a number of patients here in the clinic that have gone down that road and not really gotten anywhere. And we've actually published three case studies in our clinician's newsletter in the past two months documenting this. And when they finally took some steps to improve their gut health, all the symptoms they thought were being driven by their thyroid went away. So I share this hopefully in attempts to prevent a thyroid patient from going down an unfruitful road. Again, there's a time and a place for both these interventions. For optimizing or trying to fine tailor your thyroid hormone medication and for optimizing your gut health, I would put the optimization of your gut health first and then consider the fine tuning. Oftentimes you don't need to fine tune once you've improved the health of your gut. So kind of in close here, there's this cascade. When you're hypothyroid, you have lower stomach acid, at least 30% chance of lower stomach acid, and that lower stomach acid has been shown to increase the prevalence of SIBO. Now there is good news that SIBO can be simply and safely and without need for testing rectified by the use of probiotics and then as a preventative guard to decrease the probability that SIBO will return, you can use stomach acid to improve your digestion, prevent anemias and help to supplement with what your body, your stomach may not be making enough of, which is your stomach acid. So hopefully this helps to dispel some confusion and give you a few actionables to try to get to the root cause of where your symptoms are coming from if you're hypothyroid and you're floundering with what to do. So this is Dr. Urshio and I hope this helps you get healthy and get back to your life.