This conversation between Dr. J and Dr. Eric Belcavage explores thyroid health, focusing on Hashimoto’s and autoimmunity. Dr. Eric shares his personal and clinical journey, highlighting how functional medicine differs from conventional endocrinology.
Conventional care often manages thyroid hormone levels (TSH, free T4) with medication, overlooking immune dysfunction and root causes. Functional medicine, by contrast, investigates immune balance, inflammation, gut health, nutrient status, stress, and lifestyle.
Key insights include:
TSH alone can be misleading; full panels with T3, reverse T3, and immune markers give a clearer picture.
Hypothyroidism is often an adaptive, protective response to stress and inflammation.
Gut permeability, dysbiosis, and immune activation strongly influence thyroid autoimmunity.
Over-supplementation and excessive thyroid hormone can worsen dysfunction.
Foundational lifestyle factors are essential—diet, sleep, stress, hydration, and exercise balance.
Supplementation should be individualized (enzymes, magnesium, creatine, sulforaphane) rather than blanket protocols.
Iodine use should be personalized based on testing, not broad dosing.
Overall message: Restoring thyroid health requires a comprehensive, root-cause approach that integrates immune, gut, endocrine, and lifestyle factors—beyond medication alone.
Dr. Justin Marchegiani: [00:00:00] Hey guys, it's Dr. Justin Marjani. Welcome to the Beyond Wellness Radio podcast. Feel free and head over to justin health.com. We have all of our podcast transcriptions there, as well as video series on different health topics ranging from thyroid to hormones, ketogenic diets, and gluten. While you're there, you can also schedule a consult with myself, Dr.
Jay, and or our colleagues and staff to help dive into any pressing health issues you really wanna get to the root cause on. Again, if you enjoy the podcast, feel free and share the information with friends or family and enjoy the show. And we're live. It's Dr. Jay in the house with Dr. Eric Bell Cavi. I'm Dr.
Eric here. He's from Pennsylvania. He's a functional medicine doctor. Sees lots of patients in the areas of thyroid, gut health, functional medicine big area. So we're gonna dive in today into all these different topics here related to this. So excited to dive in. Dr. Eric, how you doing today?
Dr. Eric Balcavage: I'm doing fantastic.
Thanks for the invite.
Dr. Justin Marchegiani: Absolutely. And we put Dr. Eric's link in the description, so if you guys wanna reach out, see what he's up to, schedule a consultation, get more support from him, there'll be a link right in the description below here. [00:01:00] So feel free and check that out. So Dr. Eric excited, we connected.
I got a thyroid book out, thyroid reboot.com. It's my Amazon books out there. So I'm ex thyroid's a near and dear topic to me. I have autoimmune thyroid, Hashimoto, so I had to become an expert from my own self to really get to the root cause. Tell me about how you got into the thyroid area of functional medicine.
Is an area close to you personally, or?
Dr. Eric Balcavage: It is now. But I didn't get into it initially because I had a thyroid condition. I got into it because somebody else got diagnosed with a thyroid condition and was told that, as a 28-year-old female, you have a thyroid, you have hypothyroidism, you've got iron deficiency and fibroids.
So we'll remove your we'll do a hysterectomy, we will put you on iron and we'll put you on thyroid medication and that's how we're gonna take care of it. And so I got a phone call that said, Hey, you gotta help fix this. And I was, my background was medical technology before I went to chiropractic school.
I had to f figure out how to help a family member. And that led me into studying functional [00:02:00] medicine, finding deis and studying under him. And then,
Dr. Justin Marchegiani: yep. Ian, you mean?
Dr. Eric Balcavage: Yeah,
Dr. Justin Marchegiani: Dr. Yep.
Dr. Eric Balcavage: And un fortunately or unfortunately through the process of helping everybody else, doing training and triathlon training and four hours of sleep a night and lots of work and doing things, one day I did my blood work just to see how healthy I was.
And turns out I've got, I had Hashimoto's and glucose resistance. And for you, you had it too as well? Wow. Absolutely. Yep. Wow. Okay. I had to look at myself and say. What the heck is going on? I think I'm doing everything right. When you take a deeper look sometimes it's these foundational things that we aren't doing as well.
And those are the things that trigger immune related disorders many times.
Dr. Justin Marchegiani: So when you first found out you had this issue with Hashimoto's, were you educated about functional medicine yet? Did you go to the conventional medical doctor endocrinologist yet?
Dr. Eric Balcavage: No, I was already 12 years into function.
Dr. Justin Marchegiani: So you already got it, so you already understood, okay.
I know what to do. Yeah, I know what areas, because I just find patients that go to their conventional [00:03:00] endocrinologist, they won't even look at those antibodies. And when they do, there's not really much they do. They're not gonna put 'em on biologics or steroids. It's, those medications are too strong and have potential side effects.
So conventional medicine doesn't even really acknowledge that. And just curious your take on why that is.
Dr. Eric Balcavage: I think it's, they have a different job than we do. They're trained to provide thyroid medication. Once the gland has become dysfunctional, it can't produce sufficient thyroid hormone anymore.
And so they don't. They, I'm, most of them assume what? We assume that it's an immune driven condition. We are not gonna treat the immune system. Our job is not to identify what it is. Correct. Our job is to manage the disease. So we, Azure two markers, TSH, free T four. If TSH is high and free, T four is low, we provide T four and their job is to manage TSH.
It's a different job. There's a lot of people that are unhappy in that model, but we can't, that's their job, that's their model, that's their training. And so in the beginning I was like, why wouldn't [00:04:00] they look at all this stuff? But I soften at the longer you're in it, after 30 years, you go, ah, this is their job.
I got a different job than they do. I evaluate things differently. My job is to help somebody recover from a thyroid condition, not manage their tsh and T four.
Dr. Justin Marchegiani: I think a lot of patients, they come in, they think my medical doctor went to Harvard, went here. They must have access to all of the cutting edge information, right?
So if they didn't tell me about the things that you're telling me, it must not have been important. I think people can deduce, or let's just say push some of this functional information out because they just think if it was important, I would've got it. And I think a lot of conventional medical doctors, at least early on, feel that way too, of oh functional medicine.
If I didn't get it in medical school, then it must not have been important. Thoughts on that?
Dr. Eric Balcavage: You unfortunately, what's often taught in medical school is what's in. In the books, right? Yeah. And so what's in the books is what was valid, maybe a decade or two decades ago. Yep. And not what's the cutting edge research, it takes about 10 years for today's [00:05:00] research and findings to actually make it into a textbook and potentially even longer.
Dr. Justin Marchegiani: I think.
Dr. Eric Balcavage: Yeah. So yeah, the endocrinologist is trained in a certain way and they're taught a certain model and they're so busy doing management that they're many times don't have the time to dig in deeper or have the time to really dig into what the most recent valid research is to explain what's going on.
Dr. Justin Marchegiani: Yeah. And I think also too is you have allopathic medicine being very focused on pathophysiology. They're focused on the disease and then managing the symptoms of the disease. And when you see a functional medicine doctor person, they're looking at underlying physiology. They're looking at where it's not functioning well and what we can do to upregulate physiology.
Those are two different things. That's, I said there're two jobs. Yeah, they're two different jobs. And I tell patients outta the gate, I'm not anti-medicine, I'm just pro root cause. And a lot of times if you focus on the underlying, if you focus on treating the symptoms, it's very easy to ignore the underlying root [00:06:00] cause.
Case in point, I bang my head against the wall every day, but I take ibuprofen to cover up the symptom, the root causes, I'm banging my head against the wall. So you wanna look deep at that and that any functional medicine issue has some kind of chronic inflammatory, maybe even an autoimmune issue.
The guts at play, nutrients are at play, detoxes at play. If you ignore any of those things and just provide the drug that inhibits whatever that pathway is to control the symptom, that underlying cause just gets bigger and worse over, over each year.
Dr. Eric Balcavage: Oh yeah. I totally agree with that.
But again, we have a different job. You've got, you're going into an allopathic physician's office. You have maybe 10 to 15 minutes that you're gonna spend with that physician
Dr. Justin Marchegiani: if that,
Dr. Eric Balcavage: And what they're going to do is they're oftentimes just gonna say, what are your symptoms? Here's what I can give you to manage that.
If there's labs, and I don't, I'm not in every doctor's office, but I would venture a guess that a lot of physicians don't even actually look at the labs.
Dr. Justin Marchegiani: Correct.
Dr. Eric Balcavage: Their staff person says, Hey, everything looks good. They walk into the room, labs look good. What do you, how do you [00:07:00] feeling? Oh, you got, okay.
They say, you got high blood pressure. Your, everything else looks good. So you're healthy. We'll just give you a blood pressure medication. See you and that's it. Come back's it. But that's, unfortunately, that's the model. That's why we have a healthcare or disease care crisis Correct. In this country.
And correct the solution for us. And at least when I got into functional medicine and left allopathic medicine and came more to, chiropractic and functional medicine, I was more angry. 'cause I was angry at what I left because of my health conditions at the time. And functional medicine changed it.
So you have anger towards the other profession and it makes us a bit jaded and hard to work with the other side. But they're all good people, essentially. Just like we're all good people. We just have different jobs. And really what we need to do is learn how to communicate together for the benefit of the patient and say, Hey, that's your job.
This is my job. Let's work together. If we need meds to manage a sign or symptom or condition, we'll send them back to you. But o [00:08:00] otherwise we're gonna try and if the patient wants re restorative, recover of care, functional medicine care, send 'em to us. And let's work together to try and get the patient better.
Dr. Justin Marchegiani: I do find most patients that are seeing with me, but they're still working with a medical doctor, there's a genuine. Lack of curiosity on the medical doctor side, when patients I work with get better, I find that, and I think part of that is maybe they feel hamstrung because of the standard of care.
People don't understand. But your conventional doctor has a standard of care they have to work in. And if they don't, they, their medical board can sanction them. Maybe insurance won't cover them. And so there is that component there. But I find the genuine lack of curiosity, I see that a lot where patients get better.
I'm like, so what does your MD say about that? What does your endo say? No, nothing. I'm like, and I've asked that question hundreds of times in my 15 year career, and that's just been a commonality. Every now and then you see doctors that step up and those are the MDs that are like, Hey, I've been in this field 10, 20 years.
I'm gonna go get functional medicine training. I'm curious. I'm stuck because I know this patient isn't getting better by just throwing them on Synthroid. Yeah, their [00:09:00] TSH is better. That's a good thing. Good check in that column. But they still have all these issues and now I'm referring them out for a psych eval, antidepressants, or just saying, Hey, they're aging.
Now what?
Dr. Eric Balcavage: Yeah. I think a lot of clinicians are just too busy. They don't know what's going on. Yeah. Many of the clients that are turning to functional medicine are probably some of their hardest, most difficult, problematic patients. Yeah. 'cause they're not getting well in that model and they're getting edgy and anxious, I would say.
When maybe I'm in, in this 30 years at this point, so maybe 20 years ago, I used to get more pushback and shoved back from clinicians when they realized I was working with their clients. I really don't see it too much. Many times I'll have the clinicians actually join us on a discussion because I'm explaining to the CL client and the clinician, Hey, the patient's inappropriately medicated, here's why.
Based on the labs, and walk them through an interpretation of labs, which is totally different than what they're used to. They're used to reading labs for HRL on a lab report, not interpreting labs. [00:10:00] And so when you say, Hey, look, here's why this is inappropriate. Their TSH is normal, but it's suppressed by inflammatory markers.
You didn't, you weren't able to run the inflammatory markers. I did, and because I ran the inflammatory markers, we know two things. The TSH is normal, but it's. Inappropriately normal for the person sitting in front of us. The patient has hypothyroid signs and symptoms, and when we run a more complete panel, which again, your guidelines don't allow you to run, you can see that their TSH is normal and their T four is normal, but their T three is low or their T four is low or their, and their conversions poor and maybe the reverse T three is elevated and they have.
They don't need more thyroid medication in this situation, but they have a thyroid condition. It's not glandular yet, but it's a conversion issue, a tissue issue, and the patient is complaining. They're not nuts. They're not crazy. They don't need anxiety medication or depre or antidepressants. What they need is a strategy to identify why they [00:11:00] can't convert to T four to T three.
And have low T three in their cells and tissues. And if we address that, we may prevent them from having the gland issue to begin with. If they're on medication, lay out why they're, it's too much medication in a certain situation.
Dr. Justin Marchegiani: Okay. So let's talk about that. I see most conventional docs tend to always, under underdose, that's been the general thing I've seen where their TSH may get back, below two and a half or two or one, but, T four, T three downstream's all low, or they're not using a full spectrum glandular like an armor or an NP or a wp.
So when you talked about the inflammatory mediators suppressing the TAs, are you talking about antibodies? Are you talking about different interleukins or cytokines? What are you referring to more? Can you go more deep into that?
Dr. Eric Balcavage: Sure. So when you have inflammatory mechanisms going on, and that can be you on a general blood chemistry panel, you could look for things like CRP and homocysteine and elevated ferritin.
Yep. And fibrinogen and uric acid. Yep. As indicators of inflammatory states, if we run immune panels, especially in a patient who's got an immune driven, or we believe has an immune driven [00:12:00] condition like thyroiditis, we can look at the th one, th 17 elevations or changes in those types of cell populations.
And we know they're gonna release cytokines, and they're probably, especially th one and th 17 are gonna produce a bunch of cytokines that are gonna influence the peripheral conversion of T four to T three.
Dr. Justin Marchegiani: Got it. So you're looking at some of these immune markers, e cytokines, interleukin immune markers, like general like Quest lab, LabCorp kind of panels?
Dr. Eric Balcavage: Typically I, if we're gonna do immune panels I'm looking at typically, like Cyrex Labs is for their Cyrex immune panels. I think they're probably one of the premier immune testing sites lab. So you're looking at the
Dr. Justin Marchegiani: general th two balance with those interleukins on each side, cytokine side.
If ones you're looking at,
Dr. Eric Balcavage: You're looking at what the lymphocyte T cell population and natural killer cell populations are. And, if th one level is elevated, that's gonna be more pro-inflammatory. If it's th two is probably gonna, it may be more anti-inflammatory and maybe more more antibody producing.
On, on that client, on the
Dr. Justin Marchegiani: th two, [00:13:00] do you see more th one dominance with Hashimoto's or more th two
Dr. Eric Balcavage: Oh, TH one.
Dr. Justin Marchegiani: Yeah. Yeah.
Dr. Eric Balcavage: More tho those clients tend to be more th one, you'll see more th 17 elevations, especially in people who have mucus membrane inflammatory mechanisms going on. And the cells that tend to, especially based on the cy on the literature, it's the CD eight cells, cytotoxic CD eight cells that likely create most of the damage. A lot of times we talk about antibodies and how important they are. They're really not as important as everybody makes them out to be. They are an indication that there's an, that there's potentially thyroiditis, but a lot of people have thyroiditis.
No antibodies, but they're th one, maybe th 17 dominant, and they're not gonna produce as much antibodies.
Dr. Justin Marchegiani: Yeah. About 10% will be seronegative. Then you may see it with these cytokine markers being outta whack. You may see it with an ultrasound with just inflammation. The thyroid's inflamed, but they're not making an antibody to it.
Dr. Eric Balcavage: Yeah. I'd say even it's probably way [00:14:00] higher than that. But we don't, we're probably not evaluating everybody's lymphocytes.
So we're in we're evaluating a very small population of people with a, like a t-cell pattern and what's going on. So yeah, maybe in the, they may be running those types of panels in a conventional model on patients who are really struggling.
But I've, in, since the Cy Cyrex lymphocyte panels come out, I've, I don't know how many, I've done tons of these tasks and. The vast majority, say 80% of the people that come to me with thyroiditis, whether they've been diagnosed or not diagnosed with Hashimoto's at some point or another are th one, TH 17 or CD eight dominant, or a combination, not th two.
Dr. Justin Marchegiani: Yeah. So you have that CD four to CD eight ratio. And so typically it's the CD eight dropping, right? That CD eight, the CD four ratio. It's the CD eight dropping.
Dr. Eric Balcavage: No. If they have the CD eight cytotoxic, CD eight cells, if they're [00:15:00] elevated, those CD eight cells are what are gonna.
Infiltrate the lymph, all these cells can infiltrate the thyroid, g thyroid gland themselves, but those CD eight cells are going to are gonna be binding to tissue to the cells and then releasing their granules and destroying the cells. But not always CD eight positive, but usually it's a rise in the CD eight cells in many cases.
Dr. Justin Marchegiani: And then what about that conversation you had with the doctor? So you had the conversation about all these inflammatory compounds you talked about the CRP, the ferritin, you talked about these interleukins and cytokine panels and homocysteine. So how did the conversation go? Were they receptive?
What was the next step?
Dr. Eric Balcavage: Yeah, I, I have, I, most of the clinicians that get on, maybe there's a little bit of a little bit of why, I don't understand why you would say this. I've normalized the TSH. Why do you think it's different? And when you open up the panel and show 'em more and show you some of these things and then you say.
And our client is frustrated. They [00:16:00] don't feel well, they don't function well. And based on my research and what I've been doing for the last 30 years, here's the recommendation and my suggestion is we make this change, retest the patient. In 30 days, we'll run a thyroid panel, a lipid panel, just to make sure that not only do we see a positive change in the lip, in the thyroid panel, and there are signs and symptoms, but we also see at least one tissue indicator of a positive change in thyroid physiology.
And if the, if this, if the change was inappropriate, we go back to what you were doing. If it's not inappropriate and the patient's feeling better and the labs show it's better, then we'll continue to work through this process. And that's usually, they're like, all right, we'll give it one shot. And then once it, once we give the one shot, they're like, huh.
Yeah. They're feeling better. They're functioning better, and okay, what El what else do you need? And that conversation keeps going.
Dr. Justin Marchegiani: That makes sense. What other factors can impact TSH? So obviously if you have low thyroid hormone because your gland has been beaten up by your immune [00:17:00] system, that's a thing, right?
You have to address that because that tissue over time can lose its functionality in producing thyroid hormone. Other things like cortisol and other nutrients and blood sugar and insulin. What are the big factors that when you see this TSH looking normal, but we have downstream lower T four or low T four to T three conversion, right?
T four being more inactive. T three being more active, what are the big things that you see clinically that are the big barriers?
Dr. Eric Balcavage: Yeah. The biggest things that are gonna create a inappropriately normal TSH is excessive stress on somebody's physiology, number one, right? And so when we think about excessive stress, we think physical stress, chemical stress, emotional stress, microbial stress mindset, like the whole load.
Once somebody starts to have an excessive level of stress on their physiology changes from homeostatic regulation to allostatic regulation that triggers cell defense mechanisms, inflammatory mechanisms. We're gonna get an increased conversion of T four to T three at the [00:18:00] hypothalamus, and that's gonna start to lower TSH inappropriately in many cases.
Because the t as the TSH drops, we're gonna see a reduced T four and T three production, and that's gonna translate to symptomatology, is the argument is. Is that normal? Is it appropriate or is it inappropriate? Is it abnormal? Is the person broken? I think it's inappropriate response to somebody who's under a more acute or chronic stress response.
If you look at things like the cell danger response, when somebody's feeling threat and danger and or the level of stress on their physiology exceeds their capacity to make energy, to manage that and everything else they need to do, physiology shifts. We get a downregulation of the conversion of T four to T three and the cells to slow down the less important systems in the bo, in the cells, the tissues in the body, and a shift in energy to ramp up the cell defense mechanisms.
And part of that is to wire the [00:19:00] brain, increase flow to muscles and tissues correct and downregulate digestion, di downregulate, sex hormone regulation, detox, and all these other things. So early on that stress response will suppress. Tsh, and this is even somebody who's right, not on a medication or anything, but I would say that's the primary thing.
That's probably driving a low or inappropriately normal tsh. When somebody has hypothyroid signs and symptoms.
Dr. Justin Marchegiani: Yeah, I would agree. That's why you see lots of studies with astrada being helpful 'cause it regulates some of that stress response. But when you look at some of the people that come in, what are the big stressors?
You're starting with food, are you starting with just emotional stress? What does that intake look like and how do you prioritize the stressors that the patient's showing for?
Dr. Eric Balcavage: Yeah, so it, it's a great question because that's, to me it's not sexy. Everybody really wants the magic supplement and the magic goes to thyroid medication that's gonna fix them and it [00:20:00] doesn't exist.
If. If it did, they probably wouldn't come to see me. They probably wouldn't come to see you. They'd, yeah, they'd get a, the dose of T four, they'd have great conversion of T four to T three and they'd be happy. They just, so it doesn't happen a lot. But I initially, I'll, I have patients in my book, the thyroid debacle, we talked about 10 different of what I call fitness factors, different aspects of somebody's life that can either help them be healthy or contribute to some of their stress load.
So we talk about dietary fitness, sleep, fitness, respiration, fitness emotional fitness.
Dr. Justin Marchegiani: Yeah,
Dr. Eric Balcavage: habitual fitness. And I've since expanded that to about 18 different aspects. So I'll have patients kind. Complete that questionnaire at the start. 'cause what I wanna know is what are the biggest influencers that, at least today, they're willing to admit, are contributing to the excessive stress load?
And as not everybody's willing to admit their deepest, darkest elephant in the room that's contributing to their biggest stress load. Sometimes it's their [00:21:00] relationship with their spouse, their family, their kids, their work. But those are the things that we need to take a look at. And so oftentimes I'll take a look at that and say, okay, here there's my, the foundational things that are important, and then these are the other things that we need to work on.
But the big things mindset's huge, especially anybody who's been chronically ill, if they're telling themselves on a regular basis, I'm sick, I'm unhealthy, I don't feel good, I'll never get over this. My body's attacking me. It's gonna be hard to get them better. So mindset's important. Physical fitness is one of my foundational dietary fitness is one of those diet, foundational sleep and their habits.
Like what is this person doing from the time they get up to the time they go to bed every day? And how is that helping the, either improving their health and wellbeing or sabotaging their health and wellbeing. So I look at all those aspects, the five foundational things first. And then I look at their overall chemistry that I have available and say, okay, based on what's going on here, we gotta work on these diet, [00:22:00] lifestyle, and fitness factors.
And at the same time, we've got, here's all the systems. And I think what's important for me to explain to them is. The state they're in. You think you're, you don't know these two states, but there's homeostasis, allostasis. You may think that you, it don't, we only run in one system, so I'm gonna heal if you just gimme that.
Supplement's gonna work the way I want it to. But supplements that we take, the medications we take work differently based on the state we're in. So I need that person to understand. A, that they're not broken. Their immune system's not trying to kill them. It didn't wake up one day and forget that their body was theirs.
Instead, the body's trying to protect them from something and it's, and a perception of fear or danger. And it's e, it's in this fitness factor load that we have to address. And then here's all the systems that are becoming dysfunctional as a result of being in this chronic stress mode. The adrenals are being down, regulate, detox is being down, guts, being downregulated, sleep.
And so those are the things we [00:23:00] need to support to help recover. And there's a strategic way to do that, as you probably well know.
Dr. Justin Marchegiani: Yeah. When I see patients, you mentioned it earlier, like the, Hey, isn't that sexy? I tell patients, Hey, we're gonna build this beautiful mansion for you, but we're gonna start off just grading the land and digging a big hole and putting some concrete in and calling it a foundation.
It's not that sexy. We're not building the swimming pool or the master bedroom yet, but we're starting there. 'cause everything that sits on that has to be on solid ground. So yeah. On that.
Dr. Eric Balcavage: I think that, that's where we need to start.
Dr. Justin Marchegiani: Yeah.
Dr. Eric Balcavage: And unfortunately, depending on how, where somebody's come from, if have they, if they've come from an allopathic model and they don't know really what functional medicine is, they're, we have to almost retrain them.
This is, I know if there was a pill for every ill in that model, that's not necessarily what we do over here we have to address the root causes and deal with the foundational things that are you're going ha to have to do no matter what. If you want to, if you want to get healthy and recover.
Dr. Justin Marchegiani: Yeah.
Dr. Eric Balcavage: If they've come and we see this, [00:24:00] I, this is, my perception is I think it's great that a lot of people are coming to functional medicine, especially from an allopathic, medicine model. The problem is they're bringing their philosophy with them and that dilutes what we do in functional medicine.
We've gotta do a better job guarding the gate. We can. It's great that more people come to functional medicine, right? But what functional medicine isn't is a pill for every ill, but we just use a different pill we call a supplement, right? That is not functional medicine. So I think you're right.
What we do when we really, truly do functional medicine is we have to be engaged with the client to help them understand. It's what you want is not gonna be felt found in a bottle or a pill or a capsule. It's gonna be found in helping you improve diet, lifestyle, behavior patterns, and using those supplemental support to, IM to get you to health faster.
But it's not, the [00:25:00] supplementation isn't the tool. It's a tool. And it's a support tool, not a primary tool.
Dr. Justin Marchegiani: Correct. Yeah. When I see patients outta the gate, the first thing we look at is we're looking at their food, right? We wanna make sure the nutrient density is there. We wanna make sure anti-inflammatory fatty acids, we wanna make sure.
They're stabilizing their blood sugar, we're not on this blood sugar rollercoaster. 'cause that can be a big thing that throws off the immune system too. But conventional medicine doesn't really acknowledge diet as an issue. They write off nutrition by just, Hey, if you count calories and the calories are good, that's fine, but it looks not at the inflammation or the nutrition part of it.
And so I find that as a big pattern too. And then also we have foods that can throw off the immune system. Most people know about gluten and its impacts on Hashimoto's and maybe dairy. What are some other foundational things that patients coming in that first intake that you see? Maybe it's the same thing.
What other things like that are throwing patients off from a dietary standpoint? Yeah. Diet or just the foundational things that you see outta the gate that are glaring. Maybe it's sleep, maybe it's too much exercise. Maybe it's too sedentary. Yeah. What else do you [00:26:00] see?
Dr. Eric Balcavage: I think it, it definitely goes back to those foundational five things.
A lot of people, because they don't feel well and function well aren't doing anything physically, they're not moving on a, it's a consistent basis, and that has such a negative impact on it. The other part is that, and we see this a lot in functional medicine, the person who's trying to optimize everything, they're trying to biohack everything.
They're the athlete. This, and it's, what happened to me is that we do excessive amounts of e exercise. Sure. With limited amount of recovery, and we train in our forties or fifties like we are. In our twenties, like we still have the same recovery capacity. And a lot of the patients, it's, they're on one end of the spectrum.
They're either not doing anything and we gotta get them moving 'cause that'll help so much their gut biome. It'll help with glucose regulation, it'll help them with sleep, it'll help them with detoxification pathways, moving lymph, or we have the other extreme where the person is excessively exercising many times [00:27:00] under colorizing.
'cause their me metabolism's being compromised. And they are they think that the solution is just to do more instead of realizing what they really need to do. Is actually calm down and do last and that's a shame. Sleep critically important. And when you don't feel good, you don't function good.
It's probably hard to sleep. And what do you do? You wind up getting on Instagram, social media, this stuff and spend countless hours looking at how awesome everybody else's life is and not yours. And then you start internalizing that. And that in itself creates some challenges with sleep and behavior mindset's key.
As we said before, you've gotta believe you can get healthy. And I think one of the worst things we do, especially with people with thyroid conditions, is tell them that your immune system's attacking you. That's a terrible thing to tell somebody. Because if their immune system's outta control and it's attacking them, that sounds like a no win situation.
So instead we need to change that, [00:28:00] turn that. That discussion with somebody and say, listen, your body's not broken. Your body didn't forget how to convert T four to T three. Didn't forget how to regulate your guts or your gut or your hormones. It's just not the priority right now. The priority is protection and the pro, the priority is defense.
And so we've gotta identify and address whatever the body is trying to defend you from. And if we don't wanna do that, if we don't do that, everything we do is a management strategy and has a limited benefits.
Dr. Justin Marchegiani: So we get the fight or flight response better. Maybe we're looking at the adrenals, maybe we're making some diet and lifestyle change.
What are some of the big things, big factors that patients are doing or not doing that is exacerbating their autoimmunity? Increasing their antibodies?
Dr. Eric Balcavage: I would say besides those first things we talked about, I mean from a dietary standpoint
Dr. Justin Marchegiani: big foods, big toxins big things in the gut, anything specific that you see that just come to the top of your head.
Dr. Eric Balcavage: I from my patient base I think the biggest [00:29:00] thing a lot of people doing that's prob that's problematic is they're excessive.
They're taking way too much supplementation. And they are trying, or they've been taught that if they optimize their T three levels with T three medication that they are, or they optimize their sex hormones with hormone replacement therapy, that's going to fix them. So they are overloaded in supplementation.
I think a lot of the clients that come to see me, they're doing a pretty good job with eating a cleaner, low processed food diet. I think most of them are doing a pretty good job from a environmental toxicity standpoint. I think what the biggest challenge I see is that people are way over supplemented and they're way overmedicated.
Those are the two biggest things I see hands down.
Dr. Justin Marchegiani: Yeah. When I get patients in, out of the gate, the first thing I focus on with patients, I focus on hydration, electrolytes, and just helping them to digest their food. That's the foundation for me. I work on that. And then we're making diet and lifestyle [00:30:00] changes, so I do agree.
See patients come in with 10, 20 different things. It's like, where do you start? And then it's this pressure of like, all right, this person was like drawing this picture. Take over with their colors, their supplements, their protocol and finish the picture, right? It's no.
We're gonna start with this blank slate and we're gonna build up slowly. Thoughts on that?
Dr. Eric Balcavage: Oh yeah. It is part of my dietary fitness process. We talk about sitting down to eat, chewing your food, right? When to drink, what not to drink. Hydration fitness is a piece of it. So that's all a piece of it.
But a lot of people do come to us because they've probably been to six functional medicine practitioners already by the time they get to me. And they've already got a list of 25, 30. 40 bottles of supplements they're taking and they want to know what's the one thing I'm missing? And usually the first strategy is we're gonna go back to foundational basics.
I want you on a whole food-based diet, low processed food diet. Obviously we wanna see what they're doing and what's currently work. 'cause they probably have some input to give, but we wanna make sure that's there. We [00:31:00] wanna make sure calories and macros are balanced for what their burn rate is and their metabolism.
But we also I, usually I'm like, okay, the, one of the first things we gotta do is eliminate your supplementation. And that's it. Sometimes, for some people that's an easy thing to do. They're like, okay, I'll quit tomorrow because I don't know if I'm noticing a change. And then other people are fearful that if they reduce or eliminate their supplements, they're gonna get worse.
And usually my discussion is, if you need 30 supplements to feel this terrible, you don't need any of them. So let's start from, let's start from zero and make a, let's do supplementation as a strategic strategy, a few things at a time, see how they work, and then eliminate them. And then layer things in versus let's just add.
I think the, my, the record patient that came to see me so far was 140 capsules a day, plus lotions and powders.
Dr. Justin Marchegiani: Oh my God.
Dr. Eric Balcavage: How do you have time to. More room to eat. [00:32:00] Yeah. Yeah. And the cost, I think that was one of the things that the spouse was most happy about was the amount of money they saved just in monthly supplementation.
Dr. Justin Marchegiani: Wow. Wow. Good points on that. So a couple of questions for you on that. You hit a couple of points I wanna nail. So when you see patients coming in, I know it's gonna be individualized, you're gonna do a workup, you're gonna look at patients as an individual, you're gonna dial them in. What are some of the big supplements or nutrients that you find patients benefiting from?
And again, I get it, just because you're listening doesn't mean you take it. What do you find Things that people are missing and that help move the needle or help push the physiology in a better direction? So top three. And then I wanna know why you think it's helpful.
Dr. Eric Balcavage: If I had to give somebody like some starting things that may be important I would say.
As a general foundational thing, a digestive enzyme for most of our clients is gonna be, yeah, really important. And typically I'm leaning towards something with a little bit higher lipase in the [00:33:00] vast majority because yeah, they've got fat mal absorption issues and we want to help them digest their food.
If you're in this cell stress, your parasympathetics are downregulated, you're not making stomach acid digestive enzymes, right? Bile flows compromised. So we need to help them digest their food better. So that's number one. Number two, if I had to give a general overview is something to help manage but not suppress inflammation.
'cause inflammation in itself isn't bad. So that could be a, depending on the individual, maybe something like a systemic enzyme to help break down inflammatory, some of this inflammatory stuff a little bit faster. And then I'm a huge fan of. Creatine as a tool. To help with energy production, we have to keep in mind that when somebody's undersell stress, if they have reduced T four to T three conversion, their mitochondrial function is not gone.
It's downregulated, it's part of the adaptive response, but their prob, it takes a lot of [00:34:00] energy to make phosphate donors make creatine so that we have phosphate donors for. A TP to make energy. And so creatine is one of those things that we can take that can provide the phosphate donors for somebody who doesn't make them well, that can give them a little bit more energy boost.
And help them feel a little bit better. And there's very limited downside. And the plus side is because it's so energy dependent. 40% of methylation, I think, goes to make creatine. And so if we can give them an end product, creatine, that means they've got 40% more methylation that can go do so many other things in the body, versus giving them a bunch of B vitamins and methyl donors that they may not be able to tolerate to begin with.
And I'd say if there's one more I'm a huge fan of, for a lot of people with electrolytes and potentially some additional magnesium 'cause chronic stress and many of these people, because they don't make good energy. [00:35:00] They have cellular dehydration. They wind up drinking excessive amount of water many times and just peeing that out in minerals and magnesium back out.
So those would be the, those would be the things. I think I cheated and gave you four versus, yeah, three.
Dr. Justin Marchegiani: So we had what the enzymes, we had magnesium, we had creatine and was it an anti-inflammatory? Was one of them?
Dr. Eric Balcavage: Yeah. So we said digestive. Yeah, you could do something that's gonna be some, something that's gonna manage the inflammatory response.
So it could be sulforaphane, which I'm a big fan of. It could be it could be just a systemic enzyme for somebody who's got chronic, like Isha Pap today or Lumbo kinase. Or kinase, yeah. Yep.
Dr. Justin Marchegiani: Nattokinase. Yeah. Yep. And you mentioned the the creatinine. I like that. ‘Cause you're boosting a TP production.
You get it from protein. There's a lot in protein, but. If you're having a hard time breaking down protein plus like the amount of, 10 grams of creatine, it would take I think, dozens of pounds of meat to get it. And so if you already have malabsorption, then you're supercharging, right?
All the phosphate donors that's gonna bump up a [00:36:00] TP, which is gonna help cognitive mental fatigue, it's gonna help your cells stay hydrated better. 'cause creatine pulls water into the tissue too. I like that. That's really good.
Dr. Eric Balcavage: Yeah. So foundationally, those are things, but then a after that, like everything is, as is probably well know.
It's who's sitting in front of me. I don't have a traditional oh, I do this for 30 days. That for 30 days this for 30 days. That's, you do that when you're starting off in, in functional medicine. You go to a conference and you learn, oh, here's the 30 day gut protocol. You do this, then you do the 30 day detox protocol.
Then you do this. That's great for everybody to learn and to start. But once you're into this for a number of years, you go okay, I. We're not protocol based. We wanna look at the big picture. What's the mechanisms or what are the support products I can provide that are gonna create the biggest bang for the person's buck
Dr. Justin Marchegiani: like that?
Very good. So a couple other questions here before we wrap things up. What do you see in regards to the gut impacting things? We know 80% of the immune cells are in the gut. Gut permeability or leaky gut, so to speak, can be a big driver. Conventional medicine has rejected that [00:37:00] thought process for a long time, but people are starting to come around to that more.
There's lots of research on zonulin and SIBO and the intersite and all the gut permeability things. Where think the gut plugs in and how important of it is a factor in addressing chronic thyroid issue. 'cause people think this is a thyroid issue. How does my gut play a role?
Dr. Eric Balcavage: Yeah, the gut plays a massive role because there is if there's dysbiosis in the bowel, if there's inflammation in the bowel if there's permeability in the GI tract, even if there isn't permeability, there's a direct lymph connection from the GI tract to the thyroid tissue.
So you can definitely have issues going on when there's dysbiosis, when there's inflammation, when there's tissue damage, there's release of what we call damps danger associated molecular peptides, PAMs pathogen associated molecular peptides that get into circulation, that activate the immune system. But it is, there is, there are.
What they call pattern recognition receptors on immune cells that allow them to say, oh, that's the thing we need to go [00:38:00] get. Okay, I'm activated. Let me go kill that thing. Oh, that's the tissue that's getting damaged. Let me go clean that up or go to that tissue. But it's interesting and through my research of trying to figure out what we might be missing from this thyroid perspective, 'cause I was really struggling with the idea that the thyroid, that the immune system just attacked the thyroid gland willy-nilly.
Oh, it's just going there and destroying it for no reason, didn't make sense. And it doesn't make sense for why it's easy to get people better. But the thyroid cells themselves have these receptors for damage associated molecular peptides and pathogen and associated molecular peptides.
So when these danger particles are higher in the in circulation and they get to the thyroid gland. The literature seems to show now that can actually activate the thyroiditis and trigger the damage to the thyroid gland. And so what's the name of
Dr. Justin Marchegiani: those peptides again? So these peptides are on the thyroid, and when they get damaged, it triggers, they're that again,
Dr. Eric Balcavage: they're called pattern recognition.
Receptors are toll-like [00:39:00] receptors as you Oh
Dr. Justin Marchegiani: yeah. I know total you're talking about in the gut right now.
Dr. Eric Balcavage: No. On the thyroid gland, so if you had Oh, okay. Because I know
Dr. Justin Marchegiani: they're in the gut too. I know they play a big role with gut probability. Yeah.
Dr. Eric Balcavage: They're, but they're actually, they're on immune cells.
Okay. They're, but they're actually on thyroid cells as well. Okay. And once they bind, then you get the change in the histocompatibility complexes, you get activation and release of, in, of the thyroid cells themselves actually become immune like and release inflammatory molecules that actually activates the local T cells.
So takes these innate, naive T cells and turns them into active T cells and releases chemo tax and said, actually attract more lymphocytes into the thyroid gland that triggers the damage. So when you've got issues. Inflammation occurs that affects everything. Creates systemic changes as it starts to get more complex.
That starts to change conversion of T four to T three 'cause it impacts the dease, the things that [00:40:00] convert T four to T three or deact or increase the deactivation. Those inflammatory molecules can also trigger the changes up in the brain where we get increased conversion of T four to T three and upregulate the sympathetic nervous system further dysregulating the gut and then we get a cascade of changes.
So the gut plays a massive role. In triggering thyroiditis, it can play a massive role in the conversion or lack of conversion of T four to T three, and it can be the thing that continues to ignite immune dysregulation that not only causes thyroiditis, but creates a whole host of other immune conditions as well.
So those two, those things are tied and with anything in functional medicine. We learn in a very linear model, like this is the GI track by itself. We silo all the different organ systems. Yeah, it's the biggest problem. But the difference for anybody listening between allopathic medicine, functional medicine is I have to know when I look at a [00:41:00] thyroid panel, I don't wanna just look at your thyroid panel.
I wanna look at everything else at the same time. 'cause I know that thyroid physiology is imp impacting your glucose regulation. I know it's impacting your liver function and your mitochondrial function in the liver. And then we know it's impacting your lipids and the ability to get lipids into your adrenal glands to make your sex hormones or into other tissues to make into hormones.
So we can't silo these things down. We have to look at the big picture. So if you have gut issues, it impacts thyroid physiology. Thyroid physiology or alteration of thyroid physiology eventually is gonna start to impact the system globally.
Dr. Justin Marchegiani: Yeah, it's the biggest reason why conventional medicines and have a hard time really being successful because they are isolated, right?
Allopathic medicine, they're all siloed into their individual systems. And if you're an endocrinologist and you're just looking at TSH or even T four, how do you fix the gut issue? Because technically you gotta refer that off to the gastroenterologist. Or how do you fix the brain fog? You gotta refer 'em off to the neurologist.
And what are they gonna do well about Gabapentin or you know what? What are they gonna recommend? They're
Dr. Eric Balcavage: Stuck, [00:42:00] I guess they would argue with you that they are successful. Look how busy we are. Look how many people we see. Look how much drug sales are up.
Dr. Justin Marchegiani: Yeah.
Dr. Eric Balcavage: So that is success. If you look at how much money is spent on medical care, right?
They, and how much money they make as an individual, how much the hospitals make, how much the pharmacies make made. That is success in that model. You're talking about a different model of, it's a different yardsticks, a different yard getting you're looking at, you're looking at not the patient, just being managed.
Into optimal ranges. ‘Cause somebody might say they have high blood pressure. I gave them one now two blood pressure medications. And they're I've, that's success. We would I think you would probably agree with me, that's not success from a health, that's not health success. That's disease management.
Yeah. That wouldn't be success in my book, but we have different yardsticks, different metrics that we're using.
Dr. Justin Marchegiani: But it's amazing though that metric will change. If you jumped in any of their Porsches with them and they had a check [00:43:00] engine light pop up and they were like, oh my god, my check engine light's on.
I'm like. Hey, here's some painter's tape right over that check engine light. Look, it's fine. It's gone. They'd be like no, I gotta go to the mechanic. That light means something deeper. I gotta look under the hood. It's now you understand what we're thinking about.
Dr. Eric Balcavage: Sure. Absolutely. Listen, I agree with you, but yeah, no, that's, but that's the, that's what we're, that's what we're dealing with.
And there's, I appreciate the good people
Dr. Justin Marchegiani: in that model. I appreciate you playing the devil's advocate. 'cause it's good for people to understand what people on both sides think. 'cause it's that contrast and thinking allows you to figure out, okay, where should I go? Where's the better fit for me?
So I like that. I think that's good. But I think we have to do that, right? We
Dr. Eric Balcavage: have to educate the patient, what is it that you want, right? If so, somebody came to me and they said, I just wanna, I just want my T three to be in what somebody says they, somebody told me that my free T three needs to be between four and five.
That's what I want it to be.
Okay. Is that all you? Is that what you want? Yeah. Great. Take T three. You can make it, get it there. But I don't feel good. I tried that. I don't feel good. [00:44:00] Okay.
Dr. Justin Marchegiani: Correct.
Dr. Eric Balcavage: Then what you want is to recover your thyroid physiology. Is that better answer?
Yeah, that's what I want. Okay. That's not about the medication as much as it is. What's causing you to have this chronic health issue to begin with, that's what we need to address. Oh, I don't wanna change diet lifestyle. I don't wanna I don't wanna do that. I just want my thyroid numbers to look good.
Then go see somebody who prescribes medication. 'cause that's what you're gonna need and you're gonna need to see a bunch of different people over time because the longer you don't fix the thing, and you said this right at the start, the longer you don't address the root cause issues, the bigger the problem gets.
'cause you're in this kind of allostatic regulation longer and more systems break down, more systems become dysfunctional. And but if the patient wants. Thyroid recovery and they can get it. If you have hypo, if you have Hashimoto's, you can recover your thyroid physiology. I've got places that do it all the time.
If you don't wanna, if you can wind up taking less medication and no medication in time. Your thyroid gland can recover for most [00:45:00] people, but you have to put, do the things and address the things that you need to raise your level of health to reduce the excessive stress so that the immune inflammatory process downregulates, the conversion improves, and then your gland can finally heal and recover.
Then your gut will heal and recover and you don't cut need chronic use of, gut repair powders. You don't need chronic use of adrenal support 'cause your adrenal physiology isn't under chronic constant stress and strain.
Dr. Justin Marchegiani: Very good. All good points. I like how you mentioned the toll-like receptors.
I think that's important, right? 'cause they're signaling or they're picking up the bacteria, the virus that dysbiosis. I think that's great. The danger signals. I like that. Is there any way you are actually assessing that? Are you looking at like just the TNF alpha or the interleukins that they may produce as a result of their signaling?
How are you assessing that? Or are you, is it more just philosophical?
Dr. Eric Balcavage: No, the I think the idea, that piece of it, that idea of it is in literature that, hey, [00:46:00] these things happen, but we can't really, we're not really me have a way to really d directly measure it. So it's more theore theoretical at this point that this can happen.
But we don't have, and the biggest way to look at it would
Dr. Justin Marchegiani: be, I think the biggest way to look at it would be they do produce TNF alpha and interleukin six. So if you ran an immune panel and you saw that higher, you could potentially surmise that. But I appreciate that. Anything you wanna add to that?
Dr. Eric Balcavage: No, it, and there's a, there are a lot of tests we can run to, but in my work and doing the research and, and thinking about what's happening with a lot of these clients and pulling a lot of the research together, you start to say, okay, how what are the mechanisms? And when you start to look at the literature and the research, that, hey, these are these, some of these things make way more sense.
And we have some documentation of this now as the science gets better, that hey, the thyroid cells themselves there's actually a paper that came out. 'cause it's been my belief that thyroid physiology is more of [00:47:00] adaptive response in most cases. And but there was nothing real, there wasn't a lot of stuff to, just, to necessarily, to justify.
Even Dr. Navio in his paper on the cell agent response, talked about all the other nutrients and what they do under low stress situations and what they do under high stress situations. And I said, you know what? You don't have thyroid physiology here. And at the time he's Eric, I don't I'm not a thyroid person.
I don't, I'm really, it's not really what I do. That led me down that path. And then you start to do more work and study the stuff. And then I was like, man, this is an adaptive response. And then you read what happens when you put too much thyroid hormone into a system that has cells, potentially cells developing inappropriately.
And the challenges that may occur. And in, I think it was 2019, a paper came out talking about the increased incidents of cancer. All different types of cancer overall are generally higher in people on thyroid medication five to 10 years down the road. And there's now more papers coming out [00:48:00] showing that hypothyroidism is a protective response against cancer.
So when you think about that, you go, huh, wait a minute. If this is a protective response. Is it just a protective response against cancer? Is it a protective response about bact against bacteria and organisms? And then you see these mechanisms like, oh, the thyroid cells have these pattern recognition receptors, the same thing that immune cells stuff.
We can start to put these things together. I'm actually in the process of finishing a perspective paper to get, to send off for publishing on the whole this whole adaptive thyroid model.
Dr. Justin Marchegiani: So what are you looking at from a functional range to say, Hey, you're probably taking too much thyroid hormone. Is it T three at a certain level?
Is it a combination of suppressed TSH? What's your kind of sweet spot and what's your danger zone?
Dr. Eric Balcavage: So I look at the whole panel to begin with, plus some other labs. But if I look at TSH. Definitely if there's a suppressed TSH, but Mike, the key is we wanna make sure [00:49:00] there's appropriate levels of T four.
If the person is just on T four only and they are likely overmedicated TSH probably be probably below one in most cases. Sometimes you see these, I have one that came in today, 0.005 for A TSH. Yeah. You, so if it's the TSH suppressed, where's their T four? Where is their reverse T three.
Where's their T three. And what's that free T three to free T four ratio. Where's, what's that conversion look like? If they have higher reverse T three, they have a reduced, the higher reverse T three, low lower T three, and the free T three to free T four ratio is low. We need to get them, we need to get that medication reduced.
And the big piece of that is because if you have too much T four and circulation for the state, they're in that T four that's not getting into the cells, it's not being transported into cells. Not only can it bind to cells that are endocrine receptors on cells that are not [00:50:00] developing appropriately and create problems, but the excess T four in circulation then results in UBI Ubiquitination of uni of Dease two, which means they're gonna have less, even less conversion of T four to T three.
So there's this idea that more thyroid hormones gonna automatically transfer translate to more T three inside the cell, and that's not necessarily the case.
Dr. Justin Marchegiani: What does that word UU ubiquitination mean? I haven't heard that word before. What does that mean?
Dr. Eric Balcavage: So ubiquitination essentially means turn off.
Okay. An enzyme. So it marks it for destruction.
Dr. Justin Marchegiani: So dease enzyme is what cleaves off an iodine molecule to activate the T four to T three. And so it decreases that enzyme function.
Dr. Eric Balcavage: Yeah. And that enzyme is based on what, from signaling me mechanisms and one of the signaling mechanisms that, that either turns on or t turns off dase two is how much T four is in circulation.
Dr. Justin Marchegiani: Okay. That makes sense. And so the sweet spot is you don't want T four going above [00:51:00] what? 1.5, 1.6 free T four? Yes.
Dr. Eric Balcavage: Yeah. I definitely don't want free T four, probably over 1.5. 1.6.
Dr. Justin Marchegiani: What about T three? Free.
Dr. Eric Balcavage: Free. T three.
I, as far as high or low? Like
Dr. Justin Marchegiani: Too high and, or too low?
Dr. Eric Balcavage: From a too high perspective I would say.
It all depends on what, so is this a person who's on thyroid or T three medication or not on T three medication?
Dr. Justin Marchegiani: Yeah. They're on thyroid medication. They're doing all the right things, functional medicine wise, all the principles. But they're trying to fine tune their dose, but maybe they've gone too far.
What's that dose look like if they've gone too far?
Dr. Eric Balcavage: I don't know what it's gonna look like directly from a thyroid panel itself. Okay. We gotta look at their signs and symptoms. I would say the average person's probably when they're in a more optimal range, is between three and four.
What their T three level or T three, free T three total. T three. Free T three is gonna be, is gonna also be dependent on when we're testing them and the medication they're on. Yeah. And [00:52:00] so that becomes critical if they're taking T three medication. We need to know what type of medic? Is it slow release?
Is it regular T three? Is it a glandular? When did they take it? If they took that T three medication, let's say three hours, and that's probably, if we wanna see how high the T three bring brings their, the medication brings their T three. We probably wanna take their, have them take their T three before.
Before they, their blood draw about three hours before their blood draw. And then we know how high that T three is getting, 'cause that T three is gonna peak somewhere around four hours, five hours in that range. And then it's gonna subside as the day goes on. So if that T three is five or six within those first few hours, and then I look over at the TSH and that TSH is being suppressed, then I also have to go over and look at the T four levels and the T four medication they're on.
Because what happens in the P person who's on let's say, NP thyroid who's trying to ratchet up their T [00:53:00] three to get it in an optimal range? And that's, we can have discussion with that even means is that the glandular products are typically at a ratio of four to one T four to T three. Yeah.
That's not how we regulate T three in the BO T four and T three in the body, it's usually on average somewhere around 13 to one. But it could be as high as 18 to one down to as low as five to one. But on average, let's just say it's 13 to one. So you're getting more. T three as you're ratcheting up your thyroid medication, that excessive T three.
Is gonna suppress, start to suppress TSH too much. And if you're not fully replacing T four medication with your NP thyroid and you're suppressing the gland, you start to lose thyroid gland con contribution of T four. And now we can start to sync their T four levels and then that can have an effect on T three.
So yeah, it gets starts to get complex.
Dr. Justin Marchegiani: Yeah. Myself personally, with patients, I've been recommending for over a decade that patients take their thyroid support. And then wait about three hours to test. 'cause I [00:54:00] wanna see whether T three levels are at peak. I think most doctors conventionally have just taken the, hey, the Synthroid instructions, which T four has got a four to five day half-life.
And so they take those instructions and if you're on NP or Armor, they say, Hey, don't take your thyroid support before. It doesn't have anything to do with it. The half life's too low. But if you've got T three in there, it does matter because 50% of your T three is gone in eight to 10 hours. And so most of the time, in 24 hours, if you haven't taken it, it's not gonna be in your system.
So you're not getting a window into it. And then also I always find that taking it twice a day is by far better. You get a, just a much more even keel of it, even level throughout the day versus, you get a big drop by two, three in the afternoon, there's a and 50% drop typically according to the patients.
With that,
Dr. Eric Balcavage: I think it's the most people would be do better. It would be better on a split dose. But I think what happens with most people who wind up on glandulars, they typical wind up taking too much. And my suggestion for the vast majority of the people after doing this for so long [00:55:00] is if you feel you need T three, if the thyroid gland to replace what a thyroid gland would typically make, let's say we've removed the thyroid gland.
Dr. Justin Marchegiani: Are we talking T three within the T four glandular structure? Are we talking T three by itself?
Dr. Eric Balcavage: We're talking we're, if we had a gland Yeah. Somebody completely removed it, right?
Dr. Justin Marchegiani: Yeah.
Dr. Eric Balcavage: We might need, let's just say about a hundred micrograms of T four. Yeah. To replace what that thyroid gland would make and then they might need, the thyroid gland typically makes between maybe we five to 10 micrograms, we need to replace it.
So why are we giving anybody more than the five or 10 micrograms that a healthy thyroid gland would make? And when we start to give the glandulars, it starts to increase that dose, unfortunately. 'cause as you increase the dose, you know you get. It is more thyroid hormone than a gland can make. And the argument by some people is that we want to give them more to optimize their T three, but if you think that they've, the body [00:56:00] forgot how to convert T four to T three, then optimizing T three makes sense.
If you believe, like I do in most of these cases, the reduced if once, if you give them five to 10 micrograms and they still have low T three, and if they don't have a gland and you're fully replacing T four, you should be giving them that five to 10 micrograms of T three. But if they still have low T three, that's not, that is the optimal state for that person.
That is the optimal level. Because they, their body is adaptively. Downregulating it.
Dr. Justin Marchegiani: Yes. Unless they're just not absorbing it too. Unless they're just not absorbing it.
Dr. Eric Balcavage: Yeah. But if they're absorbing the T four, the T three is even more absorbable than the T four based on the literature.
Dr. Justin Marchegiani: So assuming the T four is being absorbed right.
Dr. Eric Balcavage: Because the T four is like somewhere between 50 and 70% absorbable. And the T three based on the stuff that I've read, is like 90% absorbable.
So I get it. You might need a little bit more, but that's the sweet spot. We see people coming in. I have people coming in. They're on 20, 30, 40, 50, 60 [00:57:00] micrograms of T three along sometimes without T four, sometimes with T four.
I've got a woman, I just looked at her lab. She's on 120 milligrams of MP thyroid and it's inappropriate for her. Her ts her 15 hours after her lo last dose of MP thyroid. She ran her labs and sent them to me. Hey, this is 15 hours after I took my meds. Her t total T three was one 70.
Oh my gosh, that's really high. Three was her free. T three was, her free T three is actually, it was like 3.1 and you would say that three point one's good. Why is that low? The reason it's low, the other part of the story is she's also pregnant, so HCG is in there is And that's creating submissions as well.
Yeah, exactly. But somebody's treating. Her and saying, Hey, we need to ratchet this up. And they were doing that before she got pregnant. It just so happens in the middle of the conversation, she wound up getting pregnant and delays to get the labs done. But we have to be [00:58:00] careful. We think that more thyroid hormone, more T three is gonna optimize the labs, and there's people in our space that's the, that's their claim to fame.
And that's okay. But I get a lot of those patients that are just overmedicated. If you've take I don't have a beef with T three, I don't have a beef with it. If you feel good, you function good, you're great on whatever you're doing, keep doing it. But I see what I see come to see me are people who are on higher, are trying to do higher and higher doses of MP, thyroid or armor because the T four didn't work and they can't get their T three level up.
So they're doing NMP thyroid plus T three, they're doing NP thyroid plus T four and T three. And you're like, wait a second. If there's reduced conversion, stop trying to fix it. And start asking the better question, which is what functional medicine should be. Yeah. Which is why is the person not able to convert and get that T three to a hundred or the free T three into the threes or the fours, whatever somebody thinks is the optimal range.
But I think that's where [00:59:00] sometimes it, it gets overblown and it initially, I think it's like heroin or not that I've ever done heroin, but you get that hit at T three and you're like, that feels good. And look at my lipids went down, right? Because the liver is highly dependent on T three from the bloodstream.
So it'll change that marker and it'll change some things. But it's also gonna create an issue because we think that only T four is getting deactivated in that inflammatory state. But T three is getting deactivated too.
Dr. Justin Marchegiani: Correct. That makes sense.
Dr. Eric Balcavage: Anything else, doc, you wanna highlight? No, I think that's it.
Oh, I think we
Dr. Justin Marchegiani: had a
Dr. Eric Balcavage: great
Dr. Justin Marchegiani: discussion. No, I think it was great. One last thing though, iodine. Just gimme your take on iodine. Obviously there are a couple of camps out there. People are recommending super doses and the very high milligram levels. People like Brownstein. People like Razzi are like, Hey, just, keep it, at the RDA one 50 or so.
What's your take? Again, assuming someone has Hashimoto's, they have antibodies, what's your take on when and how to dose iodine?
Dr. Eric Balcavage: I evaluate for it. I look for it. My biggest issue is I [01:00:00] don't think doing supplemental iodine for me makes a lot of sense for a lot of these people. 'cause a lot of them they're not deficient at least by when we can measure 'em.
How do you measure 'em? You, there's a couple different tests out there. You could do a 24 urine, 24 hour urine collection. ZR T's got a test that's supposedly, matches that. Which is easier for the client. So I like to look at blood. I like to look at urine as well. Do you do a urine with a challenge?
I don't do the, I don't do the challenge. Yeah. Okay. I don't do the challenge because you only need one client to do a heavy dose it of iodine and flare them up and you're like, all right, I'm not gonna do that. So I know there's people that swear by it, and I know there's, and I've talked to both camps and the camp that says everybody's deficient.
And the camp that says everybody is overloaded. I think it's probably for the vast majority of people, it's somewhere in between. There definitely are some. I agree. Some people agree that are deficient. Agree. And again, we have to ask why are they deficient? Is it 'cause they're just not eating [01:01:00] iodine rich foods?
And especially the people like on anti-inflammatory diets. Those are the people that we have to be a little bit, maybe sometimes more concerned about and where they live and those types of things. But with almost every. Micronutrient issue. It's not as simple as, oh, you're deficient. Just take more.
It's usually, okay, but why am I deficient? Is it because I don't eat the foods that have it? The foods don't have it. I can't digest it. I can't absorb it. I can't assimilate it. Or because I'm under cell stress, I'm not taking iodine to the thyroid gland under this stress condition. I'm shifting iodine to immune cells to try and kill whatever this bug is that I'm in, in threat from.
So I think it's just a, it's a more con, more, more convoluted issue. But if I see somebody who I think has an iodine deficiency pattern. Then I'll definitely take a look at iodine and the factors that may influence or impact its absorption.
Dr. Justin Marchegiani: Awesome, doc. I really appreciate it, guys listening. This is Dr.
Eric Bell cavi. His website is dr eric bevi.com. [01:02:00] If the spelling is off, just go to the description below here and there'll be a link for you to go right to a site. You sees patients worldwide doc? Yep. Good. Awesome. Appreciate the conversation. Anything else you wanna leave listeners with?
Dr. Eric Balcavage: No. If you need some more information, just go to the website, follow me on Instagram or listen to my podcast, thyroid Answers podcast, which I think we're gonna get you on in a short, in a very short period of time.
Dr. Justin Marchegiani: Love it. Awesome, doc. Thanks so much. You have a good day.
Dr. Eric Balcavage: Thanks for having me.
Dr. Justin Marchegiani: Thank you.
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