A New Paradigm of Fixing Hypothyroidism with Dr. Eric Balcavage

Content By: Ari Whitten & Dr. Eric Balcavage

In this episode, I am speaking with Dr. Eric Balcavage, who is a renowned thyroid health expert and author of the Thyroid Debacle. He also lectures around the country on various health topics including stem cell therapy and regenerative medicine, thyroid dysfunction, methylation dysfunction, and more. We are going to talk about his take on thyroid health.

Table of Contents

In this podcast, Dr. Balcavage and I discuss:

  • How the conventional notion of thyroid disease might be seriously misplaced
  • Why low-thyroid output might actually just be a healthy adaptive response to a less than ideal environment (and not really a disease at all).
  • “Greenwashing medicine” and why even functional medicine doctors are as guilty as conventional doctors of failing to address root causes
  • What is cellular hypothyroidism and how it shows up
  • Iodine – friend or foe?
  • Four practical strategies to reduce your symptoms

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Ari: Hey, this is Ari. Welcome back to The Energy Blueprint Podcast. I’m very excited to share today’s episode with you. It’s with a new friend of mine and a brilliant clinician named Dr. Eric Balcavage. He is a renowned thyroid health expert and the author of the new book, relatively new book, The Thyroid Debacle, which is an absolute must-read for anybody struggling with their thyroid health, who has Hashimoto’s, or who just wants to learn about and optimize their thyroid health.

In over 20 years of practice, he successfully helped thousands of people suffering with chronic health conditions. He trains and consults with hundreds of doctors on topics such as thyroid physiology, organic acid testing, methylation, and GI physiology. He also lectures locally and around the country on various health topics including stem cell therapy and regenerative medicine, thyroid dysfunction, methylation dysfunction, and more. His clinic has always been on the cutting edge of the healthcare industry.

This is somebody who I have a lot of respect for, whose work very much overlaps with a lot of the things you’ve heard me talk about over the years, particularly mitochondrial health and the cell danger response. This is really a revolutionary new paradigm of thyroid health that he’s talking about here. I think as you listen to the episode, you’re going to hear why. You’re going to get a lot of value from this. I hope you enjoy it.

Without any further ado, here is Dr. Eric Balcavage on optimizing thyroid health. Enjoy. Welcome to the show, Dr. Balcavage. Such a pleasure to have you.

Dr. Balcavage: Well, thanks for having me on the show. I appreciate it.

What the conventional and alternative functional medicine are missing when it comes to thyroid health

Ari: You have done some very interesting work around the thyroid issue epidemic. You have a relatively new book. It’s a few months old now, it’s called The Thyroid Debacle. It’s a wonderful book. I would love for you to tell people why you wrote this book. There’s obviously a ton of other natural health functional medicine practitioners out there that have already written lots and lots of books on hypothyroidism.

What compelled you to write this book? What do you feel is missing from the conventional medicine approach and the alternative functional medicine approach?

Dr. Balcavage: What I thought was missing overall is how we should be looking at what’s going on with thyroid physiology and health and disease in general. I think what we often do is tell people that their body is attacking them and their body is breaking down. I think that’s the wrong window to look through, at least, at the start. I think we’ve come from two cells to what we are today.

To think that you wake up one day and your immune system forgets who you are and just randomly starts attacking you, I think is maybe a little inaccurate. Especially when it comes to thyroid physiology, everybody’s told, “Your immune system is attacking your thyroid gland. These little antibodies are gobbling up like little Pac-Men eating away at your thyroid gland. It’s an immune system out of control.”

I just always had a problem with that concept and idea that the body was attacking itself. I wrote a book that turns the table maybe on how we look at thyroid physiology and physiology in general. What I want people to understand is their body is oftentimes not attacking themselves, at least initially, but what’s going on is adaptive change to some type of excessive cell stress. It’s not broken initially.

In time, if you have chronic excessive cell stress, tissues do start to break down. In functional medicine, we spend so much time trying to fix the levels of thyroid hormone, trying to manipulate them. We do that both allopathic and functional medicine. Allopathic medicine takes the concept like it’s thyroiditis, it’s immune, we don’t know why, doesn’t matter, the only treatment we have is to wait until the thyroid gland has lost 90% of the function, and then we give you T4, and as long as we give you enough T4 to normalize TSH, everything’s good.

The only thing they’re really concerned about is normalizing TSH. That’s a problem. I understand where they’re coming from. If the only tool you have is a hammer, you got to be careful when you use it. In functional medicine, I think we don’t do a great job either. We are saying allopathic medicine, they don’t know what they’re talking about, they don’t run thyroid antibodies, they don’t realize this is an immune or autoimmune condition.

No, they fully realize it’s an immune or autoimmune condition, but we look at autoimmune conditions like idiopathic, we don’t treat autoimmune conditions, we’re not putting everybody on cortisone, suppress their immune system. That’s not a good strategy. What we’re going to do is wait until the gland has lost 90% of its function, then we’re going to give somebody T4.

They’re like, well, they don’t even look at T3 or free T3 or reverse T3 or thyroid antibodies. Well, that’s because they’re not trying to assess or evaluate what’s happening in the peripheral tissues. They’re taught that as long as TSH is normal, everything is good. Then we say we’re going to run more comprehensive tasks. Oh, this is a person who’s converting T4 into reverse T3 and they have low T3.

Oh, those silly medical doctors, they don’t realize that the thyroid gland makes T32, and the T3 is low, so we’re going to give T3 to balance out the blood levels. We’re missing the idea that it’s not nec– Where most of the T3 is made is in the peripheral tissues, not the thyroid gland. If there’s a decreased T4 to T3 and an increased T4 to reverse T3, the cells, the tissues are deactivating it.

That means the cells are doing that for a reason. Let’s stop ignoring the reason, and let’s stop trying to play whack-a-mole with T4 and T3, and let’s just ask better questions. Why would the body, why would the cell, why would the tissue want to downregulate the metabolism? That’s a better question to ask. That’s what the book is really all about. Like, “Hey, here’s what we might see. These are the reasons why this stuff happens. Thyroid physiology is not necessarily broken. It’s adapting, so let’s try and look at the reasons why this would occur.”

When we do that, and I’ve been doing this for go almost three decades now, when you address the root issues of the excessive cell stress, reduce it, eliminate it, and get rid of that cell danger and bring us back into a restorative state, guess what? T4 to T3 conversion happens on its own. Thyroid glands start to recover. I’ve got a patient I talked to this week, her thyroid gland is actually regenerating.

Her doctor’s like, “What the heck is happening? We took out half of that thing and it’s growing back. What is going on?” She’s like, “I’ve been doing this thing.” He’s not sure what to do. The thyroid gland can recover. Why does it never recover? Because nobody pays any attention to what’s actually driving the process. I needed to change the conversation so that we’re not just greenwashing medicine with different drugs or different hormones or different supplements, but we’re actually doing what functional medicine’s all about, which is addressing root cause issues.

Greenwashing medicine

Ari: Explain that term because there probably are a lot of people that are not familiar with it, the term greenwashing medicine. What do you mean by that?

Dr. Balcavage: What I mean by that is, from a functional medicine standpoint, we say allopathic medicine is bad because all they do is provide drugs. The person’s on a stat, and that’s bad. Instead, we say we’re better, we’re going to put them on red yeast rice because that’s natural. Am I addressing the root issue, or am I just giving a different type of drug or supplement?

What I see from oftentimes is the person says those medications are bad. They go from 3 medications, they come to the functional medicine practitioner and wind up on 20 supplements. Is that better? I don’t think so. It’s more expensive. I don’t know that it’s better. If you need 20 supplements to still feel lousy and to manage this level of laziness, then we haven’t fixed anything.

Changing it from saying that a drug is bad, but a supplement is better if I still have to take it constantly, consistently every day, I don’t think that’s better. I just think we’re using a different hammer.

Ari: Got it

Dr. Balcavage: Does that make sense?

The root causes of thyroid issues

Ari: It does. I want to come back to what you were saying a minute ago as far as getting to these root causes of the thyroid issues. What you’re talking about is a big deal. This is a really revolutionary shift in paradigm around thyroid issues around hypothyroidism. I would say the dominant paradigm probably in both conventional and natural functional medicine has been that hormones are the big boss and hormones control everything.

For decades it’s like I think the go-to within the functional medicine community is you’ve got this symptom, you’ve got that symptom, you’ve got this symptom, it’s your thyroid. Everything’s a thyroid issue. That’s the big go-to. It’s like, oh, probably thyroid, probably subclinical thyroidism, and everything is linked back to and talked about from this paradigm that hormones are the big boss controlling everything else.

What you are saying is, and don’t let me put words in my mouth, feel free to correct me if I’m portraying this incorrectly, but it sounds to me like what you’re saying is that there are things going on at the cellular level, and presumably at the mitochondrial level since you mentioned the cell danger response as well, that are in a sense regulating what’s going on with that hormone. This is a shift in terms of the paradigm of what is the most upstream thing.

Instead of hormones controlling everything else, it’s this thing that’s going on at the cell level is actually affecting what’s going on with these hormones. Explain that paradigm or feel free to correct me if I’ve misportrayed it.

Dr. Balcavage: No, that’s exactly how I look at it. When people say, I think I have hypothyroid signs and symptoms, but my thyroid gland is fine, my TSH is fine, I’m like, ”Well, you absolutely could have hypothyroid signs and symptoms because hypothyroidism often starts at the tissue level, but it’s not the thing to fix, it’s the result of some type of physiology.”

The way I explained it to my patients is I said, “If I’m a cell, my primary job, if I’m in a low-stress state, is manufacturing. I want to make things: peptides, proteins, hormones, neurotransmitters, cell membranes. I want to make energy. I want to make stuff. To make stuff, I need a lot of the active thyroid hormone, T3. I grab T4 out of the bloodstream, bring it in, convert that T4 to T3, and that T3 binds to receptors and turns on the manufacturing process. Perfect. I make stuff, I feel better, got good skin, good hair, all that stuff.”

T3 also combine to receptors that turn down or turn off the immune inflammatory cell defense mechanisms of a cell. If I work at a factory and life is good at the factory, there’s no problems at the factory, I’m making stuff, but if I’m a cell and I perceive danger, I got to shift what my job is. Now my job isn’t to make stuff, manufacture all these things. My job is to protect.

Just the same way if I’m the person at the factory, I may make widgets as my daily job, but if somebody’s breaking in or there’s a fire, now I got to go into defense mode, I got to protection mode. Cells are very similar. We would do the same thing if it was us as a person. I use the analogy. I take care of a lot of women.

I’m like, ”Listen, if you’re a mom, you got a big party going on this weekend, you got four burners on, you’re cooking a bunch of food, your kids at the island eating, you’re vacuuming, doing wash, doing all those things at the same time, if somebody broke in your home and attacked your child, are you going to continue to cook? No. Are you going to turn off the burners? No. Are you going to take time to pack it up in glass Tupperware? No. Are you going to try and throw one more load of washing? No. Are you going to try and finish the vacuuming? No. Are you going to go take a nap? No. Are you going to go pee or poop? Are you going to go to have sex? No.”

If you go fight the attacker in another room and I walk in, I see food is burning, vacuum cleaner is running, washes all over the place, kitchen’s a mess, I can make an assumption that you’re a terrible housekeeper, mom, and cook, or I can ask a better question like, ”What’s going on here?” We have this perception that everything should just work like we’re in this state of balance and low stress of homeostasis, but that’s not who shows up in our office. Who shows up in our office is people under stress, they don’t feel well, they’re sick, they’re ill, they’re inflamed. The physiology works differently.

In a state of excessive cell stress, one of the things I want to do is I want to slow down the manufacturing process and ramp up the immune inflammatory process. We call that the cell danger response. To do that, there’s all these mechanisms that go along with it. One of the mechanisms to turn off the manufacturing process and turn on the cell danger protection mechanism is to downregulate the amount of T3 in a cell.

When you downregulate, you turn off the manufacturing stuff, and that causes to feel hypothyroid. Whatever tissue that’s in, if it’s your gut, you’re going to get hypothyroid-type symptoms there. If it’s the adrenal gland, ”Hey, I can’t make as much cholesterol, I can’t bring in as much cholesterol, I can’t make as much cortisol.”

There’s others. It depends on the tissue, what response you’re going to feel. We would say, ”Oh, they have hypothyroid symptoms. There must be something wrong.” Well, yes, there is something wrong, but the downregulation of thyroid physiology isn’t the thing that’s wrong. That’s the adaptive response. That helps protect the cell and it helps slow down the manufacturing. A key thing to this, and I’m not quite sure the level of the audience, I’ll say this maybe–

Ari: It’s a sophisticated audience.

Dr. Balcavage: Somebody asked me, well, why would the cell do that? Why would it do that? I said, ”Look, it’s really not that hard.” We could talk about every step of the cell danger response. In every step of the cell danger response, there’s a tie into thyroid physiology, but one of the key ones is because what do you hear in functional medicine, one of the new hot buttons is everybody, they’ve got mitochondrial dysfunction.

No kidding. If they got excessive cell stress, we’re going to downregulate the mitochondria, not because it’s broken, but on purpose. Why? Cells make energy through the mitochondria. We take food energy and turn it into cellular energy. That process produces free radicals. You’d say, what is that? That’s exhaust. We call these things oxidants. The cool thing is inside the same cell, we make these things called antioxidants.

We make enough antioxidant to balance out the amount of free radical and oxidants that’s being made as exhaust when we make energy. If I have the cells in danger, let’s say there’s a bacteria, a virus, something creating stress on that cell, what does the cell want to do? Wants to stiffen the cell membranes and increase the free radicals. Why? Because those free radicals are used to kill the threat.

Now, if I make a lot of free radicals to kill the threat and I’m pushing lots of food energy through this thing called mitochondria that’s also making a lot of free radicals, now I make a ton of oxidants. I don’t have enough antioxidant capacity, and now I get what we call oxidative stress. Now the oxidative stress would destroy the cell. Do we want to destroy all our cells? Probably not.

It’s a protective mechanism to downregulate the mitochondria to maintain some energy because the mitochondria actually becomes more efficient during that process, but it’s downregulated. When you start to look at that the science behind it, how this works, it’s beautiful design. We have to look at it that way versus broken physiology. That’s what I call cellular or tissue hypothyroidism.

It’s not like I made it up. I just looked in a– I said this is happening at the cellular level first, and then I found a bunch of papers that talk about tissue hypothyroidism from a couple decades ago. I’m like, ”This is it. This isn’t new. This is what people were talking about before.” Nobody’s paying attention. When we’re talking about what’s happening with most people, they’re not in homeostasis and then they wildly develop a thyroid problem.

They’re in excessive cell stress that triggers this allostatic regulation, and then every system that’s less important to cell defense starts to become downregulated within the cell, within the tissue, within the body.

Cellular hypothyroidism

Ari: Interesting. So much there. I absolutely love the way you’re talking about this. There’s a huge amount of overlap in the way you’re talking about all these issues and the way that I talk about energy and fatigue in the body. People listening to this podcast are probably very familiar with me talking about the cell danger response and talking about everything that you just described from another angle from the chronic fatigue story, which is obviously very, very much overlapping with the thyroid story that you’re describing.

Cellular hypothyroidism. I’m curious, and maybe part of this gets into thyroid hormone biochemistry to some extent. When we are looking at thyroid levels, let’s say T3 in the blood, so you said the cell takes in T4, converts it to T3, but when we’re looking at free T3 in the blood, what are we looking at, and is that actually a good measure of T3 levels inside of the cell?

Dr. Balcavage: Every tissue can self-regulate thyroid hormone. We could have a cell that’s in a more hypothyroid state and T3 still be within a reference range depending on what range you use; functional, lab. Everybody’s got different ranges in functional. Everybody makes stuff up. It doesn’t necessarily correlate with what’s happening inside the cell. Unfortunately, we don’t have a great measurement of what’s going on inside the cell.

If you have a low T3 state, then I would say the potential to have hypothyroidism occurring or cell stress or cell danger response occurring in more a lot of tissues is probably pretty good. We can’t just look at a thyroid panel. We have to look at a thyroid panel, then we have to look at the rest of a comprehensive metabolic panel to see if we have patterns of hypothyroidism and take that in context with our patient’s signs and symptoms.

We can’t be narrow. We got to be broader. All those thyroid tests that are available all mean something to the person who’s willing to interpret them. You could have normal T4 and T3 and still have tissue hypothyroidism. You could have low T3 for sure and have tissue hypothyroidism because where’s most of the T3 made? It’s not from the gland. It’s in the peripheral tissues.

You can have elevations of something called reverse T3 that is the deactivated form of T4 because it can go from T4 to T3 or T4 to reverse T3. Many times you’ll see the elevation of reverse T3. That’s another indication that we potentially have it. The other thing you can do is we can take a look at ratios of T4 to T3, T3, T4, T3 to reverse T3 [unintelligible 00:21:04] reverse T3 to see what’s the pattern.

It looks like they might be under conversion possibly. Then that’s where I go look at the rest of the blood panel and say, “Do I have tissue patterns of hypothyroidism? Do I have insulin resistance? Yes. I’ve got some tissue hypothyroidism impacting liver, impacting muscle tissue. Do I have a renal pattern? Yes. Okay. Do I have a liver pattern? Yes. Do I have an adrenal pattern? Yes.”

Ari: Explain what you mean by some of those.

Dr. Balcavage: Sure.

Ari: Then I want to come back to this list because I wanted to ask you, what are these patterns that are showing up. You said a renal pattern and a liver pattern. Does this mean BUN and creatinine ratios and elevated liver enzymes, ALT, and so on? What are you looking at when you’re looking at those markers to determine that there’s a pattern of what’s going on in these broader systems of metabolic function that are indicative of cellular hypothyroidism?

Dr. Balcavage: Sure. Let’s start with insulin resistance because it’s the one that aggravates me the most in functional medicine because what we hear is people say, “Hey–” People who are thyroid experts will say, “If you want to get your thyroid physiology under control, you have to fix your insulin resistance.” I think everybody thinks that the reason we have insulin resistance is because we have too much glucose consumption, too much carbohydrates.

That’s not the case in the vast majority, especially the people that come to see me who have already– they’re on a low carbohydrate diet. Why would I say insulin resistance is potentially a tissue hypothyroid pattern? Because there are things called glucose transporters. To get glucose out of the bloodstream and into a cell and tissue, it needs a transporter molecule.

It’s like the revolving door at the hotel, so we got to get the glucose in. There’s Glute 1, Glute 2, Glute 3, Glute 4. The one that most people I guess are familiar with is Glucose Transporter 4, which is the insulin-dependent one. Glute 1, Glute 3 can transport glucose in a fasted state without insulin. Then Glute 4 is the one that’s insulin dependent. What do all those glucose transporters need to be able to work appropriately? They need T3 inside the cell. If I have insulin– I call it glucose resistance.

I don’t like the insulin resistance. I call it glucose resistance. Let’s take even a step back further. Why would I have glucose resistance in the first place? Well, maybe I eat too much glucose and I don’t do anything. Is that a possibility? Maybe, but let’s just say I don’t– I’m on a mid-low carb diet. Why can’t I get the glucose in? Well, we talked about that cell danger response. When the cell perceives danger, drop in energy inside the cell, we need to stiffen the cell membrane.

When I stiffen the cell membrane, makes it harder for those transport mechanisms to bring nutrients in. Is that broken physiology or adaptive physiology? Well, it depends. If I’ve got an organism or a threat inside the cell, do I want to bring more food in to feed the threat? Probably not. If I don’t want my son and all his college buddies coming over to eat all my food and drink all the beer, don’t buy food and beer. Guess what? They’re going to go to somebody else’s house.

Same thing with the cell. If I want to get rid of the threat, starve it out, that’s one way. Stiffen the cell membranes. Bringing glucose into the cell can help that process. By downregulating the amount of T3 in the cell, I decrease the ability of those glute transporters to move from inside the cell to the cell membrane, therefore, it makes it harder to get glucose into the cell. All the glucose transporters require T3 in the cell.

Now, they don’t all fail at the same rate. That’s been shown in the science. Glute Transporter 2 hangs on the longest. Guess what that does? That pulls glucose out of the liver into the bloodstream and drives glucose into the fat tissue. Why would that be a good thing? Well, if I don’t have downregulation in mitochondria, and I need some fast fuel glucose, I can pump it from the liver into the bloodstream and I’ve got some fast fuel.

I can’t use it very efficiently, so I don’t want it hanging around too long so I can be able to pump it into the fat cells and get it out of the way. If somebody’s got insulin resistance, it’s a good chance that they might, or glucose resistance, insulin resistance, however you want to say, it’s a good chance that they may have a downregulation of their cell metabolism, cell danger response, decrease T3. I look for that.

The renal system relies heavily on T3 to function appropriately. If I see elevated BUN, I see decreased GFR, I see a decreased or an increased creatinine level, I may say, “Hey, I’m starting to develop a renal pattern here.” I decrease T3. If I’m looking at the– Do I have a liver pattern? Let me look at cholesterol levels. Let me look at my triglyceride levels because if I have downregulation of the mitochondria at the liver and if I got downregulation of T3 in the liver, I can’t get cholesterol out of the bloodstream very well.

To get cholesterol out of the bloodstream, the lipoproteins have to dock to the liver cells. Those receptors, especially the LDL receptors, require guess what to work? T3. If I have elevated cholesterol, I’ve got a problem getting cholesterol into the cell. I call that a lipid pattern or a liver pattern. The other thing you might see is elevations of triglyceride and VLDL.

Now, thyroid hormone T3 plays a part in reducing the enzymes that regulate the conversions of VLDL, the LDL, the HDL, and pulling the hydroxylase enzymes or those light pace enzymes that can be used to pull those triglycerides or those fats off. That’s one component of it, but if I have elevated triglycerides in the bloodstream and elevating VLDL, what does that tell me? A, I can’t use the triglycerides at the liver very effectively. Now, why wouldn’t I be able to use the triglycerides effectively as an alternative fuel source?

If I have downregulation of the metabolism, I can bring some of those triglycerides in, but if the mitochondria is not functioning efficiently– Fatty acid metabolism is a process that requires oxygen. When I have cell stress going on, what do I reduce? I reduce oxygen transport, I reduced mitochondrial function, so I can’t be as efficient burning fat. Now, I start to store more fat in the liver.

I get more of a fatty liver, then those triglycerides can get shunted back out, bounce into those lipoproteins, I get an elevation of VLDL that way, and VLDL can then go store stuff somewhere. I look for that pattern. There’s a number of these I talk about. When we look at a blood panel, I’m looking at the blood panel first, at the thyroid panel to say, “Do I have some disruption there?”

Then I look and I say, “Do I have inflammation markers that might cause this cellular hypothyroidism?” Then I start looking for these different patterns. Which tissues are being impacted? Do I have problems with gut function? Do I have problems with renal function? Do I have problems with the adrenal function? Do I have problems with insulin resistance or glucose resistance? I’ll look for those patterns and say, “Okay, not only do we have cell stress going on, the inflammation gives us some ideas of what tissues may really be impacted the most and where maybe we need to start.” Then I want them to take a look at what systems are really starting to be impacted more globally by the cell stress or cell danger response.

Adrenals and hypothyroidism

Ari: Can you also talk about the adrenal piece of this?

Dr. Balcavage: Sure. When we talk and we think about adrenal hormones, we think about they have to be made. How do you get cholesterol? How do you get DHEA? Let’s talk cortisol. In acute situations, the adrenal gland can generate its own cholesterol to make cortisol in acute situations. In homeostasis or in chronic stress, where does the cholesterol come from to make into cortisol? It comes from the bloodstream. How does it get there? Lipoproteins dock to the adrenal gland and dump the cholesterol into the adrenal gland to be made into pregnenolone in the mitochondria. Then that comes out, and then we can make it into downstream. If I have a tissue hypothyroidism occurring at the adrenal gland, I might start to see decreased cortisol production as a result of, “Hey, I’m struggling to get cholesterol out of the bloodstream. Hey, I’ve got high cholesterol. No, I have high cholesterol,” because it’s not getting into the tissues.

Then if we see lower cortisol production, that may be the result of I can’t bring this stuff in and make it. We’re looking at that. The other thing is, remember, T3 does support mitochondrial function. Where is that cortisol converted into pregnenolone? It’s converted in the mitochondria. If we have downregulation in the mitochondria, that too can have an impact.

The classic signs and symptoms indicative of cellular hypotyroidism

Ari: Got it. This is fascinating stuff. Basically, you’re taking a look at the thyroid panel itself, you’re taking a look at these broader metabolic markers of renal system, the liver, cortisol, insulin resistance, and it sounds like a few others, inflammatory markers, and then you’re also looking at signs and symptoms of the patients and you’re matching these together. Now, what are some of the classic signs and symptoms that you’re going to see in your patients that are indicative of cellular hypothyroidism?

Dr. Balcavage: It could be a lot of different ones with the classic things: dry skin, thinning hair, constipation, reduced libido, low energy. It sounds like, well, that could be anybody. That could be an adrenal issue. It could be this. Absolutely, because what we have when we have cell stress, depending on the tissue is you are going to have– when you have adrenal problems, you probably have some change in your cellular physiology, you have change in your thyroid physiology within the cell.

We look at the classic signs and symptoms, but we also look at, “I think I have adrenal fatigue.” Adrenal fatigue doesn’t technically exist, but you might have downregulation of your cortisol production, and it could be, hey, maybe you’re not getting ACTH stimulation to the adrenal gland. Well, let’s find out. Let’s take a look and see if that’s the case. Or maybe what we have is the adrenal glands are really stressed. Looks like the kidneys are struggling too. Adrenal glands sit right there.

Let’s take a look at is there indications that the tissue is struggling. We want to look for those patterns and we want to match those to symptoms. When you see the list of potential hypothyroid signs and symptoms, they’re endless. Why? Because downregulation of cellular physiology, T3 plays a role in that, and so any cell, any tissue could start to be downregulated. When you see the classic things like the classic person that comes in, it’s easy: thinning hair, woman, overweight, puffy, tired, fatigued, no libido, extra body fat, insulin resistance.

They’ve been told, “You eat too much. You don’t exercise. You’re just lazy. You’re crazy.” You can look at them and go, “This is the person who’s got downregulation of their cellular signaling.” That one’s pretty easy. The ones that are tougher, I think for allopathic medicine specifically, is the person who looks like you or me. We’re tired, and we’re fatigued, but we’re not overweight, we’re thinning hair, but we don’t have that typical hypothyroid, no eyebrows look, and yet we can still have hypothyroidism or down at the tissue level. I’m a great kid.

I developed my own case of Hashimoto’s. As a result of overtraining, undersleeping, poor breathing, lots of stress, four hours of sleep at night, training for triathlons, working, coaching, being a dad, run businesses, you do that for a long time, and guess what, you do your blood work one day and, “Hey, I’m insulin resistant. I got elevated cholesterol. Thyroid antibodies are positive. Whoa, what’s going on?” It’s excessive cell stress. I felt fine but my physiology was broken or adapting, I’d say.

Ari: I’ve overtrained myself into elevated TSH levels as well. My TSH levels currently are a bit high, higher than what most functional medicine doctors would say they’re looking for in the optimal range I presume is maybe from overtraining. Honestly, I have no symptoms, and I have none of the other metabolic abnormalities that you described, everything else, insulin sensitivity, inflammation, renal function, liver function, everything looks amazing, but my TSH levels are a bit elevated.

All the thyroid hormones are still in the normal range. The last test I did thyroid antibodies were maybe close to the upper limit of the normal range. I’m curious. My energy levels are phenomenal. I’m very lean. I’m very fit. My cardiovascular fitness is the best that it’s ever been in my life. I feel phenomenal. I’m wondering what you would do in a case like that, because I think there are some practitioners that are like, “Oh, your TSH levels are starting to creep up. Maybe we’ll get you on some thyroid hormone, some desiccated thyroid.” What would be your take on my situation?

Dr. Balcavage: Well, we look at what are your signs and symptoms, what do your labs show, how do you feel, what did you do in the last week, what have you been doing. TSH is not a set number. Everybody would like it to be. It should be between one and two maybe. When TSH goes up, what does that mean? Does that mean that we’re hypothyroid or does it mean that it’s stimulating the thyroid gland to produce more thyroid hormone? “Hey, I need a little bit more thyroid hormone.”

That may be what it is. “Hey, I just worked out. I just exercised. I just fasted. My TSH might go up because of changes in what I did in the last few days.” We have this idea that labs need to be within a range, and as long as they’re within the range, then they’re fine and if they’re out of the range, they’re bad. They’re the problem. What I try to tell practitioners and even my clients is that when we look at labs, what we measure gets managed. That’s one thing.

Two, we have to consider four things when we look at a blood value. Is it normal and appropriate? That’s number one. If you feel good, and all your labs are within the lab reference range or the optimal range, then maybe it’s appropriate. It’s normal and maybe it’s appropriate because you feel good and you function good.

Is a lab value normal but totally inappropriate because you can look at it whether– it doesn’t matter which range you use, and say the TSH is normal, therefore, you don’t have a hypothyroid condition. Now I look at my patient, no eyebrows, no hair, grossly overweight, no libido, constipated, and I go, “The value is in the normal range, but it’s totally inappropriate for the person sitting in front of me.”

Then you’d have to ask the next question like, “Okay, why might it be inappropriately normal? Well, hey, does this person have inflammation because the inflammation could suppress TSH. I didn’t run any inflammatory markers.” “Well, I guess you should have.” We have to see if it could be normal and inappropriate.

The other thing, we could have a lab that’s abnormal but totally appropriate for what’s going on with the person. If somebody has an elevated TSH and a low T4 or a low T3, and they look like they’re hypothyroid, and they have tiredness, fatigue, and all the symptoms, we’d say, “Wow, that’s an abnormal value, but it’s totally appropriate for the person that’s in front of me, so now I’ve got to figure out why that’s occurring.” It’s a totally normal response.

Then we can have some, “In your situation, the value is abnormal. Now I have to determine is that appropriate. Okay, well, the rest of the values look good. There’s no other tissue patterns of hypothyroidism. What did you do yesterday? Did you work out yesterday? What time did you work out? What time did you do the blood draw? Did you eat? When was the last time you ate?”

Now we have to ask the questions, maybe it’s totally appropriate. Maybe I ate not long before the test, and what did my body do is say, “Whoa, we just put a bunch of food in here. We need to increase metabolism, kick up some TSH so we can start making some more thyroid hormone to burn off the extra calories.” Got it?

Ari: Yes.

Dr. Balcavage: The last thing to consider is, is the value abnormal and totally inappropriate? These are the people that walk into a practice just like you and say, “I feel awesome. Do my blood work and tell me how awesome I am.” Then you get their blood work back and their CRP is like 42, and now you go, “Wow, this is totally inappropriate for the dude that just walked in here or the dudette that just walked in here.” Now I’m thinking, did the lab screw this up, or do I got some sinister pathology going on? I’ll rerun it again and–

Ari: Some sinister pathology that the person is apparently incapable of noticing-

Dr. Balcavage: Absolutely.

Ari: [unintelligible 00:40:20] level. Yes.

Dr. Balcavage: Yes. I’ve had at least a dozen cases where somebody has come in in a situation just like that and they had cancer, and so colon cancer, stomach cancer, but they didn’t have any complaints. You could say, “Well, shouldn’t they have felt something?” Well, feelings are relative. If I always have a pain in my foot, then that’s my normal pain in my foot. If I always have the distension, how do I know that that’s not normal?

I had a conversation with a person earlier today, we were talking about how many bowel movements do you have in a day. She’s like, “In a day?” She’s like, “I don’t have multiple bowel movements in a day. I have like one, maybe two in a week.” I’m like, “That’s abnormal. That’s not normal.” “That’s normal. That’s how I’ve been my whole life.” She didn’t see that as an abnormality because it’s just the way it’s been.

Those are the keys. When we look at those labs, we have to put them in context. You might have an elevated TSH, everything else is normal, and there’s no problem. Matter of fact, as we get older– I don’t know how old you are, so you might be younger than me.

Ari: I just turned 39.

Dr. Balcavage: You’re a bit younger than me. I’m older. As we get older, the literature shows that TSH levels tend to go up, not because of broken physiology, because the body needs to increase the amount of T3 production. TSH being upregulated can help stimulate more thyroid hormone and especially more T3 production.

Ari: Great. Excellent answer.

What if you already have hypothyroidism

Dr. Balcavage: The piece we might want to talk about because there’s people sitting back going, “Yes, but I have thyroiditis. I’ve got Hashimoto’s. My gland– Isn’t that my immune system losing control and that little Pac-Men are eating it away?” Your immune system is out of control. I would bring this back to the same thing that we’re talking about the whole time; the cell danger response.

If I have to downregulate metabolism in one cell, I do it locally. If I need to do it in one tissue, maybe I do it locally, but if it’s global or chronic, what’s the best way to turn down the metabolism of the body? Is it to continually massively do it at every individual cell or is it better to turn it off at the source? When I thought about that concept, I was like, but is this potentially what’s going on?

You and I know by reading the paper on the cell danger response that part of the cell danger response is the cells release DAMPS and PAMPS, pathogen-associated molecular peptides or proteins and damage-associated molecular proteins. For the listener, PAMPS are pieces of the organism that’s creating the problem. The cell finds the thing, takes pieces of it, throws it out into the bloodstream so that the immune system knows, “Hey, this is the thing that’s creating a problem. Make some soldiers to go find this thing and go get it.”

It can also release DAMPS, damage-associated peptides, that go out into the bloodstream so the immune system knows where to go to for help. Oh, it’s the liver that’s needs help or it’s the pancreas that needs help or whatever. These are what we call danger-associated peptides. Well, guess what? The thyroid gland has these pattern recognition receptors for the [inaudible 00:43:48] particles [inaudible 00:43:56] circulating in the bloodstream to the thyroid tissue and bind to those pattern recognition, the thyroid immune-like cells, they essentially start to damage themselves and release signaling particles that invite the lymphocytes into the thyroid gland.

Does that sound like broken physiology or adaptive physiology? To me, that sounds adaptive. I think it sounds better from a patient’s perspective. It’s not my immune system that lost control and forgot my thyroid gland is part of me. It’s my body’s saying, “Whoa, we got a bigger issue. We got to globally slow down the metabolism.” The benefit of that is if the immune system is turning this process on adaptively, then when we address the cell danger physiology, that same mechanism can downregulate.

We can shut that process down. That’s why I think when I’m working with clients as we address this, the causes, and not necessarily try to manipulate the thyroid physiology, their thyroid antibodies go down, the thyroid glands start to recover, they start to make more thyroid hormone naturally, they need less medication, sometimes none. This idea or this concept that the antibodies are eating away the thyroid gland, that’s not true either.

Thyroglobulin antibodies cause no damage to the thyroid gland based on the literature. Of course, I have a biased literature, may be biased, and I’m working with my own level of ignorance because of what I read, but when I read the scientific literature, and paper says, “Hey, thyroglobulin antibodies cause no damage to the thyroid gland and TPO antibodies cause very little damage, if any, to the thyroid gland,” man, then I’m starting to think we’re playing this Pac-Man thing up inappropriately.

One other point on that, and that is that we think that there’s– we try and differentiate thyroiditis, which is inflammation from the gland, from Hashimoto’s. If you don’t have antibodies, you don’t have Hashimoto’s. If you have thyroiditis, it’s Hashimoto’s, but what happens is you could be TH1 dominant, which means you don’t make a lot of antibodies, and thyroiditis often starts off as a TH1 dominant disorder, so it’s occurring without antibody production.

Sometimes we shift back into TH2 or balanced and we see the antibodies. Some people are TH2 dominant and make tons of antibodies. Thyroiditis is the immune system creating damage to the gland. You may or may not have antibodies based on what’s happening with the shift in your immune system. Oftentimes we’ll see people that have no thyroid antibodies, they’re told they just have thyroiditis, they don’t have Hashimoto’s. It doesn’t matter. It’s all semantics.

If you’re going to address the same, address them the same, but then as we get them better, all of a sudden, now their antibodies pop up and they think they’re worse now. You’re not worse. Your immune system is just more balanced. I try and get my patients to think of the antibodies more as maybe the cleanup crew than the Mardi Gras celebrators.

Ari: Interesting. Let me play devil’s advocate for a moment here.

Dr. Balcavage: Sure.

Can taking thyroid medication make patients feel worse?

Ari: If everything that you said is true, wouldn’t it be the case that giving a person thyroid medication, let’s say T4 or T4-T3 combination, would make them worse? If the body is adaptively intelligently downregulating metabolic function and downregulating thyroid hormone, then basically forcing the system to increase those levels, wouldn’t that be going against what the body is naturally trying to do, and therefore wouldn’t that lead to maybe the person feeling worse or maybe lead to deleterious health outcomes?

Why is it that so many people feel better when they do that? There’s literature also showing that people who are hypothyroid, who take supplementary thyroid hormones have, let’s say, lower risk of cardiovascular disease and certain other complications. How do you explain that seeming paradox?

Dr. Balcavage: There was like four things, but I’ll answer them all. If forget one, let me know because I had the same question like, okay, so why do some people feel better? Well, having excessive cell stress, we can ebb and flow. We can be in and out and be in and out. What you see in patients with hypothyroidism, if they develop hypothyroidism, and whatever created that excessive damage to the gland is addressed, or the excessive cell stress is addressed, and they get thyroid hormone, they’re going to feel better.

What we often see is people get thyroid hormone, they have a honeymoon period where they feel better, and then they plateau, and now they need more T4, and they feel better, and then they plateau. Now, why does that happen? Because you blast a whole bunch of thyroid hormone, you get a bunch of hormone into the system, you start turning on some mechanisms, and then the physiology catches up. That happens in the T4 model all the time.

That’s where people came in and say, “Hey, they got the reverse– T4 is high. They’re not feeling any better, they’re still gaining weight, and so we’ll give them T3.” When they get to T3 they go, “Oh my gosh, I feel so much better.” “Why?” “Because I didn’t have much T3 and now I have some.” Then they feel good on five micrograms, and then they don’t, and they’re like, “Okay, I’m back to where I was.”

“Okay, let’s give you 10 micrograms.” “Oh, I feel better.” and then they don’t. They go through this rollercoaster ride. They go from T4 to T4+T3 combo, and now people have them on massive doses of T3. Let’s just give them massive doses of T3 and they’ll be better.

I ask the same question. If this is a protective response, wouldn’t giving them potentially create problems? It would mean that there might be a greater incidence of something like cancer, because what can T4 do? T4 doesn’t just get converted into T3 inside the cell, but T4 combined to receptors on the plasma membrane of cells, they’re called the integrin αvβ3 receptors.

When they do that, they can stimulate the MAPK pathway, they can activate what we call non-genomic actions, but they’re genomic actions, too, but they can also cause cells to replicate. If that’s the case, and I have six cells and people are on thyroid medication, man, wouldn’t you think that people on thyroid medication might have a greater incidence of cancer?

What I did was I said to my friend Kelly Halderman, who co-authored the book with me, I said, “Kelly, I would venture a guess that if hypothyroidism is a protective mechanism, that giving people thyroid hormone medication might increase the incidence of cancer, but nobody would ever do that research paper and publish it. It’d be like suicide, to do that,” because, man, that goes against the culture of what we’re doing. We’re putting all these people on and we are potentially creating more cancers.

In 2019, a new paper comes out and it talks about the incidents of cancer in patients on hypothyroid medication, specifically T4 medication. In almost every form of cancer, people being treated for hypothyroidism had higher incidences of almost every form of cancer 5 to 10 years later. That is frightening. And so now you’re seeing papers– I’m putting together a presentation for next weekend, there’s more and more papers coming out saying exactly what I’m saying is “Tissue hypothyroidism is a protective response, especially when we have abnormal cell function.”

Let me give you one more example. I have a patient who’s an MMA, mixed martial artist. She is struggling with signs and symptoms, weight gain, can’t make weight, and her career, so you have [unintelligible 00:52:52]. This is a big deal like, “Hey, I got to do this.”

They put her on T4 medication, and she’s just wiped out, exhausted. She’s feeling awful, and they’ve got her taking L-carnitine and CoQ10 and all this stuff to make the mitochondria work better. I said, “Listen, If you have cell danger physiology going on and your body’s time to down-regulate the physiology, and you take a bunch of T4, what you’re going to do is increase your mitochondrial density, which means you’re going to have more mitochondria, but you’re going to have more crappy functioning mitochondria, which you’re going to create more oxidative stress. Now, you’re going to exercise and you feel like dirt because during your exercise, you’re pushing the system hard, but you can’t recover. You’re making so much oxidative stress, it takes you days to recover.”

We wound up doing a test called a MitoSwab test. Have you seen that test?

Ari: Yes.

Dr. Balcavage: I’m friends with the owner. I said, “Hey, man, I want to do this test.” He said, “Let’s do it. Let’s see what’s going on.” We do her MitoSwab test. Her mitochondrial density is through the roof. Her Complex 1 is 20%, her Complex 2 is functioning at 4%.

Ari: Wow.

Dr. Balcavage: Her Complex three is maybe 12%, and her Complex 4, I think, is in the 40%. Now, for an everyday Joe, those complexes should be working about 80 to 100% function. For an elite athlete, they should be 100 to 20% function. The problem was taking all that. [crosstalk]

Ari: Say that again. For an elite athlete, they should be where?

Dr. Balcavage: About 100 to 200% capacity.

Ari: 100 to 200%. Okay. Got it. [crosstalk]

Dr. Balcavage: Based on the owner of the lab and what their research has shown. The conditioned athletes [unintelligible 00:54:50] [crosstalk]–

Ari: The 100% is based on some norm of the population.

Dr. Balcavage: Yes.

Ari: Okay.

Dr. Balcavage: I’m like,We have to get you off the thyroid medication because it is increasing the number of sick mitochondria you have. Then you’ve got people that are trying to get you to burn fat efficiently. You don’t have mitochondria that can burn fat as fuel.” I think we’re crushing people.

Now, if you don’t have cell danger physiology going on, you take T4 and you feel great, awesome. Then you probably don’t have those issues going on. You may have had enough destruction of the gland that you need some T4, maybe even need a little bit of T3. By the time you’ve officially diagnosed it’s primary hypothyroidism, you’ve lost greater than 90% of the function of the thyroid gland. That’s not the beginning of a condition.

The whole time that’s going on, you have less and less thyroid hormone in the system. That also means there’s less and less potential conversion that’s happening at the tissue level.

Now, you had other questions there and I forgot them, so remind me what they were. [crosstalk]

Iodine and hypothyroidism

Ari: No. I think what you said there is a perfect answer to what I asked, and that explains it. Okay. I have a couple more questions for you, and this is absolutely fascinating stuff. You’re brilliant at the way you’re laying this all out and teaching it.

I have a friend– You probably know him, maybe you’re familiar with his work. His name is Dr. Alan Christianson. He’s been talking about hypothyroidism for a long time. He wrote a book recently, I think it came out about a year ago. I think it’s called The Thyroid Reset Diet. The crux of this book is basically– It revolves around iodine.

This is a weird thing that goes on in this whole space because if you talk to the vast majority of alternative health, natural health functional medicine type people, the vast majority of them say, “Oh, you’ve got hypothyroidism, iodine supplementation is key because it’s involved in thyroid hormone synthesis. You got to make sure that you’re taking iodine, taking seaweed, whatever it is.”

Conversely, you’ve got people like Alan Christianson saying that actually, we have a very narrow range for the space between iodine deficiency and iodine excess. Actually, most people are in iodine excess, and that this iodine excess is actually highly toxic to the thyroid gland. Here’s all this research showing that iodine restriction, avoiding foods that are rich in iodine, avoiding certainly the use of iodine supplements will actually improve thyroid function. He used this as very, very central to this whole story of hypothyroidism and resolving it. What is your take on that?

Dr. Balcavage: I think for some people taking iodine could be beneficial. I think for some people depleting their iodine or not getting much iodine could be beneficial. I think there’s a whole group of people that live in the gray space in between. When we have an idea, a theory, a bias, and we treat people a certain way, some of those people get better and the people that don’t, they leave our process, and we don’t know what happened to them.

Maybe they got better or maybe they didn’t get better.

We have a problem in functional medicine where we think it’s all about a deficiency, it’s about too much. We think that we can just give something and it’s going to do what we want it to do. I don’t think that’s the case. I think Naviaux’s paper points that out. I have patients– I don’t spend that much time [crosstalk]–

Ari: For people listening, Naviaux’s paper is the cell danger response paper.

Dr. Balcavage: Yes. On that paper, he’s got pictures. Google cell danger response and looks for the pictures. What it shows is that in homeostasis, these nutrients we take in from our diet and nutrition, in non-stress states they do one thing, and in stress states, they do something else.

A great example of this is something called tryptophan. Tryptophan, we use to make B3 and a bunch of things, but one of the things we use it to make is called serotonin. Serotonin makes us feel good, that can be converted to melatonin, which helps us get to sleep and helps be an antioxidant for the brain. Under stress conditions, [inaudible 00:59:55] serotonin production, to make more things like kynurenic acid and quinolinic acid that could be more neurotoxic. It decreases the amount of tryptophan that goes to serotonin. Why would the body do that? That doesn’t sound like a good thing.

If I can use those chemicals to make something, maybe to fight off a threat or a toxin and make me more stimulated to be able to fight things off, maybe that does make some sense. If I have less serotonin, maybe I don’t feel so happy and want to go hang out with all my friends. The body does things in different ways.

A little side note there, the other thing that happens with serotonin, not only do we not make much, but we metabolize it much faster under a stress condition and so we feel that depressed state.

What happens when we metabolize the serotonin, we make more of something called hydrogen peroxide. Now, what is hydrogen peroxide? That is an antimicrobial. Oh my goodness, isn’t that crazy? We make an antimicrobial out of this thing. How does that benefit? If I have a threat, if I have an organism, I can use hydrogen peroxide. You know what? Guess what? When I deactivate thyroid hormone in the cell, now I have this iodine that I can bind to that and make something that’s even more powerful antimicrobial. How about that? This is crazy science.

I’ve read Alan’s stuff, got his book, I agree with a lot of the stuff he says. I know that the other end of the spectrum, and I agree with some of what they say, but we don’t have great tools to measure iodine physiology in the body. There’s not much that shows there’s huge accuracy on an individual. You have to do multiple tests over a series of days to really get an idea.

I haven’t put that much time and attention. I try my tell my patients like, “Don’t go out of your way to take a whole bunch of iodine, but you also don’t have to be neurotic to eliminate it.” This is rarely about one individual thing like I need methyl folate. I don’t know if you necessarily need high-dose methyl folate. I don’t know that it’s just a methyl-B12 issue, or “Hey, I’m allergic to B6.” No, you’re not allergic to B6.

When you take these things, we want them to do something to make us feel good. Again, if I’m giving a nutrient to somebody and I need it to not feel good, I need it to do something that’s protective, that thing might not make me feel good. I understand both concepts, but I think the reality is somewhere more closer to the middle for the vast majority of people.

How to fix cellular hypothyroidism

Ari: Got it. I’m really enjoying this, Dr. Balcavage, and I want to be also respectful of your time. I’ve had you on for a while here and we also did about a 20 or 30-minute call prior to starting the podcast. Maybe my last– I don’t want to lie so I’ll say one of my last questions-

-is how do you approach fixing this? We’ve got the paradigm, we’ve got the conceptual framework that you’ve laid out. I think it’s very compelling. I think you’re spot on with the way that you’re doing this but one of the problems with this system’s thinking approach is that it’s complex. Most people generally like the simple stuff. It tends to stick better when you say, “Oh, it’s this one thing or that one thing. All you got to do is this and this,” and then you fix it. The medication approach, for example, or take this thyroid supplement approach is an easier-to-grasp solution for most people than the big-picture approach you’ve laid out here.

Maybe you can simplify how this breaks down on a practical level. Let’s say, you’ve got somebody who’s a patient of yours. You identify their thyroid panel indicates hypothyroidism. Their broader metabolic panel indicates lots of issues that are congruent with the thyroid issue. They’ve got signs and symptoms, they’re overweight, they’ve got fatigue, they’ve got these other issues that are also linking up. Now, what do you do about it?

Dr. Balcavage: I know exactly what you’re talking about because it is so much easier to treat the diagnosis and manage the diagnosis than it is to address the patient and treat the individual patient. I could have 20 people that show up in my office with tissue hypothyroidism and glandular hypothyroidism, thyroiditis, gut issues.

What we love, especially in functional medicine, is the protocol. Just tell me the protocol. Just tell me what to do. Do I need a gut protocol, do I need a detox protocol? What do I need? This isn’t sexy.

We see the post like Epstein-Barr Virus is the cause of hypothyroidism or H. pylori the cause of Hashimoto’s. Everybody’s racing out to treat Hashimoto’s because everybody’s got H. pylori. You have Hashimoto’s, it’s got to be H. pylori. I’ve read that in a blog post. Somebody taught me that in a class. That’s what it is.

My method isn’t sexy. It’s individual based. When I look at those things, my simplified version of this is we have to look at our patient’s health history, health timeline, signs, and symptoms and say, “How did we get here?” We look at their– What I call their fitness factors. We have to talk about their emotional fitness because emotional fitness can create a stress response that changes our chemistry and physiology. We do a questionnaire on their emotional fitness, like, “Is this a problem? Look at your health history, your health timeline. You have lots of traumas and things. Let’s scale this. Where is this on a category scale of 0 to 10 for you?” Real versus perceived.

We take a look at their physical fitness. Are you over-training or undertrained? We have to take a look at their physical fitness. I want to take a look at their sleep fitness. What’s your sleep status? Do you sleep every night? Do you get six to eight hours? Are you waking up chronically through the night? If that’s busted, we got to work on what’s going on with this. Is it habits, is it behaviors? Is it something else that’s creating it? Let’s address it.

Let’s talk about respiratory fitness. What’s your respiratory rate? “Oh, I’m 25. Just like the norm.” That sucks. You should be somewhere under 12. Even lower is better as a respiratory rate. What’s your control to hold breath time test? Do you mouth breathe at night? “Of course not. I don’t mouth breath at night. I don’t snore.” Of course, you do if you got inflammatory issues. We look at metabolic fitness, let’s go on the chemistry. We already talked about that. We talk about their habitual fitness. What do you do day in, day out that’s creating this environment?

I look at all of those pieces and then I start saying, “What are the ones that I got to start to look at first?” I’m working on diet and nutritional fitness. Let’s get to a more whole food, real food diet. I hate what we’ve done with the diet religions. Carnivore is better than vegan, vegan’s better than whatever. We’ve circled the wagons, we’re shooting in when we should really be using all of our collective energy and saying, “Hey, processed food is probably one of the things that’s killing us.” That’s not sexy either, so we should [crosstalk]–

Ari: The market incentivizes people to take radical positions in order to make money and misrepresent the literature and [crosstalk]–

Dr. Balcavage: Absolutely. What I tell people is, “Listen, here’s how I’m going to help you. We’re going to identify the stressors that are contributing to this cell danger response, physical, chemical, emotional, microbial, habits, behaviors, environment, toxins. We’re going to look at all those things. Two, we’re going to try and reduce or eliminate those stressors as much as possible so that we can start to see a shift from allostasis, cell danger physiology to homeostasis.

How are we going to see that? Because you’re going to start losing weight. Your symptoms are going to start to improve, and then we know we’re starting into a healing process. Then what are we going to do? We’re going to support the recovery of those tissues, diet, nutrition, exercise, habits, behaviors, and then we’re going to support health versus this disease state. It’s not sexy.

Now, somebody can say, “I have an adrenal problem. I have a gut problem.” Listen, when you have excessive self-stress, if you need a name for it, what you have is a multisystem adaptive disorder. That’s what you have. “No. I have adrenal–” Of course, you do. You’re going to have an adrenal problem. You’re going to have a sex hormone problem. You’re going to have PCOS, you’re going to have– Name it.

When you have excessive cell stress and downregulation cell metabolism, you’re going to have, at some point in time, multiple systems are going to break down. You can treat the multiple systems like the disease state or you can get to the root. That is habits, diet, nutrition, behavior, respiration, trauma, all those things. It is not sexy, but could it be Epstein-Barr? It could be, but let’s not hang our hat on Epstein-Barr. Let’s check it but let’s not hang our hat on that.

At the end of the day, it’s all about the foundational principles of what functional medicine’s about. Good diet, good nutrition, good assimilation, good habits, good beliefs, good thoughts. All these things that nobody wants to pay attention to. We’re jumping over dollar bills to pick up pennies many times by running all these expensive tests, chasing something down, but not working on our breathing, not working on our mindset, not working on our habits, right?

Ari: Yes. I [crosstalk]–

Dr. Balcavage: It doesn’t sound sexy, but that’s what’s worked.

Ari: I have so much I want to say in response to that. I want to first drop the mic on your behalf because that was a powerful moment. Everything you just said is so spot on. I love it.

I find also that there is a tendency among functional medicine practitioners who are– I have lots of friends and colleagues who are, who tend to, as you were implying there, tend to overlook all these foundational factors in human health, and then are just looking at things from this perspective of almost assuming that people have foundational habits in place. Then it’s like, “Okay, let’s go to these tests, run our panels, run our organic acid panels, run our hormone panel, and then run our hair mineral analysis panel and whatever else.”

Then in response to whatever abnormalities appear there, it’s like, “Okay, let’s put you on this protocol. We’ll put you on the detox protocol. We’ll put you on the gut-fixed protocol. We’ll put you on the whatever else protocol.” Prescribe this and that supplement for you.

When you’re skipping over all of those foundational aspects, really dialing them in, you’re missing the boat, in my opinion, because the vast majority, over 80% of the chronic disease burden in this country is from nutrition and lifestyle factors. We cannot just presume everybody’s already got that dialled in. Almost universally, with very few exceptions, people actually have a lot of work to do. If you really understand that– And that’s, I think, the issue is that deep understanding of those factors and how to do them well, is lacking in most practitioners.

When you really understand that, there is almost always a lot of work to do on that front to dial in someone’s circadian rhythm habits and exercise habits and hormetic stress habits and nutrition habits, and light exposure habits. When you dial those things in, I see massive shifts in people’s health.

Dr. Balcavage: Yes, and a lot of people will say, “I’ve done everything.” [crosstalk]

Ari: Everybody thinks they’ve done everything, and then when you actually talk to them, you find out they’ve done everything that in their limited awareness that they’re aware of doing, but they actually are very far from doing everything.

Dr. Balcavage: Yes, with our own bias, with our own level of ignorance. It’s not you’re dumb, it’s like, “This is what I know, and I’m doing what I know.” Okay, but that’s wrong, right?

Ari: Right.

Dr. Balcavage: What’s a great example of that? Eating fat causes you to be fat. How many of us lived with that bias and level of ignorance? Hey, I was taught that. We taught patients that. The food pyramid, eat 11 servings of grains and carbohydrates every day. Keep the fats really low because they cause fats. What do we do? We just blew people up and made them chronically inflamed and obese.

We think we’re doing it– And for all of us, we do better than we are, and we think we’re doing our max. We don’t realize there’s another level to be better. We stay in our comfort zone, we don’t push things, we don’t realize there’s that next level. We get trapped in that model.

I think the other thing is understanding what health is and that’s a whole nother conversation. That’s maybe a whole nother podcast is, what the heck is it? Nobody’s got a really good definition of it. I talk about health in the book and what my understanding and definition and what are the fitness factors and what is physical fitness and emotional fitness. What does that mean? I have my definitions in the book and selfless plug. If you want to know what those things are, go out and buy my book, The Thyroid Debacle.

It’s interesting because when I ask physicians like, “What’s your definition?” “It’s a state of physical, chemical, and emotional well-being.” All right, so what is well-being? “Well, it’s when you’re healthy.” You can’t do that.

I had a physician on who was talking to me about health and longevity, and I said, “What’s the definition of health?” He did not want to have that conversation because he’s like, “Well, uh.” I’m like, “Tell me how we monitor it. How do we measure it?” He did not want to have that conversation.

Matter of fact, I got, from somebody, I guess he’s a follower of him, got a comment in my podcast like, “You shouldn’t have pushed him on– Asking him that type of question. He didn’t feel comfortable.” Look, I didn’t do it to be uncomfortable, but I just did it [inaudible 01:14:51] [silence] what that actually is and a way to assess it. We don’t have that at this point.

Dr. Balcavage’s top tips to eliminate cellular hypothyroidism

Ari: Absolutely, my last question to you. I think you’re going to have a little bit of resistance to this given the big-picture nature of the work that you’re doing. If you could narrow it down to three factors, three practical strategies or areas that you feel you see the biggest improvements in your patients when you’re working to fix hypothyroidism, just the absolute biggest needle movers. When we address this, this, and this, I very frequently– Maybe not always, but I very frequently see massive shifts in a person’s health and well-being.

Dr. Balcavage: Can I cheat with four?

Ari: Yes, absolutely. I give you permission to cheat. I’m a very bad professor. [chuckles]

Dr. Balcavage: Number one, eat more real food, less processed food. Start there. I don’t care if it’s organic, inorganic. Start with eating more real food, less processed food. Eat more real food, less processed food. Eat it the way it came out of the water, walked the earth, off the tree, aisled the ground, step one. Step two, protect your sleep and quiet time. You’ve got to get sleep.

It destroyed me for decades just thinking I was tough with four hours of sleep at night, sleeps for the week. You need your sleep. That’s when you recover. That’s when your brain restores everything. You need to flush your brain. There’s so much important stuff that happens with sleep. If you have [crosstalk]–

Ari: I like when people say, “I’ll sleep when I’m dead.” I’m like, “Okay, but you’re going to die a lot sooner with that attitude, just so you know.” chuckles]

Dr. Balcavage: That was me. That was me saying that, and then it leads to poor health. The third, you got to restore proper breathing. Most of us believe that we breathe appropriately. Most of us are over breathing. Most of us are improperly and disordered breathing, especially at night when we’re not paying attention to how we’re breathing and just breathing inappropriately. You might have higher oxygen saturation but you’re having less oxygen get to the tissue. Look up the Bohr effect, and you can read all about it, but shut your mouth, tape it shut, learn how to breathe through your nose again and life can be a lot different.

Then the fourth one is, get your head right because what goes on between the 6 inches of ears makes a huge difference in how your physiology works. Not that you’re crazy, not that you’re making up stuff but your thoughts, emotions, feelings change your physiology. If you’re a person who doesn’t like presenting in front of a large group– And I told you I’m putting out there right now to speak in front of 4,000 people on thyroid physiology, you’d have that “Oh, no,” moment. Your fighter flight system would kick in. You would change the chemistry running through your body. You would go through the four Ps. I’m going to pass out, I’m going to puke, I’m going to pee, I’m going to poop. Those things are going to happen.

What happened? Your thoughts about something that didn’t even happen yet had totally changed your chemistry. That’s a massive change but think about the stinking thinking we do day in, day out and how that could slowly erode away at our physiology just because of the way we think, and think of the flip side of that. Remember when you met that person that you fell in love with for the first time and all the waves of emotion that go through you and how light you felt and how wonderful you felt every time you met them? That again, is your thoughts and your feelings changing your chemistry.

We have the ability to change the physiology based on our thoughts, our feelings, and what goes on, so those four things. If you have no money, you do those four things. Now, how do you do it? That’s a whole nother conversation. Sometimes you can do it on your own, sometimes you need help. Many times you do, but those four things are literally free to work on and everybody ignores them.

Ari: Absolutely brilliant, my friend. It’s been a great pleasure to have this conversation with you. I hope it’s the first of many, and I highly recommend everybody go out and go onto Amazon or wherever you buy books and get The Thyroid Debacle. Learn more from this man, Doctor Balcavage. I keep wanting to say Balcavage because I was reading all the emails we were exchanging and in my head, I kept saying “Balcavage,” but I’ve learned since talking to you, it’s less French than I thought it was.

Dr. Balcavage: Yes, more Polish, less French. [chuckles]

Ari: More Polish, less French. If somebody’s interested in working with you directly, where should they reach out?

Dr. Balcavage: They can go to rejuvagencenter.com and they can book a discovery call where we have a conversation because I want to talk to everybody before and decide if we’re a good match. I usually do discovery calls of just “What’s going on, what are you looking for?” If you’re coming to me, I want to explain to you what I do, so we’re not wasting money having you come in and pay for a consultation for something that you’re not really resonating with.

They could find me on Instagram if you want to hear more of my posts. That’s probably where I’m most prolific. I just learned how to use Instagram a couple of years ago and now, I think I got that dialed in a little bit. I also have a podcast called Thyroid Answers Podcast. I’ll look forward to having you on the Thyroid Answers Podcast. We’ll talk about energy and everything else. My podcast has been out. I think we’re on year six. We talk about all aspects of health, but do the eyes of the cell danger response and adaptive thyroid physiology.

Ari: Beautiful. Wonderful, brilliant stuff. Thank you so much for the work you do, and I hope to talk to you again very soon.

Dr. Balcavage: I appreciate it. Thanks for having me on.

Show Notes

What the conventional and alternative functional medicine are missing when it comes to thyroid health (01:45)
Greenwashing medicine (07:28)
The root causes of thyroid issues (08:48)
Cellular hypothyroidism (18:09)
Adrenals and hypothyroidism (29:20)
The classic signs and symptoms indicative of cellular hypothyroidism (31:08)
What if you already have hypothyroidism (42:00)
Can taking thyroid medication make patients feel worse? (47:36)
Iodine and hypothyroidism (56:15)
How to fix cellular hypothyroidism (1:03:00)
Dr. Balcavage’s top tips to eliminate cellular hypothyroidism (1:15:15)


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