OneMedicine Podcast

Rob Lutz 00:00
Hello and welcome to the OneMedicine Podcast with Today's Practitioner. In each episode, we share the expertise of a respected thought leader. Some you'll know, and others you'll probably meet for the first time. We cover topics important to you, always with a focus on improving the health outcomes of the patients you treat, while expanding your understanding of the many healing modalities being used today.

Rob Lutz 00:24
Hi, welcome to the OneMedicine Podcast. I'm your host, Rob Lutz, and with me today, we've got Corey Schuler from the Allergy Research Group, and we're going to talk about thyroid health. So we've got quite a bit to chat about here and, but before we do that, I know a lot of people already know you, Corey. You've been in the industry a long time, and well-known and well-respected. But could you just share a couple of minutes, a little bit about your background and what you're doing?

Dr. Corey Schuler 00:47
Yeah, thanks for having me, Rob. My background is a little bit diverse, which means I have a little bit of a goofy approach to just about everything now. I've been trained in conventional medicine as a nurse practitioner, but I actually started my career in chiropractic medicine, and it kind of moved into nutrition, and then expanded into that internal medicine idea, and then just took my research into a PhD program on, really, patient preferences and kind of understanding this multimodal interaction between people and their practitioners. So from, that's my education side of things. I started in the industry a little bit longer ago than I frankly would like to admit, as you noted here, but I've worked for some really great companies and created some products along the way. So this is, right now I'm serving in Medical Affairs at Allergy Research Group.

Rob Lutz 01:40
Great. Well, thank you, and thanks for coming on the show. So we're going to talk about thyroid health. And you know, it feels to me, I'm not a practitioner, but it feels to me just with conversations with people that I know, thyroid health and issues seem to be coming up more frequently. And I don't know if it's just because I'm aware of it or not, but it was actually a conversation I had with someone over the weekend that a lot of his friends, mostly women, you know, are expressing some concern that they're having some thyroid issues. First of all, is that something that you're seeing, or is there more prevalence of some issues at this point, or is it just--was it just coincidental?

Dr. Corey Schuler 02:03
Yeah, good question. Is it an awareness thing, or is it actually a change in disease states? Good question. I think there's probably a little bit of both.

Dr. Corey Schuler 02:25
I think there's truth in both of those, because thyroid function has just so many different impacts on different systems. People can kind of pull on that thread, and it is a little bit like a great mimicker, kind of like Lyme disease, or, you know, mycotoxin disease or mycotoxin illness--that is, I think it's a little bit of both. And yeah, it does lean towards women. It always has, ever since we've sort of continued or started collecting data that way. We've noticed almost like a seven to one or even an eight to one prevalence for women as compared to men. But that really all falls apart when there's one person sitting in front of you hurting. Right? And so that's sort of my focus of it. It's like, "Oh, yep, we see it, and we should work on it."

Rob Lutz 02:25
Sure.

Rob Lutz 03:13
So when you see a patient, what are some of the symptoms that you notice, and what are some of the symptoms that maybe other practitioners should notice, if that makes sense?

Dr. Corey Schuler 03:22
Yeah, great question, right? The textbooks tell us for hypothyroidism, we're gonna see constipation, we're gonna see fatigue, and then always like, oh, hair loss. It's particularly to the lateral aspects of the, like, two-thirds of the eyebrows. Dry skin, itchy skin, low mood. It really is a laundry list of things that are implicated, even in conventional training, of what you might see, but primarily what--you know, it's weight gain and fatigue are the two key indicators of like, "Okay. We at least need to investigate this."

Dr. Corey Schuler 04:00
And so when you look to investigate, what are some of the things that you do?

Dr. Corey Schuler 04:03
Yeah, I mean, because the serology or the lab tests are so easy and, frankly, inexpensive, we like to do that. Right? If I was exclusively conventional, I'd run TSH, and then if that was positive, the lab would reflex that to free T4 and that would be it. And that's the end of my investigation. Because I'm the way I am, right, I like to look at free T4 and free T3. I always look at thyroid autoantibodies, especially if there's any family or personal history of autoimmune disease, or if I suspect that that could be implicated in it, because of either inflammatory symptoms or, frankly, just suspicion. So I tend to run the autoantibodies pretty commonly.

Rob Lutz 04:46
And then what, just specifically, what do you what do you look for? Any kind of particular numbers or scores, things of that nature, that really tip it off for you?

Dr. Corey Schuler 04:54
Yeah, good question. So everybody in my, like, little camp of thyroid professionals has their own measures of ideal, and I'm going to put them in terms of the reference ranges. Right? If I had my magic wand and I said, "What's your perfect TSH?" I think it's around 1.6 to 1.8, and that's kind of ideal. But I'm also very aware that TSH levels don't necessarily correlate well to how people feel, and that's what I more care about. When it comes to free T4 and free T3 I want, I'm looking at free T4 basically right in the middle of the reference range, and I like free T3 at the higher end of normal, when possible, if I'm really trying to optimize thyroid function.

Rob Lutz 05:40
Okay, great. Thank you. You know, so you touched on something that, you know, thyroid can really have an interplay with a lot of different systems in the body, and maybe that's why it's such a critical thing to be looking at. But, a driver of autoimmune disease, you know, cardiovascular risk, adrenal health, stress, things like that--I'd like to pick apart each one of those if we have time. But what if we just start with the autoimmune disease as a starting point? Could you just talk to that for a little bit? You know, what's with that?

Dr. Corey Schuler 06:07
Yeah, I have a long list of things that are potential immune disruptors, things that can maybe cause that hypervigilance of autoimmune conditions, or just autoimmunity in general, and it's some of the basics. Right? The standard American diet, poor sleep, nutrient insufficiencies. Right? We're going to cover these, kind of like, just in good medicine. But there's also some genetic components, some HLA-B27 impacts, and some others on that toxin load. But when it comes to things that I think are most modifiable, it's those two big ones of chronic stress and latent infections. And I'll say latent infections probably doesn't get the press that it maybe should when involved in this, because--well, for good reason--it's a bit ubiquitous. Right? A lot of people, up to maybe 90% of people, have positive serology on EBV or Epstein-Barr virus. We'd probably have something similar when it comes to HH6. And so if you think about that in the conventional lens, it's like, "Well, if everybody's positive, not everybody has thyroid disease or autoimmune disease, so maybe I should just ignore it." But I think of it a little bit differently than that.

Rob Lutz 07:22
So what, in that respect, what do you do? What's your go to?

Dr. Corey Schuler 07:26
Yeah. Interestingly, I'm not a virologist, and I'm not somebody that spends my functional medicine clinical time pulling apart and piecing together all of these different viral load concerns. I actually take a step back a bit, given that context of the ubiquitousness nature of it. Instead, I have to think about, "Okay, well, what are, what's modifiable?" And I'm kind of eyeing in on this idea of natural killer cell, or the innate immunity part of the body. Whereas if I say, "Hey, let's stimulate the immune system in an autoimmune disease," most of my friends would be like, "Whoa!" Like, they get nervous when you do that, because you can exacerbate symptoms. And I agree, but when we kind of focus on this contribution of, all right, latent infections, there's--by definition, they're sitting below the surface. They're sort of tucked away. And the question is, "What makes them rise up to cause symptomatology?" And usually it is that natural killer cell, is that dome that kind of keeps things down, and one of the main things that allows that dome to be dismissed is going to be something like chronic stress. And there's a number of different, like, questions of how that works, but let's just leave it at, all right, cortisol is probably implicated in this, or cortisol dysregulation is implicated in this. There's an underlying inflammatory concern about it, which allows those latent infections to pop up. And we can, how do I say, dismiss or confuse those latent infections being active as just part of another disease process. And that's like a lot of words to say, "Hey, if you have Epstein-Barr virus and you have--and that's a latent infection, because when you were 16, you got it and you got sick and you were tired for a month or two, and now you're 45 and you're tired again." A lot of people ascribe that tiredness to modern-day living, maybe their disease condition, something like that, when in reality, it's their immune system failing to keep those latent infections at bay.

Rob Lutz 09:35
And it could be caused by chronic stress, or is it potentially the cause, it's making it worse, or is that what's causing you to have a dysregulated stress response in some way? Is there kind of a--yes? Is it a yes answer to that? Kind of?

Dr. Corey Schuler 09:52
It is a yes answer to that. There's a bidirectional issue there. Right? And immune dysregulation can cause the chronic stress or contribute to the chronic stress. Right? It might be that, hey, life is out of control, and that's the chronic stress, and it could be these biochemical stressors that are stimulating that chronic stress. So either way, like, that can happen. I can't necessarily affect all of that all at once, and so I have to think about it as pragmatically as possible. What can we do right now? And, just to get a little bit nerdy for a second, if you'll allow for that, like there's the latent infection piece of it. It's really a chronic stimulation of both B cell and T cell, and that results in a change in intolerance. And that might be one of the things that we're paying attention to, and we're also paying attention to this, like, viral molecular mimicry. Right? If the body's trying to get rid of, or at least minimize, that viral load, it can attack other tissues that kind of look a lot like it. And so molecular mimicry, as well as B- and T-cell stimulation, are at least two--there's a handful of other mechanisms, but those are the two I like to pay attention to.

Dr. Corey Schuler 11:12
Yeah.

Rob Lutz 11:12
Do you go there first? Do you wait? Is it simultaneous?

Dr. Corey Schuler 11:15
It's simultaneous, but stacked, if you'll allow for that, because right, stress management can be, can take a long time to see the beneficial effects. Right? If I tell somebody, "I want you to meditate for 10 minutes," and they're like, "Alright, I did it! Now I'm cured!" Like, it's not really a thing. Right? It's a habitual, long-term strategy, and sometimes those stress-management pieces of things take a while to learn. Right? If we're in the groove of deep, chronic stress all the time, it's hard to create or develop or get rid of habits that are causing that. And so I usually start with some degree of supplementation to biochemically regulate the hypothalamic-pituitary-adrenal axis. We've talked ad nauseum about that in our world, but it's important to start and get some relief in some degree from that, while those habits are built.

Rob Lutz 11:25
And do you ever just go right to the stress management? Is that something that, is there a sequence, I guess? You know, if you're looking at stresses, what are the issues?

Rob Lutz 12:00
Kind of a side question, but it relates to stress, and curious if it plays a role with thyroid health. We hear a lot about the vagus nerve, or I do anyway. You know, there's a lot more of that coming out, and different ways to, you know, stimulate the vagus nerve, whether it's electrical stimulation or humming or some of the other things. What are your thoughts about that? Is it just kind of a hype-y thing? Or is there, is there something there? Is it something that, what do you think?

Dr. Corey Schuler 12:24
Great question, and it is--I'm gonna jump in my DeLorean for a second. Go back in time with me--is that when I started, I was like, "Yeah, that's fluffy stuff." Like, "Yep, no, that that." As I've gotten more mature and actually paid attention, I find that to be one of the more heavy hitters of beneficial effects. And you're right, and I create, you know, handouts and I spend a lot of time, actually, in clinic talking about neural regulation and parasympathetic drive and stimulating the vagus nerve. And so I'm all in on that stuff. And yeah, I mean, I have my list of things that I like. And, you know, some of them are very expensive, some of them are dirt cheap, and I kind of like all of them. And so, I like to present on really driving that as much as possible.

Rob Lutz 13:25
Yeah.

Dr. Corey Schuler 13:25
Like, if I can name names, I don't have any interest in these companies, but like, the Pulsetto around the neck, I can explain, "Oh, yep. That's short term." Like, it only takes a few minutes at a time and, but it's very strong, whereas Apollo Neuro, or other things like that, are a little bit more gentle, and you can use them a lot longer throughout the day. Yep, and there's an expense to them, etc. But humming, singing, gargling, and different positions are really critical in what I call the stress management protocols.

Rob Lutz 13:55
Yeah. I mean, I've noticed, I won't put too much more into this one, but I track my heart rate variability like, you know, got all the little gadgets and so forth. But when I meditate, my heart rate variability just goes through the roof, you know, it's up over 100, whereas if I'm sitting at my desk working, sometimes it'll drop down into the low 20s. And so I know it's how I'm breathing, probably, that's driving that. It's, I think it's just kind of incredible that the breath can have such a huge impact.

Dr. Corey Schuler 14:18
Yeah.

Rob Lutz 14:18
It's just so easily overlooked, because we do it all the time, right? But anyway, that's a whole other topic. Yeah. So, you know, we talked about dysfunction and autoimmune types. Do you want to talk a little bit more about that? Because I think that's autoimmunity, thyroid health, is there more to talk about there?

Dr. Corey Schuler 14:39
There's always more to talk about. But I mean, from a, from again, practical standpoint, no. As long as we know that, "Hey, all right. Hey, I haven't heard about latent infections causing or driving autoimmune disease." Okay, now that's good. That's in our awareness. That's in our sphere. Let's start paying attention to it. Again, when it comes to thyroid, HH6 is usually the one, and I'll share a detail on this. HH6, or human herpes virus 6, has variants, and variant B is the one that usually causes, like, roseola. That's usually an infant type of condition that, so then it becomes comes latent. That's not as problematic. The A strain actually is, and that is sequestered, typically in neurologic-type tissue, so think like glial cells, but also the thyroid. And so that one's a little bit more problematic, and there's no, like, FDA drug that's gonna target latent, or even active, HH6 either A or B. So that kind of opens us up in the natural world of things to do what we can for it.

Rob Lutz 15:25
And so that, when you say do what we can for it, are we talking about various supplements that a patient could take? Or other?

Rob Lutz 15:51
Yeah.

Dr. Corey Schuler 15:51
Yeah, I mean, the the one that probably gets the most heat in a good way, is probably just shiitake mushroom and shiitake mushroom extract. It probably just has the most evidence to support. There's other ways of doing it, but as long as people tolerate and are comfortable with it, I like to get shiitake mushroom from food, but also we really get some good, high-concentration stuff in dietary supplements. And there's some in particular that are very high concentration, and they end up being cost-prohibitive, frankly, for some people, especially if this is more of a lifelong thing that we need to work on. And so while we talk about, and this is a different topic, but like we talk about detoxification protocols. Some people like to do heavy-handed detoxification protocols. I'm more on the trickle detox side of things. Similarly, I like to be on the trickle immunostimulatory side of things to get natural killer cells. And so a little bit often, an increased frequency, is my preference on helping with those natural killer cells.

Dr. Corey Schuler 15:55
And the chronic stress piece.

Rob Lutz 16:20
Right. What about selenium? I know that's one that's commonly referred to as, and that's an inexpensive supplement. But what role does that play?

Dr. Corey Schuler 16:50
You know, selenium, super cheap. It's barely an inconvenience, often in multivitamins, that sort of thing. And, you know, in the world of thyroid, that's one of the main converters of T4 to T3, so we gotta have selenium when we're supporting thyroid. Interestingly, there's now a number of studies looking at a combination of Myo-inositol and selenium in a ratio, and it's not super-high dose, that seems to work better than selenium alone, but can mitigate some of the autoantibody response, as well as modify TSH to a degree. So that's very exciting, because it's, you know, when something's cheap, easily accessible, and works, I love it.

Rob Lutz 17:49
Yeah, awesome. So anything else that you want to mention about, you know, thyroid and the immune system, how they kind of work and play with each other, or how one's out of whack and it can impact the other? I know we covered a little bit already, but anything else there?

Dr. Corey Schuler 18:04
Yeah, not as much on on the cause side of things, but on the consequence side of things, there's certainly things that we should be paying attention to. Early in my career, I started paying attention to these, how autoimmune conditions kind of beget one another, and so if you have one, that means we should be paying attention and surveil other potential manifestations of that autoimmune disease. So like, you know, gluten intolerance, or celiac disease, and Hashimoto's is probably now one of the more famous combinations thereof. But there are, there's autoimmunity to the small intestine. Right? We've learned about anti-vinculin antibodies, and that sort of thing, and it usually expresses itself as small-intestinal bacterial overgrowth or fungal overgrowth. Okay, got it. There's also--we're paying attention to the vasculature as an autoimmune target, which if you talk to cardiology, or even some of my colleagues, they'll look at me sideways and say, "What do you mean?" And then I just bring them back to what we learned early on in our training about, well, how does atherosclerosis really start? It starts with that foam cell, you know, being developed. The foam cell is created because immune tissue, or immune cells, enter that tissue and kind of set up camp, and so that decreases the size of the lumen and often leads to hypertension. And so the consequences of a smoldering autoimmune disease are not to be mistaken, and it reminds me, it's probably a good time to just talk, not necessarily about cases, but like real people here. Too often, we have these patients--you know, I do my assessment, and I see all those lab numbers look pretty good, but I'll see, like, thyroid peroxidase be elevated, so those autoimmune markers be elevated, but their thyroid is normal, and they really don't have many of the thyroid symptoms. I'm still paying interest and attention to that because of what could occur later. And so, yep, I'm paying attention to cardiovascular issues, as well as those other bits and pieces, and I think that might be forgotten a little bit about, especially the way our medical system is broken apart into people's parts. I recently had a young man, actually, still in his late teens, and he, early on, had been ill, and yes, he had a positive thyroid antibodies. His endocrinologist didn't necessarily want to intervene because TSH and his thyroid hormones looked pretty good, and fine and good. However, he would develop these other symptoms that weren't explained by anybody else in endocrinology. So when he came to see me, we recognized that, yep, he did have an intolerance to gluten, and he was, actually had developed Raynaud's syndrome, and he was probably working on one more condition that we didn't necessarily come to an answer with, but he was losing some peripheral vision. I was actually worried about demyelination, or like an MS kind of condition, in him and, but if you look at him on the street, he looked totally normal, healthy. I feel like we were able to intervene and catch some of these things way earlier, decades earlier, than maybe the medical system would have caught.

Rob Lutz 21:25
So is that kind of a pattern that you were seeing and you've seen with other patients? Or, you know, just things that maybe other practitioners might not have connected the dots, it sounds like to me. Is that what you did?

Dr. Corey Schuler 21:36
Yeah, that's, I mean, just trying to--I don't want to overuse the word holistic--but just zooming out on the whole view of the person and stepping out of our specialties sometimes can be really helpful. And when I work, I have a colleague who does a lot of thyroid work, and essentially she just sees all women, all thyroid, all the time, and she picks up on these things that she's like, "Hey, have you ever noticed that, why is TPO always elevated, but TGA isn't? Like, let's start thinking about that," and we'll spend a handful of minutes chatting about it, dumping into PubMed, and finding other connections that maybe are helpful and sometimes are just not, and they're just red herrings.

Rob Lutz 22:21
Yeah, that's interesting. So anything else about Hashimoto's, you know, from an integrative care perspective? Anything else that you want to go do a little bit deeper on?

Dr. Corey Schuler 22:33
Maybe not deeper, but maybe wider.

Dr. Corey Schuler 22:35
And when, because sometimes I get Hashimoto's patients that roll their eyes a little bit at me, but I do bring it back to some fundamentals and basics, and so I won't spend a ton of time on this, but the reality is that we really do have to dial in diet. We really want to have a micronutrient-rich diet. Frankly, I think protein is a really good idea, because sometimes fatigue stimulates people to not exercise enough or not weight train, and so I like getting protein in there. Speaking of exercise and weight training, right, I do want my thyroid patients to be strength training at least twice a week, and heavy, and if possible, you know, going to the Nth degree. You know, Pilates is great for a lot of things, and yoga is great for a lot of things. I want people lifting heavy things and putting them back down, and so that's fundamentally important, as well as the sleep. Right? If you don't sleep, you don't heal, and I find a lot of my Hashimoto's patients do have dysregulated sleep, and that's on the individual person. If we zoom out just a little bit more, like, "Who are we talking about here?" We're seeing the patients being diagnosed, typically between the ages of, like, 30 and 45, and often women, often in a bit of a career trajectory, family trajectory, where there might be part of that sandwich generation, taking care of parents and kids simultaneously, and there's just a lot going on. And so I really have to put into context not what they have, but what they're experiencing, and what we can do about mitigating some of those things. Because I failed to mention it, but it's important to mention, when I think about hypothalamic-pituitary-adrenal axis stuff, right, that sounds very physiological. I actually think about it in terms of, like, "All right, what of these stressors that you're experiencing has an end in sight? Do you know is going to happen? Which part of these stressors is in the past, and which of these stressors really doesn't have an end in sight and you're going to continue experiencing it? What can we do to duct tape you together while you're going through that?" And that actually gets some shade on me sometimes, because that is what we refer to as, like just working on symptoms, maybe.

Rob Lutz 22:35
Okay.

Rob Lutz 24:55
I guess what I'm hearing is, to me, you're talking about a lot of foundational health strategies, whether it's your nutrition, your exercise, your stress management, and probably every single condition out there would benefit from that. And it would also probably help alleviate, you know, the potential for some of these things if we all focused on that a little bit more. It's not sexy. It's not fun. It doesn't give you a quick fix, but it gives you that foundation that allows you to respond better to whatever's happening in your world. So from a foundational nutrition standpoint related to thyroid health, you know, what are some of those nutrients that you want to make sure that your patients are taking, just from a foundational standpoint? We mentioned selenium, of course, but are there others that are just kind of key in your mind?

Dr. Corey Schuler 25:43
Yeah, I might as well jump to something controversial, and that's iodine. Some of my colleagues love it. "The more, the better." And some of my colleagues are like, "I don't even like people to eat seaweed, because it has iodine in it." And I have been on both sides of that camp, and I kind of learned that, because I used to be like, "Yep. There is some potential triggers to that." As I've looked a little bit deeper at the iodine pathophysiology or physiology, I recognize that if--without iodine, we really do, the thyroid really struggles to produce, because right, T4 and T3 each contain iodine. And so if we have a frank deficiency or avoid all iodine sources, the body can really not do well, and when the body freaks out at not having enough, it triages whatever it needs to and sometimes that results in further autoimmune stimulation. And so I like to go low and slow, but actually bring iodine levels up relatively quickly, so much so that I'm using superphysiologic doses in order to get them to where they need to go. And I usually start at that, those physiologic doses. 150 to 225 micrograms a day is what you see in a lot of supplements, or through foods. But if I look at the epidemiology on food intake in places like Japan, we have, you know, milligram dosages of iodine, and so sometimes I find that to be really helpful as well. So I can't, can't really, can't forget about iodine when it comes to thyroid.

Rob Lutz 27:20
Okay, any others? So selenium, iodine, what else? Anything?

Dr. Corey Schuler 27:25
Yeah, from a--how to say it? Everything is important. Even things, like, that we forget about. Vitamin A, oftentimes we're not paying attention to, but we really do need vitamin A, especially in the, we'll talk about the the thyroid, or the, excuse me, the latent infection piece of it, that's going to be important. Vitamin D, right? Gotten plenty of press in the last, whatever, two decades, that's going to help stimulate T regulatory cells, so that helps keep the autoimmune or the adaptive immune system from going in excess. And so, yes, I like vitamin D levels with my autoimmune disease patients in general. I really like that in the optimal range. You know, the 60 to 80 has been quoted before. I fall into that camp. I think that's a reasonable idea. And so sometimes that takes 125 micrograms or 5000 IU as a maintenance dose, and sometimes even a little bit higher to achieve those levels. And then, from a maintenance perspective, I like giving all of those fat-soluble nutrients once I dial that in, so that we're not just overdoing vitamin D alone. It's impossible to talk about anything in metabolism without spending a little bit of time, and we'll only spend a little bit of time, on the B vitamins because they're they're easy to get, but oftentimes I find that people are maybe not methylating properly. Maybe not. Maybe they're hyperutilizing it due to acute or chronic stressors. And so B vitamins, as well as vitamin C, I tend to be on the higher side of things when it comes to autoimmune and specifically Hashimoto's thyroid, I guess.

Rob Lutz 29:04
Just as a side question, you know, there's a lot of genetic tests that can be done. Is that something you ever suggest your patients do? Like a 3X4 or some of these others that are out there? Is that?

Dr. Corey Schuler 29:16
Yeah. I do like 3X4 and just genetic testing in general. Sometimes it's a bit cost-prohibitive and also, like, it's a little bit harder to modify. Right? So I like having that information. It's not a requirement from me, but it also can give us clues on things that they can handle a little bit better or tolerate better. I think Yael Joffe has done, uh, God's work to be able to make sure that people are aware of what is and isn't usable and modifiable when it comes to genetics.

Rob Lutz 29:48
Yeah. No, I found, I went through, I did one of the tests, and you know, I have a challenge of vitamin D, my B vitamins, you know, a few other things that then showed up, your know, as I did my more advanced lipid testing as well last year. So I found it very interesting and kind of coincided, you know, lined up with what I was seeing anyway. But yeah, that's interesting. So, you know, talk a little bit about the functional lab testing and interpretation, some patterns that you might see with stress, inflammation, nutrient deficiency, that kind of comes up in those tests.

Dr. Corey Schuler 30:20
Yeah.

Rob Lutz 30:21
Does that make sense?

Dr. Corey Schuler 30:22
It does. And I think it's more of, because in my initial panel, most of the time I am looking at inflammatory markers. Right? C-reactive protein is the one that gets, is popularized. It is an acute phase reactant and, same with like, changes in iron levels. And so we're looking at those in my individuals who are overweight or maybe carrying extra fat to lean mass composition. I also run the old-school sedimentation rate, because C-reactive protein, in particular, can be falsely normal, and so I'm looking at sed rate and C-reactive protein together. I also look at just neutrophil to lymphocyte count. We had to learn this kind of the hard way. We found that a high neutrophil to lymphocyte count has a negative impact on prognosis in a lot of very serious conditions, but we can also squint and hallucinate a little bit and say, "All right, this person is, yep, they're struggling with things. They don't have one of those serious conditions, but can we at least pay attention to a neutrophil to lymphocyte count?" I like that around 2 to 1, if at all possible, so long as those are in normal range. And that can be another marker of inflammation. And yes, inflammation is a rabbit hole into and of itself.

Rob Lutz 31:41
Mm hm.

Dr. Corey Schuler 31:42
You've talked to a number of experts on that, and so we won't belabor that, but like, yep, food sensitivities do come into play with that. This can be, how do I say it? Food-sensitivity testing can be great, and food-sensitivity elimination challenge diets can be great, but I also note that it also can be quality-of-life deteriorating.

Rob Lutz 32:03
Sure.

Dr. Corey Schuler 32:03
And so I don't want to, I don't want to cause inflammation whenever possible, but I don't want to develop an orthorexia type of situation or an avoidance or a, "I can never go out and do anything," kind of thing. Sometimes, it's like you make choices and then your choices make you, and we'll kind of handle it on the back end. So yes, food sensitivities come into play quite often, but what are those other things that are maybe more inflammatory that we can get rid of, and modifiable and environmental impact, things like the mycotoxin thing. I don't want to spend a lot of time on this idea of, "Mold is everywhere, and some of us react poorly to it," but I also can't not do that.

Rob Lutz 32:47
Right.

Dr. Corey Schuler 32:48
It's a pretty big deal, and when it affects people, it affects them really dramatically.

Rob Lutz 32:49
You know, we talked about some of the key things we wanted to make sure that we're covering, and cardiovascular risk was one that was, I think, kind of at the top of the list, and we touched on it. Is there more that you want to talk about that as you guide other practitioners that are looking at this? Is that something that most of them aren't thinking about, that, you know, thyroid and cardiovascular health are so intertwined in some ways?

Dr. Corey Schuler 33:15
Yeah, I would. The, again, going back to more conventional training, we hear about things like hyperthyroid storms, right, where people end up in the emergency room, and they have heart palpitations and maybe even a cardiovascular incident. And if we would have thought about it, yeah, that can be caused by thyroid, because we know that T3, a particularly active thyroid hormone, has a significant impact on heart rate. It also has significant impact on the contractility and the vascular tone, as well as things like lipid metabolism. Right? We learned that if you have hypothyroidism, your cholesterol is going to go up, but we sort of forgot about that when everybody started jumping from cholesterol to statin medication. And so there are pieces of this that matter. What I think matters most is that subclinical hypothyroidism, or just autoimmunity in general, really tends to affect arterial stiffness. And I love arteries to be nice and flexible and being able to adapt whenever possible. And that might be the piece of it that I want most people to start paying really close attention to, because if we're just looking at calcium scores, or we're just looking at lipid panels, or we're just looking at blood pressure, those things are good to look at, but it sort of doesn't tell us the why behind them. Maybe it was a bad diet for years and years and years, and maybe it was these, this smoldering autoimmunity that contributed to it, or maybe a little bit of both.

Rob Lutz 34:52
So how would you measure that? How would you look at endothelial health? Is there a test that you go to?

Dr. Corey Schuler 34:57
Yeah. Yeah. The endopat test is probably the better of things that I have run into. However, sometimes the advanced looked, look at things can be, again, cost-prohibitive. And so what I say is, "Sometimes it's okay to just treat as if." And that sounds funny coming from a functional-medicine oriented guy, but the likelihood is that arteries continue to get stiff through age and that sort of thing. I'm just looking for premature arterial stiffness. And so what can I do to improve that? One, of course, is going to be actual cardiovascular activity, and so if somebody's been sedentary for a long time, that is something that I can pay attention to. And we can also pay attention to even, like, nitric oxide availability, even the Berkeley strips, or things that you can measure, salivary. Those can be helpful to give a good understanding of it. Bottom line on all of this, and it's not recognized as a good marker, but I like to look at homocysteine levels. I think homocysteine levels are an extremely good marker for that, and it's relatively inexpensive and easy to measure and easy to monitor, as opposed to some other interventions.

Rob Lutz 36:15
Yeah. So you mentioned--go ahead and just kind of support endothelial health, even though you might not know, because there are probably side benefits to some of these other things. What are some of the nutrients that, or botanicals, that you might recommend for a patient just looking to support that?

Dr. Corey Schuler 36:33
The list is long, and new things are coming out all the time. What I've, what I like at the moment and have liked now for quite a while, is olive leaf extract, which usually gets its intent, or you know, people think of it as, "Oh, olive leaf extract. That's going to help with immune-system stuff, right?" Well in, I don't remember the year of the study, but there was a really nice study that actually looked at high-concentration oleuropein from olive leaf extract. It was anywhere between 160 and 240 milligrams of oleuropein per day, and that went--they actually did a head-to-head study with captopril in, let's see, in hypertensive individuals, and it performed really quite well compared to the pharmacologic measures. And so I was like,"Oh, that's pretty neat." There's also a study on twins using oleuropein as well. And so it got me interested in, like, "Okay, what are these polyphenols? How are these polyphenols interacting?" And if you've done any kind of study or look into the vascular, like the lipid panels and vasculature, and you're like, "Okay, how can I--I know I can't modify LP(a) very much, but what can I do around it?" And almost everything says more polyphenols, the better. So from a supplement standpoint, oleuropein, big on my list right now. It falls in line too with the Mediterranean diet. I say both. They are probably a reasonable approach.

Rob Lutz 38:00
Well, that's interesting. You know, I mentioned that I had my lipid testing done last December, and I had a podcast with Dr. Mark Houston, and he mentioned LP(a).

Rob Lutz 38:10
And so I had it tested. And I'm thinking, "Ah, I exercise a lot. I eat pretty well." You know, of course, LP(a) is more genetic. Well, mine is extremely high. It's 230. And I don't really have any terrible risk factors otherwise but, so learning about olive leaf extract sounds like it'd be a good one for me as well, to add to my daily consumption of things. But yeah, that's interesting. So are there other cardiovascular issues, connections with thyroid health? Other guidance that you might provide for patients and practitioners?

Dr. Corey Schuler 38:10
Yeah.

Dr. Corey Schuler 38:47
Let's see. Good, good question, because it's more of a matter of, and actually, I'm going to take a step back because of your comment, the comment about LP(a), and just so, for everyone's references, I think that the note right now is like, "Okay, anything over 50, we need to be paying attention to." And the conventional sort of consensus is, "All right, well, LP(a) is elevated, so then just fix everything else, because we can't do much for it."

Rob Lutz 39:14
Yeah.

Dr. Corey Schuler 39:14
Probably not completely out of range, but usually that results in, you know, statin medications and that sort of thing. What I would say instead is endothelial inflammation is hard to measure. It really isn't an easy thing. You can have a completely normal C-reactive protein, you can have a completely normal sedimentation rate, and there's still inflammation going on there. The targeted assessment of that is, I'll say, extremely difficult, and it's complicated by all the complications that affect the heart.

Rob Lutz 39:51
Yeah.

Dr. Corey Schuler 39:51
What I like to think about when I'm looking at a patient, you know, right in the eyes, and say, "All right, we have some markers that aren't where really they need to be. The nitric oxide stimulation is probably our best bet." And there's some pluses and minuses to that, but I found that repeatedly, even just like glutathione and citrulline combination can be really helpful for that. We know it from the science in athletes. We don't know, really, the long-term benefits of that, although we do see changes in blood pressure numbers pretty rapidly, and I'd say rapidly within a week, sometimes we see changes, which we don't, we often--

Rob Lutz 39:52
Wow!

Dr. Corey Schuler 39:56
Don't see with normal antihypertensive medications. Now, is that sustained? Is it? Lots of questions there, but I think nitric oxide supplementation ideas, as well as just, you know, things like beets and pomegranates.

Rob Lutz 40:47
Right.

Dr. Corey Schuler 40:47
From a dietary perspective, are really critical, and incorporating these on--again, trickle improvement, rather than a massive change, improvement is really importan to keep cardiovascular health on par.

Rob Lutz 41:01
That's great. Yeah, I, so I've been kind of working on my stuff now for about six months. I'm going to get retested here in a couple of weeks, and I'm hoping for some improvements in some of the markers that were just not ideal. But with my high LP(a), I definitely felt it was, at this point, turning 60 this year, that it was important to get these things in line and really address them.

Dr. Corey Schuler 41:23
Yeah. Yeah, and I failed to mention, even though it's another rabbit hole that we could go down, is the idea of mitochondria. Right? We talk about mitochondria a lot, again, just where the density of mitochondria are, you know, brain, kidney, liver, heart.

Rob Lutz 41:31
Right.

Dr. Corey Schuler 41:39
So cardiomyocytes got tons of mitochondria in them, if we can do anything to improve that. Oftentimes, somebody who's been in the health and longevity space for a long time is already doing a lot to that. If they're not, though, you know, CoQ10 goes a long ways.

Rob Lutz 41:56
Yeah. Yeah, so I'm taking Ubiquinol, and, you know, just one of the, one of the ones on my list of things to take for my heart health. Did you, maybe you could talk a little bit more about thyroid hormone effect on lipid profiles. You know you touched on it, endothelial function, but specifically, what is that mechanism? Is there one that you could identify that's happening, that's going to impact the endothelial function?

Rob Lutz 41:56
Sure.

Dr. Corey Schuler 41:56
And just getting enough and sufficient amounts is probably the place I start on that. We can definitely go down mitochondrial co-factors to help with endothelial health long-term as well.

Dr. Corey Schuler 42:31
That's a good one. I don't have the mechanism off the top of my head, but what I can tell you is I think it has more to do with lipid peroxidation of LDL than anything else, and actually CoQ10 plays a significant role in that. But if we can stimulate thyroid function and US thyroid hormones, there is a stimulatory benefit to HDL and, sort of, that scavenging of the lipid peroxidation products. And so that's one that is, that we pay attention to. Super-interesting, though, sometimes I find individuals with autoimmune disease, especially the smoldering autoimmune disease, to have already extremely high levels of HDL, in a basic panel, not the advanced lipid panel, but really high HDL levels already, and they're like, "Yeah, my cardiologist and my other primary care doctor love how great my HDL is, but I never exercise." That's actually a clue to me that says I think we need to be paying attention to that. Because what that means is the body is stimulating HDL cholesterol, because it probably is lipid peroxidation. It's a clue to me to do that advanced lipid panel, if they're open to it.

Dr. Corey Schuler 43:43
To see what particle size and particle shape are, or particle number are, to see if we can do more of it. I just had a 68-year-old gentleman. He's in the in the tech space, and he really is doing his best to optimize everything, and his lipid panel looks golden, like it's a thing of beauty. His cardiologist kisses him on the cheek, because it's so good. And the problem is that he did have that exact pattern. He had this really high, elevated HDL, and when I asked him about he's like, "Oh, yeah. I have chronic urticaria, and I don't know what it's from, and no one's ever cared about it, because it's pretty much under control." And then we did the advanced lipid panel. LP(a), very elevated. Apolipo B, elevated. Particle size, he was in that wrong pattern of lipid peroxidation, and so we went down this path of like, "What can we do to scavenge those free radicals and heal those peroxidized particles?"

Rob Lutz 43:43
Yeah.

Rob Lutz 44:44
That's really interesting. So, you know, as we're starting to wrap up here, you know, I always like to ask, is there a takeaway? What's a key takeaway? You know, if there's one thing the other practitioners who are listening, you'd like to share with them, what's that pearl for you? What's that one takeaway?

Dr. Corey Schuler 45:00
Yeah. Probably two, if you'll allow me.

Rob Lutz 45:03
Sure.

Dr. Corey Schuler 45:04
One is TSH never tells the story. TSH never, ever tells the story, and us integrated practitioners probably know that, but if anybody's listening that thinks they're ruling out thyroid because TSH was normal, stop doing that. Please, look a little bit deeper to that. And the other one, which is that it's not always your thyroid. It's not always your thyroid. Sometimes it's the causes and contributors of your thyroid condition that are actually the things that need to be modified. And just mucking around on adding more thyroid hormones and playing that game of like, "Okay, you're on Synthroid, and so every year we check your TSH, and we're gonna keep increasing it forever." That's probably not good management. And those other things that are popping up that you're not attributing to the thyroid, maybe that, maybe some of those contributory markers or contributory effects. But not everything should be related to your thyroid, and just the, land on that avatar of a patient who comes in and they have a known thyroid condition. Every new symptom that they have, they attribute to their thyroid dysfunction. It's our job to listen and be paying attention to that and to also look a little bit deeper. So, I probably said three or four on there.

Rob Lutz 45:50
Yeah. That's great. Yeah.

Dr. Corey Schuler 45:51
That's where I'd like to land.

Rob Lutz 46:20
Awesome. And I guess there's maybe just one last question. But is there one myth about thyroid treatment you wish would go away?

Dr. Corey Schuler 46:35
Yeah, that thyroid antibody testing doesn't matter. That's the one that, if I could stricken that from all of our brains, that would be the one.

Rob Lutz 46:46
Awesome. Well, thank you, Corey. This was really great, very informative, and as I mentioned earlier, we are putting together a thyroid health resource center with Allergy Research Group, and so there'll be a lot of other content in there that relate to this and, but we'll link to that from the show notes of the podcast, which I really appreciate you coming on, so thank you so much, Corey.

Dr. Corey Schuler 47:07
Thanks for having me.

Rob Lutz 47:09
Thanks for listening to the OneMedicine Podcast. I hope you found today's episode interesting and came away with a few insights you can apply to your practice. If you're looking for the show notes, they can be found in the link below. If you want to go deeper on this topic or anything else, please visit todayspractitioner.com and consider registering for our weekly newsletter as well. Thanks again, and I hope you'll join us next time.