In this episode, we discuss:
- Why this study was needed
- How the study was funded and designed
- The impact of using diet and lifestyle to treat Hashimoto’s
- Individual case studies
- Taking a Functional Medicine approach to Hashimoto’s
- Health coaching and collaborative care
- “Efficacy of the Autoimmune Protocol Diet for Inflammatory Bowel Disease,” published in Inflammatory Bowel Diseases
- The SAD to AIP in 6 online health coaching program
- “Efficacy of the Autoimmune Protocol Diet as Part of a Multi-disciplinary, Supported Lifestyle Intervention for Hashimoto’s Thyroiditis,” published in Cureus
- Genova Diagnostics
- ADAPT Practitioner Training Program
- ADAPT Health Coach Training Program
- Resilient Roots
- A Medicinal Mind
Hey, everyone, it’s Chris Kresser. Welcome to another episode of Revolution Health Radio. This week I’m excited to welcome Angie Alt and Rob Abbott as my guests. We’re going to be discussing the very exciting results of a study they just completed looking at the autoimmune protocol and other behavior and lifestyle interventions as a potential treatment for Hashimoto’s.
And if you’ve been listening to the show for awhile, you may recall that I had Angie and Dr. Konijeti on to discuss the results of their study on the autoimmune protocol as a treatment for inflammatory bowel disease. That was the first peer-reviewed study on AIP that had ever been done, and this is now the second looking at AIP as an intervention for autoimmune disease, and I think there are already some others under way.
So it’s really exciting to see this formal research being done on a protocol that we’ve known anecdotally has been effective for many years. And this particular study was interesting because it didn’t just look at the AIP diet; it looked at other behavior and lifestyle interventions. So I’m looking forward to talking with Rob and Angie about their results. Let’s dive in.
Chris Kresser: Thank you so much for being here. I’m really looking forward to diving in.
Angie Alt: Yeah, thanks so much for having us on, Chris.
Chris Kresser: So tell us a little bit about what you set out to discover in this study.
Rob Abbott: Angie, do you want to go first?
Angie Alt: Do you want? I was just going to say, why don’t you begin, Dr. Abbott?
Why This Study Was Needed
Rob Abbott: Okay. Well, yeah, so essentially what we really tried to discover, I think folks in this space are probably familiar with how diets can impact chronic disease. And while we can be a little bit of an echo chamber in the space ourselves, it is getting out into the larger medical space.
And so, Angie, specifically, has been really pioneering work to look at the autoimmune protocol, or AIP, as part of a larger dietary and lifestyle intervention for folks with autoimmune disease and was part of the first study looking at AIP and a lifestyle program for folks with inflammatory bowel disease. And that was back in 2017, I think, when it finally got published.
Chris Kresser: Yeah, we talked about that on the show. That was an exciting finding, for sure.
Rob Abbott: I remember when I heard about it, it was, I think, through Angie and you, Chris. I mean, it just, it blew up in the space. And I freaked out. I was like, this is so cool that this is being done. Research, collection from scripts. Dr. Konijeti was interested to do it. I still remember reading the paper initially and not fully realizing that Angie and Mickey had been a part of it and seeing stuff in the methods of the paper.
Of course, I sent a message to Mickey. And Mickey’s like, “Of course, Rob. Duh.” This was us. But after that paper came out I thought it was just amazing. And so I really wanted to connect and got to meet Angie and Mickey at one of the ancestral health symposiums. And we decided to kind of collaborate, as they had realized through doing some surveys of their audience, that they wanted to, their audience really wanted more research, more evidence behind this approach for various autoimmune conditions. And to sort of bolster, hopefully, the push into the broader medical community. And it was just a natural partnership for me to join the team and kind of bring a medical perspective.
But also a layperson’s perspective in having grown up in medical school, reading your articles, Chris, and seeing how to translate some of the more nuanced science into a more lay audience description but not lose its value. And, but we started talking about the, I said, “Hey, it would be an awesome idea to do another study because I don’t want to wait another five years for some grant funding institution to finally come around and say let’s study this.” I was like, “Let’s do this on our own,” not fully realizing what it was going to take to do it, but just knowing that Angie had used her program before. And then we had the pieces.
And so yeah, I came to Angie and Mickey and sat down. I was like, “Hey, what do we want to study and who do we want to study? What population?” And so it was obvious we wanted to use her framework, the SAD to AIP in 6 online health coaching program that she used with the AIP IBD study and has been using for multiple years with great clinical success. And that was going to be the foundation. And then we sort of said well, also from our clinical experience and having had a couple of my own patients in residency go through the program with Angie, with autoimmune thyroid disease or Hashimoto’s and having a good clinical background, I think those individuals do well in the program. It made sense to study that population.
Also when you consider there’s no other treatments outside of hormone replacement for folks with Hashimoto’s and the massive population that’s affected, it just seemed clear that we needed to provide, hopefully, some evidence for good or for bad, that you could do something besides just put people on hormone replacement. And to top it all off, I was looking at some of the literature—and you’ve probably seen this too, Chris—hormone replacement isn’t life-changing for a lot of people. Yes, it can be helpful, but a lot of people still continue with tons of symptoms. And so they’re just left out there to dry with nothing.
Chris Kresser: Yeah.
Rob Abbott: So I won’t ramble too much further, but we essentially were like, “Yeah, we want to study this population. We want to use Angie’s program, but we want to add even another twist.” And I think the biggest point I want to make as we get into the conversation today was this study was not a diet study. It was a personalized medicine, Functional Medicine, functional nutrition, and health coaching intervention.
And I think one of the issues that I had, probably the only major issue that I had with the first AIP IBD study was that the title focused too much on AIP and made it seem like it was the diet. And it didn’t give credence to Angie’s program. It didn’t give really, it didn’t acknowledge, unless you read in the paper and understood her program, that this wasn’t simply handing people a recipe book and saying do this. There was engagement, there was a community, there was all these other facets, which we know multidisciplinary, multifaceted interventions are important.
But I felt that we really needed to utilize those tools that we’re learning in this therapeutic context and use that for good, rather than just simply using the power of one tool, which is AIP.
Chris Kresser: Absolutely. Yeah, it’s so important. Especially with the very well-established connection between stress and autoimmune disease and sleep deprivation and physical activity, and the relationship that all of these inputs have on autoimmune conditions like Hashimoto’s and IBD. Super, super important.
How the Study Was Funded and Designed
Chris Kresser: So how was the study funded and designed, given that you didn’t go through the traditional process to get this done?
Angie Alt: So, after we did this giant survey of our community with just thousands and thousands of responses, we saw as Rob kind of said that our community really wanted the research and they were willing to get behind it. So we decided that we would crowdfund to be able to do the research. And then also Rob partnered with Genova and they got behind us and obviously donated a lot in terms of testing. But we went out to our community and we said, “Hey, guys, we have an opportunity to do this and will you support us?” And we raised $12,000 in about three weeks.
Yeah, it was awesome. It was really awesome to see that kind of support and have Genova get behind us. And with that, and honestly, that research team being willing to put in a lot of hours for no pay—
Chris Kresser: Yeah.
Angie Alt: But that’s okay. That’s an investment in the future that we were all willing to make. So we went for it from there. It was very lean, obviously, to do it on that budget, but we made it happen. And more than anything, I think knowing that our community was willing to get behind us like that was an awesome feeling.
Chris Kresser: Yeah, I love that model. Because this kind of science, it is just not tainted by commercial interests that have a certain agenda in attaining a particular outcome. It’s not studying medication intervention; it’s so valuable and necessary. And yet, there’s so little public funding available for it. But now we have this huge and growing audience of people who are what I call citizen scientists and passionate advocates for health and wellness and advancing our understanding of these concepts who are willing to support these kind of efforts.
In an ideal world, our tax dollars would be going toward that, or at least part of them. But in the world we live in, that’s not happening to the extent that it needs to. So it’s so great to see that you leverage the interest and support of your community to make this happen.
Angie Alt: Yeah, it was awesome to kind of get to do such a unique approach to it and show that we could eliminate that conflict of interest where the money was coming from and just go out there and do the science.
Chris Kresser: Cool. So how did you set the study up, given that it was a multifaceted intervention and you’re not just studying the impact of single monotherapy, like a drug? How did you set up the study?
Rob Abbott: Yeah, so we used the structure from the AIP IBD study—and I’ll kind of go back and forth and call the first study the AIP IBD study and our study the AIP HT study—but we wanted to use the original, as much of the original study design from that first pilot, recognizing it was a really good first rough draft and it made sense from both a budget perspective and a practical perspective to use a single arm.
So we knew going into it that we would have the limitation of not having a control group. So there would be no randomization. Everyone would be in an intervention. Blinding isn’t really a realistic thing to do in a multifaceted lifestyle intervention. And also it’s kind of irrelevant. So it’s kind of a critique that wasn’t really valid. But we had a single arm and we wanted to get around 15 to 20 individuals based off the budget size and also having had experience with, for Angie seeing the group dynamics, we didn’t want to huge group. But we also didn’t want too small of a group. And between 15 and 20 was sort of an ideal group size where people felt connected, but not overwhelmed by any one person. But also not, it’s like five of us doing this.
And we put out a survey to, once again, to social media, with somewhat strict parameters. It’s always challenging to try to balance when you’re making the exclusion/inclusion criteria for who you want to study to make sure you’re not inserting too much selection bias, which is one of my pet peeves, that people selection bias in making inclusion criteria extremely specific. So I wanted to still make it broad, but relevant. And so we ended up picking individuals between the ages of 20 and 45 with a history of Hashimoto’s thyroiditis, which for me, I just needed to either see that on a medical history form, proven from a medical record from a physician, or evidence of elevated antibodies.
And it could be, the antibodies could’ve been just out of normal. I didn’t care. We weren’t looking for people with antibodies, TPO antibodies, any thyroglobulin antibodies in the hundreds and hundreds and thousands. Because I didn’t want to have that bias. And we also took the safety precautions of we didn’t want pregnant women or breastfeeding women, and we also had the restriction for being either normal weight or just overweight. So BMI less than 30, essentially, 29.9. And that one was more of a safety mechanism. Because I’ve seen Angie’s program and I knew it was going to work.
And so I wanted to minimize knowing people’s thyroid medication would change. And I wasn’t able to provide direct care for the participants like I would in my own clinic. I wanted to minimize massive, potential massive weight loss over the intervention and the need to be monitoring thyroid during the intervention itself. So we wanted to get people who either were normal weight or overweight, which some people said—and I agree—people with Hashimoto’s have problems with weight. America has problems with weight.
So there was a substantial group of people who we couldn’t enroll because they didn’t fit the BMI category. But it was more from a safety perspective. And I still would, well, maybe not completely generalizable, I would still generalize some of the findings, as we’ll talk about later, to that group. The age restriction was also to try to minimize the menopausal hormone effects of confounding on was there other privations for someone in their late 40s or mid 50s. And so we took the 20 to 45, also knowing that’s typically the age range where people are diagnosed or affected with Hashimoto’s to begin with.
So we identified a population that while specific, was, I think, a good representation of who is most disproportionately affected with Hashimoto’s. If we had just studied old black men and found results, it would’ve been pretty poorly designed and wouldn’t be generalizable because this is a small fraction of individuals who are affected versus middle-aged. We ended up getting just women. We had it opened to men and women, but just ended up getting women. But that population was potentially, when you’re going to do a pilot, the best representation for the wider population. And we also, in doing it on social media, we’re able to get people across the country in multiple states. And so we had, I think, 12 or 13 states represented.
There were a couple multiple people from California and Virginia and Texas. But we had, actually, a good spread of individuals across multiple states, which even a small sample, it was pretty awesome to be able to even get that diverse of a group with only 17 people getting enrolled. So we had 17 folks, and the main questions that we wanted to ask in this study were combining subjective and objective outcome measures. So the main thing, and what I am interested in, and you probably agree too, Chris, is I want to see the patient actually see subjective improvement either in their symptoms, their quality of life, some parameters that means something to them.
And so our primary outcome was improvement in quality of life using the SF-36, which is a pretty comprehensive quality-of-life questionnaire. It’s pretty well validated, and as a secondary outcome, we also included the MSQ, or Medical Symptom Questionnaire that was developed by Jeffrey Bland through the Institute for Functional Medicine, which I find, and probably many people in this audience find, very helpful in the clinic, to objectify in some way someone’s symptom burden. So those were the two main markers.
Subjective, yes, but we had to find some way to objectify that person’s experience. But knowing that if we didn’t see any improvement there and we saw objective improvement, I actually wouldn’t care as much. Because I really wanted to see people feel better. That being said, we obviously did measure thyroid antibodies and hormones. So we had a full thyroid panel to look at all hormones as well as the TPO antibodies and antithyroglobulin antibodies.
And I did, a priority, have a hypothesis that would see, having seen patients before, need less medication and have increases in hormone that we would see TSH drop. That we would see hormones change in a way that people would not need as much medication. And that maybe in the short period of time, antibodies would even drop as well. And the whole study itself was designed to only last 10 weeks. So, I mean, it’s a really short time, and I would’ve loved to study a longer period of time. But we didn’t really have the budget to keep doing labs every six weeks or 10 weeks.
Chris Kresser: Sure.
Rob Abbott: But even within 10 weeks, we thought maybe we’ll see a decrease in antibodies. And in the last two markers that we had from a statistical structure and outcome measure was, and I didn’t really have a priority hypothesis before the study looking at this, because it’s not up to study population that this marker is routinely used in. But I wanted to somehow quantify inflammation. So we ended up using high-sensitivity C-reactive protein as some non-specific marker for inflammation knowing that if someone was not acutely sick, this marker shouldn’t be elevated, shouldn’t be abnormal.
So we wanted to follow and see if we could see some immune modulation via this hsCRP, or we also used a complete blood cell count, which had a differential. So we’re looking at white blood cells, lymphocytes, eosinophils, monocytes, that kind of thing. So I had those markers to see would we see any kind of immune modulation. Interestingly, the last thing I also included, which I don’t want to get too far off in the weeds, but I’ve always been really upset about these studies looking at vitamin D and changes.
And I just think that there’s so many variables that can impact vitamin D. That even to say if you put someone in the hospital and control everything, to say that your intervention changed vitamin D is still a bit of a stretch, and to me it’s, like, irrelevant anyway because it’s in a hospital. But I actually included it because I have seen a lot of patients come to me with really high vitamin D because it’s, like, a universal medication to take.
Chris Kresser: Yep, everyone’s taking a high dose of it.
Rob Abbott: And so I was like, from a safety standpoint, I kind of knew the population we might get. So I actually included that on there. But once again there was, there’s no reason to have any kind of hypothesis changing because there’s just so many variables. And we did end up finding some people that had vitamin D in the 80s, 90s and even had high calcium. And so I was able to actually help them to mitigate that.
But the quality-of-life questionnaire, the symptom questionnaire, and the thyroid panel were the main outcome measures and things we were looking at. And we did labs at the beginning of the study, and 10 to 12 weeks later, we repeated the labs again and wanted to see how they changed.
Chris Kresser: Great. So tell us what you found.
A new study from Angie Alt and Dr. Rob Abbott shows promising results for the autoimmune protocol (AIP) diet as a way to treat Hashimoto’s disease. In this episode of Revolution Health Radio, I talk with Angie and Dr. Abbott about their findings, and we discuss how behavior and lifestyle interventions impacted their results.
The Impact of Using Diet and Lifestyle to Treat Hashimoto’s
Rob Abbott: So I’ll go a little bit, and then I’ll let Angie talk a little bit more about the dynamics. And so what we ended up finding was in the beginning the average antibody level—and I put this in context with some of the results—the average antibody level was only, TPO antibody was only around 200. And I’d love maybe your thoughts on this, Chris, but for me, clinically, like, around 200 is a pretty good clinical win. And I didn’t know what it was going to be before. We talked about I didn’t know what people’s levels were. They just had to be somewhat abnormal when we enrolled folks.
So I saw that at the beginning and I was, like, I don’t think, before the study even started, I don’t think there’s going to be a way we’re going to see it decrease in just 10 weeks if we’re starting at 200 versus 1,000. But then again, if we started at 1,000 and it came down to 500, was that your intervention? Or was that just them getting back to regression to the mean? But the average antibody level at the beginning was only 200 and average TSH in the beginning was around 2. So we had a pretty good sample, pretty good average.
Chris Kresser: Would you speculate that that was due to the population that you were recruiting from, which is a population that already has a pretty high level of health awareness given that they’re in the community, Angie’s community?
Rob Abbott: Yes, I would completely agree that we, and in looking at, we did food frequency questionnaires in the beginning. While it’s wrought with all sorts of peril, especially the first one that was asking them to look at their diet over the last year, pretty generally, when I looked through everyone’s food frequency questionnaire, if represented a diet that I would call above average, it was definitely not Standard American Diet. It wasn’t AIP. It wasn’t even strictly Paleo. But it was better than average.
And then when you started to talk with people—and Angie could probably provide more insight within the group—we were starting with people that were doing a lot of stuff right. Or had done stuff right and had heard about AIP and believed that it would work. That’s another sort of result critique was why would you enroll people at, they had an expectancy. Well, you’re not going to, from a lifestyle-change standpoint of the person doesn’t believe that it’s going to help them, then it’s stupid to enroll people who don’t know what it is or don’t believe it’s going to work.
Chris Kresser: Well, yeah, and the other thing is that placebo-controlled model comes out of studying monotherapies and drug interventions.
Rob Abbott: Correct.
Chris Kresser: It’s a really relevant or valid in a model like Functional Medicine where you are using multiple different interventions. And I think in that case perhaps with a longer study and a bigger budget, comparing against the standard of care is what makes the most sense. And I know that’s what Mark Hyman and the folks at Cleveland Clinic are doing in a lot of their research. Because the whole placebo-controlled thing is an artifact of drug trials.
Rob Abbott: Correct. Yeah, I know, and that’s exactly how if you’re going to design, how we’re hoping to design future studies, is having a control arm that either is a weightless group or is receiving the continued standard of care that you’re already getting or maybe it was getting some slightly different dietary treatment. But when you have all these multifaceted elements, it’s just silly to try to figure it out which one is doing what.
And people are probably familiar with Dr. Dean Ornish, who probably pioneered this field of lifestyle, studying lifestyle medicine very rigorously. And if you go and talk to him, and I’m sure you’re probably pretty good friends with him, Chris, you go and talk to him and people are just giving him all sorts of crap for, “Oh, your low-fat, plant-based vegetarian diet is, you’re killing people by not giving them fat.” But if you ask him the most important element of his intervention, he’ll tell you it’s love. Not the other elements. It’s the connection. It’s this loving compassion of the group both within themselves and being cared for.
And so I say all that to once again say this is a complex intervention in Functional Medicine. It’s complex, so it doesn’t make sense to study it in a way that it was used for supplement trials or drug trials.
Chris Kresser: Yeah. And to be fair, there are downsides to this method of research that we’re talking about. And Dean Ornish does studies because he has used some of those studies to claim that the low-fat, higher carbohydrate, plant-based diet is what was responsible for the outcome in those interventions. And you can’t know that that’s true or you can’t know that that’s not true based on those, the way that those studies were designed.
What you can say is that a multifaceted intervention that involves XYZ was effective compared to whatever it was being studied against. I think then you could design further studies that would just compare single elements of those interventions. So you compare, for example, the low-fat diet versus the low-carb diet. And of course those studies have been done and are being done. So it’s still useful, but it’s just important, I think, to be objective and recognize the strengths and weaknesses of various research designs, as I know you did in this case.
Rob Abbott: Yeah. It’s all about making the appropriate conclusion, and I want the community, too, to hear as we get to that point later in the podcast, we want to make sure we make the appropriate conclusions from our research and be positively critical. Don’t say it’s something that it’s not and see it as a rough draft to make future changes.
But yeah, and so coming back to the results, across the group for both the thyroid hormones and thyroid antibodies, we didn’t see any clinically or statistically significant changes. Big Pharma could’ve come in and said that was actually a positive because people didn’t get worse. But I won’t say that. We didn’t say that.
So we didn’t see things as a group, but six out of the 13 women, so one woman was unable to finish the study because she actually got pregnant. Pretty awesome reason to get kicked out.
Chris Kresser: Absolutely.
Rob Abbott: And those towards the end of the study, so 16 women out of the 17 finished, and we didn’t see any changes statistically when you looked at the group or clinically at the thyroid hormone or antibody levels. We did see that six out of the 13 women who started the intervention on hormone replacement medication decreased their medication by the end of the study.
In some cases, a couple people actually decreased at the beginning and decreased even more at the end. And this was all based off of the testing that we performed and clinical symptoms and monitoring from their local physician. And so that’s a huge, huge percentage. And there were even other people, when you look at the individual statistics, which I tried to include everything raw in the paper so people could see what we did.
Chris Kresser: Thank you.
Rob Abbott: Because one of my pet peeves, there’s a few of my pet peeves.
Chris Kresser: Absolutely my pet peeve.
Rob Abbott: I hate trying to figure out from one figure what was studied and what was interpreted. And so I just, I wanted it all to be there so people could be their own critical citizen scientist. And even the figures that we used, I tried to include the raw data. Because we had few enough people, it didn’t get too nuts to have one figure so you could see, “Oh, yeah, there’s kind of an outlier there. This is that.” So you could be a better critical judge, rather than, like, artifactually making some weird figure and just things that misrepresent the data.
So yeah, so almost half the people on replacement decreased medication, and some people who even had TSH’s in the beginning that were up in the fours came down to the twos. So they didn’t actually decrease meds by the end of the study. My guess is they probably were going to decrease them soon. They saw big decreases in their TSH. And a couple people even specifically, when you looked, I wanted to see was it just weight loss? And there was weight loss across the group, both clinically and statistically significant weight loss, both in the whole group as a whole and even the overweight group. But a couple people needed less medication and they didn’t lose weight.
The TSH dropped, they didn’t lose weight or someone had a big TSH drop, and they lost a couple pounds. And this is self-report. You have to take it for what it is. But at least from a self-report I couldn’t explain these changes. And one woman even was on T3 medication at the beginning of the study and had no T4. And I told her, like, you have to get your prescriber to give you T4. This is not safe. And I get her labs back at the end of the study and I ask her, oh, so she’s got some T4 now.
And I’m like, “So what did you start taking?” And she’s like, “Oh, I just, I’m taking a little bit less T3.” And I was like, “What? You’re not taking any T4?” And so my hypothesis for her was maybe there was obviously a suppression effect because she was taking a little bit less T3. But her thyroid started making T4 again.
Chris Kresser: Yeah.
Rob Abbott: Both the intervention? I can’t say what. The intervention plus a little bit less suppression. But there is enough of these cases mixed in there that it was clearly this decrease in TSH, and the individual’s need for less medication was not just from weight loss. For some people, yeah. It had an impact. But even as a group, it was an average around six or seven pounds. We’re not talking about 20 pounds, which we tried to avoid by not having obese individuals.
So when you look at that level—and I’m not trying to artifactually create something that doesn’t exist. I’m just telling you what we saw on the individual level, it’s pretty remarkable. And I don’t know, Chris, you probably had some reflections, but Angie, you’ll probably provide some even further insights working with the people day in and day out. And we can get into some of the other results. But that was pretty awesome stuff in a 10-week intervention.
Chris Kresser: Yeah, that’s phenomenal, and it matches very well with my clinical experience having done this for over a decade. Typically, what I expect to see when we first start working with someone with Hashimoto’s is, and we put them on AIP or a similar nutrient-dense anti-inflammatory kind of diet intervention as well as the lifestyle modification, is an improvement in TSH.
And actually the talk we have to give, as you did, Rob and Angie, is “Hey, whether someone in our clinic is the prescribing physician or someone else, you have to be in touch with them because what often happens here is as you reduce the inflammatory burden, your thyroid function is going to improve. And it’s going to start producing more endogenous thyroid hormone. Therefore the dose that you’re on now of your thyroid medication is going to likely be too high and you might start to experience hyperthyroid symptoms in some cases. Because the dose that was necessary for you before you started this intervention is now too high.”
And we don’t say anything to them about any expecting a change in antibodies in the first few months. And I think one of the reasons for that is that studies have shown that antibody production can often trail what’s happening clinically by a few weeks or more. So the changes that I make today, like, if I have Hashimoto’s and I make changes today, that’s not going to show up in my antibodies tomorrow. It might be three or four weeks or even more before my antibodies drop.
Angie Alt: Yeah, that’s totally true. It was lucky, I think, for Rob and I because we had partnered in the past on patients that he was seeing in his clinic. And then he asked them to enroll in my program. And we already had had the experience of one of his patients in my program coming to me and saying, “Oh, you know, I feel badly now. I’m starting to have probably hyper symptoms. I don’t think this is working.”
And then I could say, “Oh well, I think it actually is working. That’s why you’re feeling this way. Let’s go back to Dr. Abbott and have an adjustment in your medication.” And sure enough, that was the right approach, that we were well prepared for that with the women we were working with in the study.
Chris Kresser: Yeah, I imagine that helped too because some people might’ve dropped out or not made those changes. And that’s why we’re always very careful to alert people to that upfront. Because it can avoid outcomes that wouldn’t be desirable because they know what to expect.
Angie Alt: Right, exactly. They’re less anxious and they’re more prepared for how things might change.
Individual Case Studies
Chris Kresser: Yeah. So, Angie, I’d love to hear a little bit more about some of the specific case studies. I think that could help bring this to life for people. Oftentimes when we’re looking at a study, we’re just looking at data and averages. We’re not looking at the experience of individual people. And I think it’s, I always love to talk to the researchers because I get a lot more color and life in terms of what actually happened in the study and how the intervention affected people. So can we maybe share a few anecdotes from particular people in this study?
Angie Alt: Yeah. Gosh, there was so many kind of special little things that happened along the way. I’m trying to focus on a few of them. I know one thing that we ran into, because we had also Genova’s lab behind us and some more specialized Functional Medicine type of testing, we got to see things that I didn’t get to learn about when I participated in an IBD study.
And through the organic acids tests, we got to see things like heavy metal issues and things like that come up for women. And we had—Rob, you might have to correct me if I’m wrong here—but we had at least one or two women who actually came into the study with some heavy metal issues. And when we got those results back, we met with those women. And because this is a study that’s totally dietary and lifestyle focused, we weren’t going to do anything outside any specialized protocols to try to address that.
But we made recommendations to the women like increasing things like parsley and cilantro in their diet, kind of adding those herbs in where they could. I think I encouraged a few of those women to blend those fresh herbs into their bone broth. Find ways to bring it into their diet a little bit more frequently. And at the end of the study when they had those tests repeated, we found that they didn’t have that heavy metal toxicity anymore. And that was just by adding herbs over a 10-week period. I was really blown away by that.
Rob Abbott: Yeah, we didn’t do a formal statistical analysis from components of the organic acids, mainly because it was all exploratory, and would have to be for a second paper anyway.
Chris Kresser: For research purposes only.
Rob Abbott: Yeah. Because we designed the study without even having them, and it was a generous donation from Genova that helped us to use that in a more specialized Functional Medicine intervention, which we can talk about. But yeah, so I looked at women in the beginning, and we used the Genova Diagnostics NutrEval with toxic element screen.
So it included whole blood, arsenic, lead, mercury, and cadmium. And as I just said, we weren’t doing, we had no scope to be able to do any kind of fancy detoxification intervention, but a lot of folks came up in the beginning. And you can take this for what it is. It’s just a whole blood sample. It’s not a urine provocation. It’s just what’s in the blood at that time based off of Genova’s reference ranges. And several came back with high mercury. And some had dental amalgams, some didn’t. And it was seafood. But mercury seemed to be a problem.
And a couple people even had lead show up as an issue. So we made note of it, as Angie said, with folks and gave some what may seem maybe inconsequential small changes, but maybe something to psychologically help them feel like they could detoxify. And I figured at best like we’d see a 50/50 wash. Like, maybe some people would go up, some people would go down, just statistical noise from this. But almost universally—and I don’t have a statistical calculation on this, and so you can just take my word for what it is—but almost universally looking at it, anyone who was high came down, either still staying out of the normal range or even becoming normal.
There was nobody who went from essentially no toxicity to toxicity. And so I don’t know what to make of that fully, because it is just of a single type point test. It’s a whole blood test. But it was fascinating to me to see that clearly there was something going on to get detoxification systems online and aspects of this intervention. Because the whole blood mercury that was there in the beginning was not. And this was just 10 weeks, and these people didn’t move, they didn’t change anything radical. And even just if you had stopped eating tuna as much, that still wouldn’t have had a big effect, at least in my opinion. And so that was kind of just a fascinating unexpected finding from the NutrEval.
Chris Kresser: Actually not unexpected for me. I can’t remember, some time ago, somewhere wrote something, a blog in the Practitioner Training Program, I’m not sure. Rob, maybe you remember from the ADAPT program, but there are actually studies that correlate mercury exposure with thyroid antibody production. One from Ann Haynes, actually, looked at data from 2007 and 2008, I believe, and they found women with the highest blood mercury levels showed greater odds for higher thyroglobulin antibody production.
And I’ve seen similar findings for lead and arsenic, I believe. And it makes sense. I mean, we know that these metals cause inflammation and oxidative stress and that the thyroid is particularly susceptible to that. So it’s definitely one of the things that I explore in my patients with Hashimoto’s and other autoimmune conditions.
Angie Alt: Yeah, I mean, that was, like I said, I’ve never been in a situation where I was able to see those laboratory changes myself, and that was really cool to watch that. I think in terms of other case studies, even though she didn’t get to finish with us, obviously our participant who came into the program dealing with infertility and really having a high personal goal to perhaps restore fertility and become pregnant, obviously having—
Chris Kresser: I was going to ask you that when Rob had mentioned that she dropped out because she got pregnant. What was going through my mind was, was she trying to conceive and then not able to conceive? And did this intervention help with that? So that’s really cool.
Angie Alt: Yeah, definitely. I think it was about week nine, she came to us and said, “Hey, you guys, I don’t think I can continue this study because I’m pregnant.”
Chris Kresser: Yay. That’s the best news ever.
Angie Alt: And so we were like, well, we don’t mind that at all. That’s amazing. But not totally unexpected for me either. I’ve seen that happen over the last six years several times during the course of my program. And it even happened with a younger woman who had very premature ovarian failure. And she even got pregnant, which absolutely floored her doctors. And so obviously that was really exciting.
Chris Kresser: I’d take all of those infertility diagnoses with a big grain of salt.
Angie Alt: Yes.
Chris Kresser: Because I’ve learned over the years that, and Robb Wolf used to talk about this a lot, where when people would come to his gym and he would start advising them on diet, get them on a Paleo diet, get them working out, if they were young women, he would ask them about conception and birth control.
Because what you found was so many women would just get pregnant and they weren’t necessarily trying to. But they had not been getting pregnant with not using birth control or paying much attention to it. And then when they clean up their diet and address their physical activity and start improving their health, all of a sudden the body’s like, “Oh, hey, all right. Things are cooking now. Now we can do this.” And I will often warn my young female or women of child-bearing age of that too, especially if they’re not planning to do it to get pregnant, to watch out and pay more attention.
Angie Alt: Yeah. I’ve definitely adopted the same approach over the years, Chris. I say to them at the beginning, “Pay attention, ladies. Those of you who aren’t planning it might have a surprise, and for those of you who are planning it, you might achieve your goal.”
Chris Kresser: Right, right. So I’m just, I’m rewinding a little bit because I just had to look something up here. So yeah, I’m looking at a study of, I mentioned the mercury and Ann Haynes. And this one, this is from the Journal of Environmental Pollutants. “Lead and Cadmium Exposure, Higher Thyroid Antibodies and Thyroid Dysfunction in Chinese Women.” They found correlation between lead and cadmium levels and higher TSH and hypothyroidism and higher antibody production in women.
Yeah. And then there’s a whole bunch of other studies if you look. And if you pull that one up, you’ll see tons of similar articles along the same line. So it is, I’m glad you mentioned that. Because it’s one of the things that is often unexplored, and it’s one of the reasons that the conventional approach to treating Hashimoto’s is so lacking. Because it’s the classic example of symptom-based disease management where the dysfunction, the ultimate effect of Hashimoto’s or hypothyroidism, is low thyroid hormones. So the intervention is then thyroid hormone. Just give thyroid hormone without any attention on why the thyroid hormone is low in the first place and what’s causing that.
And Rob, this is probably a good segue. You are, among many other qualifications, you are an ADAPT-trained practitioner who has studied Functional Medicine, and this is the approach that you are bringing to your work and this study in particular. So how did the ADAPT practitioner training inform the way that you looked at this, designing the study and the outcomes?
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Taking a Functional Medicine Approach to Hashimoto’s
Rob Abbott: Yeah, well, I just think, I’ll keep the story short, and I don’t want to embarrass you, Chris. But I mean, my story even getting into this space is nuts. Over six and a half years ago I was a patient myself, having stopped medical school, not knowing what was going on with my life. And I came across Chris’s podcast, actually, in the hospital and started listening to it and just, like, light bulbs went off in my head. Like, this is how I’m going to get myself better and this is what I’m going to do to help people when I come back to school. And so I went through all of school knowing, all of traditional medical school knowing this is the approach I wanted to take, and before I even met Angie and Mickey in person, I was handing out some of your articles to patients in the hospital. Handing out books and recipes.
Chris Kresser: You were that annoying guy.
Rob Abbott: I was, eventually, but my attendings just stopped caring because they’re like, “He seems to really care about these people. He’s probably doing something helpful.” But then I got the lucky opportunity between my fourth year of medical school and beginning residency to be a part of the ADAPT program. And it was a great time period because my fourth year was, it’s the easiest year of medical school by far. It’s all this elective time, mostly doing research. Actually had time to really pour myself into the program and then put it into practice too, and residency to some limited extent.
And the structure of how to really, it’s all conceptual framework. I mean there’s some beautiful pearls at how to really practice the clinical medicine day in and day out, which isn’t always necessarily taught through the Institute for Functional Medicine. But I had some good core protocols, but it was more the conceptual framework. How do you think about these things? What types of questions are you asking? It even helped inform how I did my notes and created treatment plans. And I had beautiful handouts that I could give to people that you provided in the program, which was, I mean, talk about a work that you don’t want to do on your own when there’s something already there. I did not want to reinvent that wheel. So that’s beautiful resources. But it really was a conceptual framework of how to, what kind of questions to ask people and to honor their story.
And so I carried that through residency and recognized too that that was going to be a valuable piece for our intervention. And so I actually met with the women at the beginning of the study individually, all virtually, and went over their initial lab testings, their testing findings, their goals and told them we’d be meeting again midway through the study to go over some of the more nuances of the organic acids test and the stool test, still just making dietary recommendations. We weren’t going to do anything high-level intervention. And then met with them again at the end of the study to go over the final results.
And so had this constant individual functional care, and in between there, Angie and I and the other health coach, Andrea Hirsch, we met together to kind of go through everybody and come up with those goals for people and all be on the same page. So it would be just this wonderful multidisciplinary team dynamic, which now, when I first did the ADAPT training, the health coaching program hadn’t come out yet. But folks are now in your ADAPT health coaching training.
And so what this intervention became was basically just blending really personalized Functional Medicine with an integrated—I say that because we were communicating together, not just integrative—but this integrated approach where I could communicate with Angie doing and Andrea doing continuous health coaching with the group in a community setting. And there’s just, I start to get speechless when I realize the implications of what we study. And while I don’t want to go jumping and say everyone used to do this, but we are validating the personalized care movement. We’re validating the principles of Functional Medicine. We’re validating the role of health coaches. And we’re validating the reason to do it altogether.
And Chris, I mean, you’re basically, I mean, I’m preaching to the choir here, but you’re training folks to basically embody these roles, to play these roles for people in different ways. And it’s got to be the future. But this study and hopefully future studies that we design with this multidisciplinary structure are beginning to show the efficacy for multiple chronic immune conditions, autoimmune conditions. And we have to use this. We have to use this structure. So I’ll stop there because like I said, I’m running out of words. But it’s so awesome to me.
Health Coaching and Collaborative Care
Chris Kresser: Yeah, kudos to you both. I mean, it’s just this study, I was super excited when I heard about it because it really is a manifestation of the vision that I’ve had for a long time of this collaborative practice model, where you link licensed clinicians that are maximizing scope of their practice, ordering tests, interpreting the results, prescribing treatment, with the support of the allied providers like health coaches who are working in the trenches day to day with people that actually support them in making the changes that need to be made. And that is the only way forward here.
We’ll never have enough doctors to address chronic disease, and they’re not arguably the people who should be working intensively with people to make the changes that are required because they don’t have the time or even the training to do the diet behavior and lifestyle support. That’s the job of a health coach. And likewise, health coaches are not trained to order and interpret lab tests and prescribe treatment and do procedures and the things that doctors do. So putting them together in this way and then tying that to a solid and rigorous research that can prove the outcomes is just, it’s amazing. I’m so excited about what you guys have done.
And Angie, I’d love to hear a little bit more about your perspective as the health coach in this intervention. We just heard from Rob from a physician’s perspective. And how was it for you to be involved in this and working with patients and working with Rob?
Angie Alt: Yeah, I mean, it’s an awesome model. For me, it’s a dream-come-true situation. Since the beginning, when I started my health coach training and then eventually went on to add nutritional therapy training to it and started working with people and then realized that the best way for me to leverage what I was doing would be in a group setting, and then to culminate in this opportunity to get to work side by side with the doctor and really, really take the load off of his shoulders in some ways and let the best of his skills and expertise really shine and come through for these women. And then also in turn have his respect that I knew how to do this piece of leading them through the process. And we could communicate in real time about that and pivot as needed for the patient’s needs. That’s an awesome feeling, and the outcomes speak for themselves. It’s obviously clear that doing this model is best for everyone. I think health coaches can essentially stand in the gap. We’re the bridge between the patient and the doctor, and we’re where the real-life stuff happens. And that’s not the best use of the doctor’s time, but it’s a great use of our time.
Chris Kresser: Absolutely, yeah. And as you said, it allows you to work on a multidisciplinary team, it recognizes you as a legitimate healthcare professional who has a lot to offer and is an essential member of the team. And especially with interventions like this. If the intervention is just a drug, what is a health coach doing there?
Rob Abbott: “Did you take your medicine this morning?”
Chris Kresser: And there are actually health educators that help ensure the people do that, and I’m not saying that’s not valuable. But in a medical model where you have these multifaceted interventions that are diet, behavior, and lifestyle based, health coaching becomes absolutely essential.
Because we know that 6 percent, only 6 percent of Americans currently are following even just the top five health behaviors identified by the CDC, much less a more rigorous protocol like AIP that also involves stress management and getting enough sleep and physical activity. So we cannot actually do this without health coaches, just like we can’t make as much progress as we want to make with health coaching alone without collaboration with clinicians.
Angie Alt: Right. Exactly. I guess that’s another piece of it for me, Chris. You know that that’s a point of frustration that I came up against many times in the past and probably will still in the future to some extent—knowing that my clients probably need some next-level stuff, but they’re having trouble accessing that care or I don’t have a partnership with a doctor that I can recommend them to, something like that.
And so it was awesome in this setting to be … We could proactively address things like symptoms starting to become hyper. We could proactively deal with what was coming out on the lab work and what Rob was interpreting there. That’s awesome to get to do that in almost real time.
Chris Kresser: Absolutely. And I mean, we could go on and on. Unfortunately, I have to wrap this up in a minute here. But we’re all on the same page there and share the same vision. And that’s of course, for me, why I am training both practitioners and health coaches. Because that, to have health coaches and clinicians that are trained in the same not just philosophical framework, but the same practical framework, where they have a shared understanding of the diagnosis to treatment, the diet and lifestyle behavior changes, the framework for looking at these conditions and how to intervene.
To me, that’s where it gets very powerful. Because when you can do that in collaboration and you’re starting with that shared framework, it gets really exciting, as you have proven with this study. So thank you both for doing this work, and I’m excited to see what is coming next and for coming onto the show and sharing the results with us.
Angie Alt: Thanks for having us, Chris.
Rob Abbott: Yeah, thank you, Chris. And thank you for giving us the framework to even study in the first place. And I know you’ll continue to support and create the clinicians and health coaches that will carry out the care and the research that we’re just beginning now. So, yeah, thank you.
Chris Kresser: Yes, yes, we just wrapped up enrollment for the second cohort of the ADAPT Health Coach Training Program, which is very exciting. And the first cohort just graduated in early June here and just phenomenal results. If you want to check out some of the experiences that people had in the program and how it changed their life, you can go to ChrisKresser.com/stories. We’ve collated a number of videos and written stories from people in the program. It’s just been super gratifying and rewarding for me to see that.
And then we have enrollments for the fall, both the Practitioner Training Program and the Health Coach Training Program coming up this fall. So you can learn more about those at ChrisKresser.com. Click on health coaching or Functional Medicine. And then Rob and Angie, where can people find out more about your work?
Rob Abbott: Angie, you can go first.
Angie Alt: Everybody can find me and my partner Mickey Trescott over at autoimmunewellness.com. You’ll find links to the full articles for both the AIP IBD and the AIP Hashi study articles. You can find them there. You can find our books, you can find our podcast, you can find our social media. All the things.
Rob Abbott: And you’ll find a little bit of myself over there too. I do get to write and have been lucky to be able to partner with Angie and Mickey. I realized too, and I’ll just throw it in there, it’s, like, self-explanatory to me, but the people’s symptom burden and quality of life did get radically better. I think I didn’t actually say that explicitly because we jumped to thyroid and that podcast. But people got way better in this study.
Chris Kresser: Yeah, that was one of the main positive findings of this study in some ways.
Rob Abbott: Dramatic improvement in quality of life and radical decrease in symptom burden, which was amazing. Yeah, I have a collaborative clinic practice, a Functional Medicine nutrition practice, in Charlottesville, Virginia, called Resilient Roots. It’s formed out of the structure that was in the ADAPT framework. So I work alongside a nutritionist, and we’re using some of the structure that was in the ADAPT framework.
So I can’t tell people enough how beneficial that program can be. And so we’re seeing folks locally in Virginia and actually doing virtual care too, Functional Medicine care, not full-scope medical care. But so if you want to be a new patient of our practice and have been aware of Chris Kresser, we utilize those principles in our clinic. And I also do some podcast and poetry and other blogs and things on my personal site, called A Medicinal Mind. And even, and I keep forgetting about this too because it was a long time ago, but I do have an eBook, the second version of it too, a free eBook on the website that was my encyclopedia. It’s an abridged version of all the resources that are out there for you to learn about—integrative health, Functional Medicine, and it’s got podcasts, it has books, it has blog articles, it has conferences. It’s just, there’s a wealth of things on there. Even if you’re in this space, you’re going to find something on there. Someone you haven’t heard of. And maybe you find a new podcast to listen to. And I updated it last year. I haven’t updated it this year.
But definitely, sign up for the email list, download and get that eBook and share it with people. Because it was my encyclopedia for what I found in all my rabbit hole diets during my medical school training to try to find Functional Medicine. And I was like, I wanted to have something like this to help narrow this down. So that eBook is there for folks if they want to download it.
Chris Kresser: That’s a great resource. Great resource. I’ve seen that and highly recommend it. What’s the website, Rob?
Chris Kresser: Great. And I highly recommend those of you who need additional help, and if Rob and Angie are a good fit for what you’re looking for, they’re both phenomenal practitioners in their own right. And I can’t recommend working with them enough.
So thanks, everybody, for listening. Hope this was inspiring to hear. There’s so many phenomenal developments happening in the field right now. It’s really, it’s just so rewarding for me to be a part of all of this, and I know so many of you are passionate about it, whether you’re considering a career in the health professions or you’re just, again, a citizen scientist and health advocate and someone who wants to support this movement going forward, we appreciate your help and your advocacy.
So thanks for listening. Continue to send in your questions, ChrisKresser.com/podcast, and we’ll talk to you next time.
Do you have Hashimoto’s disease? Have you tried an AIP diet to treat the condition? Comment below and share your story.
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