Bayesian Investor Blog

Mainstream medicine has become increasingly standardized over the past few decades.

Standardization has some benefits: reduced inequality, improved procedures for minimizing mistakes, and increased predictability. Those attributes are often easier to verify than health effects.

Standardization is not so great for promoting innovation (standardizing a few building blocks may promote innovation, but that’s not what medicine has done). Yet medicine is an area where we have a relatively high need for more innovation.

It would be nice if one system of medicine provided everything that I want from medicine. Just like it would be nice if one company could provide all my transportation needs, or every type of food that I want, or an operating system with all the software that I want to use.

Alas, none of those seem close to being feasible this decade. Yet I get the impression that many more people expect it of medicine than is the case for food or transportation.

I’ve reached an age when it’s valuable to ask a good deal from medicine. So in addition to a standard doctor, I’ve engaged with a competing “brand” of medicine.

Specifically, the functional medicine practitioners at Chris Kresser’s Adapt180.

Why?

Some of the shortcomings of mainstream medicine are the result of optimizing for patients who dislike taking lots of tests, and for those who will only follow easy instructions, and/or have little willingness to alter their lifestyle. Doctors don’t gain much by pushing lifestyle changes and/or treatments that patients won’t adopt.

I’m unclear whether there are many patients who are eager to find a doctor who improves on that – I’ll guess it’s maybe 1 to 10% of the population?

Other shortcomings are due to systemic biases toward using patented treatments, and to a presumption that normal health is good enough, i.e. that it’s not worth putting much effort into becoming healthier than an average person of comparable age.

My experience

I went to Kresser’s organization (CCFM at the time; he started Adapt180 over the summer) due to some moderate, persistent fatigue that started after a mid-2019 hernia surgery.

I had also experienced 4 months of postoperative cognitive dysfunction (POCD). I can’t tell whether the recovery was due to natural causes, or to high doses of curcumin and several other anti-inflammatory supplements.

My biggest problem seems to have been SIBO, most likely triggered by the surgery, and possibly exacerbated by consuming lots of sugar alcohols such as erythritol and xylitol.

They detected a bit of giardia, which had probably been giving me minor problems. I believe I contracted it in 1974 while hiking in Wyoming (back when hikers normally drank from streams).

The SIBO treatment seems to have cured the giardia.

They also detected and treated high thallium levels. I can’t tell how thallium affected me – it’s pretty clearly undesirable, but I’ve found little information about the magnitude of its effects, and my experience was confounded by treating it at the same time as the SIBO treatment.

My main source of thallium was Brad’s Kale Chips. Kale concentrates thallium more than do other plants, and many soils have unnatural thallium levels from coal-related air pollution. See this soil map.

Brad’s has a variety of healthy chips that don’t include kale, and I recommend those as substitutes for kale chips. I tested their broccoli cheddar chips when I tested the kale chips (broccoli seems to have a medium risk for concentrating thallium), and their thallium levels were 1/165.8 the levels in the kale chips.

SIBO tests are pretty inconvenient: I needed to go on an extremely restrictive diet for a day, then take breath samples every 20 or 30 minutes over a period of three hours. Many patients likely won’t consider it worth the effort, since treatments don’t work very reliably. I needed three separate treatments over a period of 8 months before I achieved clear success. Each individual treatment seemed to produce some progress. I didn’t cut my sugar alcohol consumption until the third treatment – I can’t tell whether that was important.

I gather that many people with SIBO never identify the cause, so it keeps coming back. It’s no wonder that a standard doctor isn’t interested in testing for it.

I got maybe a 5 or 10% increase in my productivity, a better mood, and maybe avoided some unknown future health problems. That’s worth the time, effort, and money that I put into it. But I can imagine that a number of people would not consider it worthwhile.

I still seem to have some mysterious problems with my T3 levels being lower than optimal. I had been expecting that it was part of whatever was causing my fatigue. Now that that seems to have mostly not been the case, I’m planning to do some more investigations into increasing my T3 levels – which would likely give me a bit more energy.

Controversy

How do mainstream medical experts react to functional medicine?

Often by ignoring it. Sometimes with words such as overtesting, overtreatment, and unproven.

Here’s a hostile reaction that Google ranked fairly high:

I can sense our resident clinical pathologists getting concussions from all the facepalming. Does Cole really think that the population isn’t taken into account, that the reference ranges for thyroid function tests aren’t determined from healthy people without known thyroid disease? Here’s how reference ranges are really determined.

There’s some apparent disagreement over whether reference ranges (e.g. for blood test results) are based on a random sample of people versus the somewhat biased set of people who seek out blood tests, but much of the disagreement is about how many people ought to be told that their results are out of range.

I followed the link behind the term “really determined”, and found explanations that mostly suggest that mainstream medicine does a half-assed job. E.g.:

Step 8: Decide how many people you want to freak out.

We’re about to set a reference range for this lab value. The more narrow we make it, the more people will fall outside of it, get a little * on their lab form, and run to their closest doctor friend for explanation. The standard practice is to freak out 5% of the people. In other words, we’ll make cutpoints such that 95% of the population will fall inside. If you’re with me on the math, that means 2.5% of people will have a value that’s too high and 2.5% will have a value that’s too low.

I.e. the standard practice is to pick an arbitrary cutoff, with little regard to the costs and benefits of treating whatever caused the unusual reading. I’m guessing that’s at least in part due to reluctance of reference range experts to take responsibility for treatment decisions.

The effects of that standard practice vary a lot from test to test.

For vitamin D or B12, abnormally high levels might mean increased risk of kidney stones if you’re deficient in vitamin K2, or might be a sign of liver problems. But those readings are probably also compatible with great health. Reacting to high readings in those vitamins might be better than doing nothing, but there are probably better ways to handle the relevant risks. So it’s hard to say whether any high values here ought to be flagged as abnormal.

For thyroid levels, there’s a good deal of disagreement, even among mainstream doctors, about what levels are worth treating.

We know fairly well that a century ago, a large fraction of people had iodine deficiencies that caused blatant thyroid problems. Enough that it sort of made sense to treat everyone by adding iodine to salt.

Iodine deficiencies aren’t common today, but many other things cause variations in thyroid levels. So it shouldn’t be too surprising if way more than 5% of the population would be better off if their thyroid levels were optimized.

My experience with fluctuating thyroid levels leaves me strongly dissatisfied with the conventional use of thyroid reference ranges. I’ve felt a big difference in mood and energy levels between times when I had a “normal” TSH of 4, versus when I had a TSH between 1 and 2 (which is where the median person is).

This example illustrates some common themes that distinguish functional medicine from other brands of medicine: functional medicine aims for a higher standard of health, and is more willing to accept subjective measures of benefit.

Caveats

There doesn’t appear to be any authority that regulates the term “functional medicine”, so it’s not a brand in the sense of Tesla or Trader Joe’s. It functions more like “libertarian” or “Rationalist”. I expect that there are larger quality variations among functional medicine practitioners than among mainstream doctors, and therefore plenty of quacks who identify as functional medicine practitioners.

Good practitioners have no easy way to convince prospective patients of their quality (Kresser did so via blogging and writing books), so the ones that are recognizably good are a bit expensive, and have long waiting lists on top of that.

You may have noticed that I’ve mostly described functional medicine in terms of what kind of person it helps, and said less of its practices or paradigms. That’s not an accident. I see some differences in terms of functional medicine being more Bayesian and mainstream medicine being more High Modernist, but those probably explain less than half of what’s distinctive about functional medicine. I see many of the differences as being more like the differences between brands of cars – a fair amount of it is simply due to catering to different types of customers.

Functional medicine is definitely not appropriate for everyone. It’s mainly for people with enough chronic problems (such as aging) to justify putting an above-average amount of time and effort into improving their health.

P.S. – I previously mentioned that ashwagandha had strong effects on my thyroid levels. That is no longer true. My current guess is that the strong effects involved interactions between ashwagandha and high iodine levels (from eating kelp powder), and vanished when my iodine levels returned to normal.