I recently had the pleasure of having a conversation with David Brownstein, MD, who is a board certified family physician, integrative practitioner and an expert in thyroid disease, hormones and iodine. He is also the author of fourteen books and is a popular keynote speaker at Restorative Medicine Conferences. In our conversation, he graciously shared details about his typical method for evaluating patients and specifics on his treatment plans using nutrients, herbs, hormones and occasionally pharmaceuticals as needed. I think you’ll find the information he shared to be noteworthy and relevant to your own practice.
MF (Dr. Friedman): Dr. Brownstein, can you please tell us a little about yourself, and what made you interested in doing holistic medicine?
DB (Dr. Brownstein): I consider myself a holistic family practitioner, and I’ve been practicing holistic medicine for over 20 years. I’m the medical director for the Center for Holistic Medicine in West Bloomfield, Michigan. After medical school, I came out of residency and was practicing conventional medicine for about six months, and was starting to realize that patients weren’t getting better on the drug therapies I was trained to use. I was having to prescribe more drugs to treat the side effects from other drugs that I had put them on, but most importantly, I didn’t think that patients were getting better.
At the same time that realization came to me, my dad was really sick with heart disease. He had his first heart attack at age 40, and his second heart attack at 42. At that time in my life, he was on 12 different medications for cholesterol, high blood pressure and diabetes, and he looked like he was going to die at any moment. He was having continued angina over 20 years, which was getting worse. And, so I was having the problems at work where I was unhappy with the therapies that I had in my arsenal and I was not feeling good about where my father was.
A patient happened to give me a book “Healing with Nutrition” by Jonathan Wright, MD, and asked me to read it. I normally would not have read it, but I was just feeling a little unsure of things at that time. I opened the book to the chapter on cardiovascular disease. Dr. Wright talked about the underlying causes of cardiovascular disease, and I took that information from that book and started researching other things, and I checked a few blood tests on my dad, based on what I read. And the first two blood tests that I checked on him were thyroid levels and testosterone levels, and he had a zero testosterone level (a below detectable limit on the lab test), and his thyroid levels were in the lower range of normal. I put him on some natural desiccated thyroid hormone and natural testosterone, and in seven days of doing that, his twenty-plus year history of angina went away, never to return. His cholesterol, in the 300s, fell below 200 without changing his poor dietary habits. More importantly, he looked better and acted better, and that was the moment I decided that I was going to search for a better way to treat patients. I began researching holistic medicine, made an abrupt U-turn from what I was doing in my practice, and built on that for the last twenty-plus years.
MF: Wow. I was wondering, in the last 20 years of experience, was there anything that surprised you about healing?
DB: Well, what surprises me is why holistic principles aren’t taught in our medical schools and why we’re so reliant on the drug model of diagnosing pathology. And, furthermore, why we are trained to prescribe one drug as treatment, when one drug doesn’t remedy the underlying cause of the illness in probably 95% of the cases? The other thing that surprises me is when I see the effects of using natural therapies, I’m amazed every day in my practice that we are not trained in these methods, and I question why.
MF: What therapies do you use in your practice?
DB: Every patient that comes to my office gets a complete hormonal and nutritional evaluation. I use serum testing of hormones, and I check the adrenal, pituitary, and thyroid hormones. And I do a nutritional evaluation of vitamins and minerals. I also take a complete dietary history. I look for imbalances, and then I meet back with the patients and talk to them about what I found, and perhaps how to correct those imbalances. Everyone gets a complete thyroid analysis -- free T4, free T3, TSH, reverse T3, and thyroid antibodies. Everybody gets free and total testosterone, sex hormone binding globulin, progesterone, estradiol, total estrogen, pregnenolone, DHEA, IGF-1, and IGF binding protein 3. I test 25 hydroxy D3, 1,25 hydroxy D3, check thiamine levels, B12 levels, RBC magnesium, zinc, copper, as well as a urinary iodine level.
So I’ll see patients back in a couple of weeks after doing the initial workup, and part of that initial workup is a complete history, including dietary and social history. And then I’ll see them back and try to put the picture together for what I think has thrown them off balance, and part of that will be correcting these nutritional and hormonal imbalances using bioidentical hormones, B12, thiamine, desiccated thyroid, and then working with them dietary-wise and some of their social issues.
MF: Okay, so for example, with vitamin D3, do you have a target level which you want in the blood?
DB: Well, I like the D3 over 30 ng/mL. But I also check the 1,25 D3 to make sure they’re not imbalanced with that as well.
MF: For the iodine, you said you do a urinary test, right?
DB: Yes. Urinary secretion test. Either spot urine, if they’re not taking iodine, and loading test if they’re already taking iodine.
MF: Say someone comes in and their thyroid tests are normal, but their iodine levels are low, I assume you’d give them iodine, right?
DB: Yes, because iodine is needed for more than the thyroid. The thyroid only holds less than 1% of the body’s iodine store; the skin holds 20%, the breasts hold 5%. Our whole body needs iodine.
MF: So what would your protocol be if someone was low on iodine?
DB: Generally, I start most patients with 25 mg a day and adjust it as needed. If they have endocrine disease, such as breast, prostate, pancreas, or thyroid, sometimes I’ll start with more.
MF: And when you’re giving 25 mg a day, how do you assess when to stop?
DB: Well, we need iodine on a daily basis. The body doesn’t have much of iodine stored, so if you stop taking it, you’ll go back to deficiency stage very quickly.
MF: So most of your patients on it are on indefinitely, then?
DB: Yes, most are on 25 mg, I would say, in my practice.
MF: So when you’re giving someone iodine and if the TSH is high, it could be because of iodine or also it could be because the person has had hypothyroidism and not producing enough T3 or T4. But how do you go about determining which one it is?
DB: Because I don’t just check TSH levels; I check T3, T4, and reverse T3 every time I do it, and if you check that, that’s how you can differentiate between what’s going on.
MF: The big question, or the big fear is: when you give iodine to a lot of people, are any of them going to become hyper/hypothyroid? Have you ever had patients become hyper/hypothyroid, who were not previously, when you give them iodine?
DB: I’ve had a few patients become hyperthyroid. They had autonomously functioning nodules; that’s a contraindication to iodine. Unfortunately, unless you’re going to do a radioactive iodine scan on everybody before you give them iodine, you don’t really know who those are, and that will only occur when you give them iodine. In our practice of thousands of patients on it for over 16 years of using it, we’ve had maybe a total of 10 patients who we diagnosed with autonomously functioning nodules. And those patients simply can’t take iodine until they get their nodules removed either through radioactive iodine treatment or surgical removal.
MF: Do you think it’s possible the iodine caused the hypothyroid, or is it because they already had hypothyroid?
DB: No, I have not seen iodine precipitate a hypothyroid state. They may have a hypothyroid condition when iodine is started, but I do not believe iodine causes hypothyroidism.
MF: So, when you give an iodine prescription -- let’s say someone has Graves disease, whether they’re hypo or hyper, do you give the same iodine then?
DB: Sometimes I use more. I’ll start them at 25 mg and quickly move up. The old-time treatment for Graves’ disease was iodine in high doses, and it works marvelously in the vast majority of people who do it.
MF: Let's say someone comes in and they’ve got Graves’ and there’s just a little bit of tachycardia, and their TSH is really suppressed and iodine level is low, you just start them off with 25mg a day and then go up once a week?
DB: Well, I will start them off on things to help their thyroid work better such as magnesium, vitamin C, and selenium. Correcting their nutritional imbalances is part of that initial evaluation. And then, in two weeks I’ll try a therapeutic trial of iodine and usually start at 50 mg.
MF: Would you give them a beta blocker or something like that?
DB: Yeah, absolutely. I’d use a beta blocker for symptom control, without question — if they need it. When it works like it should work , they get better within a couple of weeks. I usually have them re-check their blood levels two to four weeks after they start those to make sure we’re not going in the wrong direction.
MF: How does it help with the utilization of hormones?
DB: Iodine is needed for the production of every hormone in the body -- the pituitary, ovaries, testicles, etc. Therefore, a lack of iodine will cause an imbalance in the entire hormonal cascade.
MF: Regarding the topic of iodine, since conventional medicine tends to have a controversial stance about high dosages and whether it’s safe, do you have a boilerplate statement that you tell people who are concerned about iodine toxicity which explains why you think it's safe or not toxic?
DB: Iodine levels have fallen nearly 60 percent in the last 40 years, and during that same time-period we have seen epidemic increases in all the thyroid illnesses -- autoimmune, hypothyroid, cancer -- as well as epidemic increases involving cancer of the breast, ovary, uterus, prostate, pancreas. We are going down the wrong path right now for almost all those illnesses and I think iodine should be a big part of our re-assessing. My partners and I have been using iodine for a combined 45 years of experience between the three of us. If we were having problems with iodine, we wouldn't have any patients. We use it without side effects for the vast majority of people and if there are side effects, they are easily managed.
MF: Have you ever been able to give someone iodine and then they don't need thyroid hormones?
DB: Absolutely, I call it the rule of thirds, regarding the people who are on thyroid hormone when they see me and I put them on iodine. I tell my patients that the rule of thirds comes into play here -- a third of you will not need thyroid hormone, you just needed iodine; a third of you will need less thyroid hormone, probably about 50% less from what you are on; and the last third will probably need to stay on the same dosage. The problem is, I don't know which third they are in when I start iodine therapy. So, I counsel my patients when I put them on iodine if they are already taking thyroid hormones and tell them if you start to feel any hyperthyroid symptoms, immediately cut back the thyroid in half. If it continues, call me and then we get a blood test and probably cut it back even further.
MF: Do you check other physiological symptoms that are related to thyroid, such as body temperature?
DB: Absolutely. We have patients record body temperatures and they bring them in to me.
MF: So most of your patients’ body temperatures go up on iodine, correct?
DB: I don't get so focused on body temperature, more focused on how they are feeling. And if they are feeling better and they have low body temperature, I don't make a big issue out of that. If the body temperature comes up and they are feeling poorly, that doesn't help much either, but I do use the information.
MF: Do you give desiccated thyroid, and what’s your typical dosage for desiccated thyroid?
DB: My dosing has markedly changed due to iodine, and the first 10 years of my practice, I would estimate that the average dosage was 2 grains. Now, since they are all on iodine, it's a 1/4 to ½ a grain.
MF: That's impressive. And also, what other hormones do you prescribe fairly commonly, like progesterone, estriol, or DHEA?
DB: I prescribe DHEA and pregnenolone to most of my patients.
MF: What dose you feel comfortable with for DHEA?
DB: So for women 5-10 mg for most, and men 10-20 mg, generally.
I use pregnenolone with it, and again the dosing’s a little higher for men -- maybe 25-50 mg, 10-25 mg for women. For progesterone, I use topical and oral, and average dosing is about 50-100 mg for women and 10 mg for men.
MF: Do you also prescribe testosterone?
DM: I use testosterone a lot so for men, the average dose is 60 mg a week, either injection or topical and then women 1-5 mg per week.
MF: Do you find infections in many of your patients who have autoimmune disease?
DB: Yes, you will find that in most of the patients with autoimmune disease. CMV is a big one, candida, mycoplasma, and chlamydia. I’ll use doxycycline.
JP: Do you find that there are any surprising deficiencies that are very common in people, beyond the iodine you discussed, that people just don’t realize?
DB: Oh, yes. The most common nutritional deficiencies I see are B12, thiamine, and potassium - those would be the big three. Iron is another big deal, if it’s too high or too low, it throws off thyroid function. The body gets way out off. So I see a lot of people with too high iron, a lot of people with too low iron.
JP: And with Americans mainly being very overfed, do you blame the food supply or do you blame absorption, or where do you think it's coming from?
DB: We see a lot of people who I will consider somewhat malnourished and yet they are overweight. Yes, the problem is too many refined foods and they are lacking basic vitamins and minerals. And it causes their body to be bigger but there is still deficiency in basics -- vitamins and minerals.
JP: I know that you sometimes talk about detox, do you think that has a role in increasing rates of autoimmune diseases now?
DB: Absolutely. I get a hair test on everybody. One of the reasons I use the hair test is to screen for heavy metal toxicity and then I do further testing with challenge tests, and I have found that over 80 percent of people have toxic levels of mercury and over 90 percent have toxic levels of lead. That can certainly set off autoimmune system problems that need to be addressed. To address toxicities, we look for the sources and try to correct that first. Then we try detoxing, first starting by correcting nutritional imbalances and hormonal imbalances.
JP: What kind of advice would you give to new practitioners who are trying to make the same transition you did, such as starting as a conventional doctor and then realizing they want to get into integrated medicine?
DB: The best advice I can give them is to start with the basics. I started checking people for one thing at a time and then learning about that, then moving on to the next. That has worked for me, it has worked for my partner and it can work for others. I will also suggest, do not get overwhelmed with trying to learn everything at once.
Dr. Brownstein is on the advisory committee of the Restorative Medicine Herbal Certification program. More information HERE.