Cease Fire: Stop Attacking Your Thyroid

PART 1:

DEFINING THE THYROID,

HASHIMOTO’S, & AUTOIMMUNITY

This e-book is about Hashimoto’s thyroid disease.

We cover what it is, the root causes of autoimmunity, and Hashimoto’s disease and how to resolve or, at the very least, improve a case of Hashimoto’s.

We start at the beginning with an overview of the thyroid and how it functions.

WHAT IS THE THYROID?

The thyroid is a butterfly-shaped endocrine gland that sits at the front of the neck, along the front of the windpipe.

The thyroid controls metabolism, the rate at which the body produces energy from nutrients and oxygen (The Endocrine Society, 2019). It affects critical body functions, such as energy level and heart rate (American Thyroid Association, 2020). The thyroid secretes several hormones, collectively called thyroid hormones. These hormones influence every cell, tissue and organ in the body.

Thyroid hormones regulate multiple functions in the body; the way the body uses energy, consumes oxygen and produces heat (The Endocrine Society, 2019).

Thyroid disorders are fairly common (American Thyroid Association, 2020):

• More than 12% of the US population will develop a thyroid condition during their lifetime

• Women are 5 - 8 times more likely than men to have thyroid problems

• One woman in eight will develop a thyroid disorder during her lifetime

• Up to 60% of those with thyroid disease are unaware they have it

Most thyroid diseases are life-long conditions that can be managed with medical attention and/or diet and lifestyle habits.

In this E book, we will give you the information on how to manage Hashimoto’s thyroid condition through diet and lifestyle.

HOW DOES THE THYROID WORK? WHAT DOES IT DO?

The thyroid makes thyroid hormones. It uses iodine and the amino acid tyrosine to make thyroid hormones (Shahid MA, 2020). Thyroid hormones are essential for proper metabolic activity and have multiple effects on every organ system in the body. Thyroid function influences growth and development, affects metabolism, mental function, energy level, digestive health and bowel movements, cardiovascular function and bone health (Panicker, 2011).

The main hormones produced by the thyroid gland are (Shahid MA, 2020):

• T4 (thyroxine)

• T3 (3,5,3'-triiodothyronine) -> a small amount is made in the thyroid gland and much is produced elsewhere because T4 is converted to T3 in other tissues like the liver and gut

• RT3 (reverse 3,5,3'-triiodothyronine)

These thyroid hormones are controlled by TSH (thyroid stimulating hormone) from the pituitary gland.

The most common thyroid problems involve abnormal production of thyroid hormones. If the thyroid produces too little thyroid hormones, this condition is called hypothyroidism. Producing too much thyroid hormone results in a condition known as hyperthyroidism. There can be an issue with the conversion from T4 to T3, which would cause low T3. Thyroid hormone receptor sites can get blocked which would create the

WHAT CAN GO WRONG WITH THE THYROID?

same effect. Other thyroid disorders can range from a small, harmless goiter or enlarged gland that needs no treatment to thyroid cancer.

COMMON CAUSES OF GENERAL THYROID DISORDERS

• Nutrient deficiencies including iodine, zinc, iron, vitamin D or selenium (Fröhlich E, 2019)

• Autoimmune (AI) diseases, leading either to Graves disease (hyperthyroidism) or Hashimoto's disease (hypothyroidism) (Fröhlich E, 2019)

• Inflammation of the thyroid, caused by a virus or bacteria (including chronic viral infections like Epstein Barr Virus)

• Nodules, or non-cancerous lumps, inside the thyroid

• Cancerous tumors on the thyroid gland

• Occasionally, pregnancy can initiate thyroid problems to start or get worse. The opposite can happen and thyroid conditions can improve during pregnancy.

In Functional Medicine, we like to identify the root causes of a health problem. There are other underlying causes which can lead to or contribute greatly to a thyroid disorder. Let’s turn now specifically to Hashimoto’s thyroid disease.

WHAT IS HASHIMOTO’S?

Hashimoto's disease, or Hashimoto's thyroiditis, is an autoimmune disease that damages the thyroid gland. It causes the thyroid to not make enough thyroid hormone. Hashi’s is the most common cause of hypothyroidism or underactive thyroid.

In Hashimoto's disease, the immune system makes antibodies that attack the thyroid gland. This damages the thyroid gland, so it does not make enough thyroid hormone. Hashimoto's disease often leads to hypothyroidism and the symptoms of low thyroid.

• Hashimoto’s is the main cause of hypothyroidism (Fröhlich E, 2019).

• Hashimoto thyroiditis affects 1 to 2% of the population in the US (NIH US National Library of Medicine, 2020).

• Hashimoto’s, and autoimmune diseases generally, are more common in women than in men, which is related to hormonal factors (Fröhlich E, 2019).

• The risk of getting Hashimoto's disease is higher if you already have another autoimmune disease, such as rheumatoid arthritis, celiac disease, type 1 diabetes, lupus, etc.

In Hashimoto’s, antibodies against own thyroid tissue damage the thyroid gland. This is the issue in autoimmune disease: the immune system mistakenly attacks own tissue. In the case of Hashimoto’s, it is the thyroid that is under an autoimmune attack.

Antibodies of the immune system mistakenly attack thyroperoxidase (TPO) and thyroglobulin (Fröhlich E, 2019). These are important molecules for thyroid function.

Thyroperoxidase is an enzyme that adds iodine to thyroglobulin for the production of thyroid hormones (ScienceDirect, 2020). It is essential to making T4 and T3, the hormones that the thyroid is responsible for making (ScienceDirect, 2020).

Thyroglobulin is a protein involved in making T4 and T3 (ScienceDirect, 2020).

If the thyroid cannot make enough thyroid hormones called T4 and T3, because it is under autoimmune attack, then there is not enough thyroid hormone for the thyroid to

function well. Without the hormones T4 and T3, the thyroid is underactive or low. This is why Hashi’s can feel similar to low or underactive thyroid, which is called hypothyroidism.

WHAT ARE THE SYMPTOMS OF HASHI’S?

Symptoms of thyroid disorders can be quite varied. This is because the thyroid is so critical to metabolism and affects every cell of the body. Hashimoto's disease typically leads to low thyroid function or hypothyroidism.

Similar to hypothyroidism, symptoms are:

• Fatigue and sluggishness

• Increased sensitivity to cold

• Constipation

• Pale, dry skin

• A puffy face

• Brittle nails

• Hair loss

• Unexplained weight gain

• Muscle aches, muscle weakness, joint pain and stiffness

• Excessive or prolonged menstrual bleeding

• Depression

• Memory lapses

WHAT ARE THE CAUSES OF HASHIMOTO’S?

In Hashimoto’s, there are root causes of an autoimmune disease and then specifically, root causes of Hashimoto’s disease. Some causes might be unexpected but are definitely worth considering and addressing to improve thyroid health.

WHAT ARE THE ROOT CAUSES OF AUTOIMMUNITY (AI)?

As an autoimmune disease, Hashimoto’s is caused by the triad of autoimmunity.

Dr. Fasano is a world-renowned gastroenterologist and research scientist, who is also a world-leading expert in autoimmunity. He has done extensive research on autoimmunity and came up with the model of the triad of AI.

The Triad of Autoimmunity = three components that lead to the development of autoimmunity:

• A Genetic Predisposition to AI

• An Environmental Trigger

• Intestinal Permeability, also called leaky gut

Dr. Fasano has further developed the triad of AI to come up with the 5 pillars of chronic inflammatory disease, including autoimmunity (Gustafson, 2018).

These 5 factors will can shift a genetic predisposition to potentially developing autoimmunity to a clinical diagnosis of AI (Gustafson, 2018).

THE 5 FACTORS IN CHRONIC INFLAMMATORY DISEASE

1. A genetic predisposition

2. An environmental trigger that may contribute to autoimmunity

3. A reason for the immune system to become overactivated and why it over activates the inflammation response against its own body

4. A reason for the gut barrier to become damaged and ‘leaky’

5. The composition of the microbiome

Point 1 is genetic and cannot be changed.

Point 2, the environmental trigger, is difficult to identify, although we mention further in this E-book what to look for.

Points 3-5 are directly related to gut health. This is where Functional Medicine can make an impact. This is why we spend so much time discussing gut health and how to improve it.

‘All disease begins in the gut’, said Hippocrates, c. 460-370 BC, over 2,000 years ago. Gut health is critical in cases of autoimmunity. As an autoimmune disease, Hashi’s is linked to poor gut health. Leaky gut, or intestinal permeability, is involved, as well as other possible GI problems.

The microbiome is a collection of microbes that live in and on the human body. The gut microbiome is the collection of microbes that live in the gut.

The gut has the largest number and diversity of microbes. The gut bacteria composition changes across the digestive tract. In the stomach and small intestine, there are relatively few species of bacteria.

The colon or large intestine is where most of the microbiome lives. The large intestine has approximately 39 trillion microbial cells that include bacteria, viruses and fungi (Sender R, 2016). It is estimated that we have 37.2 trillion human cells (Bianconi E, 2013). Research says that a realistic estimate of the number of microbes living in the human body is about 40 trillion, which is close to the number of human cells (Sender R, 2016).

The large intestine is home to somewhere from 200 to 1,000 different bacterial species (Yang J, 2020). But the majority are bacteria from about 30 or 40 species. Fungi, viruses and other types of microbes are also part of the gut flora, but less is known about them.

There are a small number of core microbial species shared by most people. Beyond that, populations of microbes can vary widely from person to person. Within one person, the microbial populations stay fairly constant over time. Changes can occur due to changes in lifestyle, diet and age.

WHAT ARE THE GUT ISSUES THAT CAN CAUSE AUTOIMMUNITY AND HASHIMOTO’S DISEASE?

OVERALL GUT FUNCTION

The composition of the gut bacteria plays an important role in thyroid function (Fröhlich E, 2019). Dysbiosis, or an imbalanced gut microbiome, is emerging as a key issue in people with thyroid disorders (Fröhlich E, 2019). The gut bacteria can influence the metabolism of thyroid hormones, the uptake of the crucial thyroid minerals iodine, iron, zinc and selenium, how the thyroid medication Levothyroxine functions and whether or not a person develops an autoimmune disease (Fröhlich E, 2019).

The true incidence of digestive symptoms in people with thyroid disorders is, unfortunately, not well documented (Maser C, 2006). Slower intestinal motility and transit time in the gut has widely been accepted as the leading cause of digestive symptoms of thyroid disease (Maser C, 2006). In one specific thyroid disorder, hyperthyroidism, the reported frequency of gastrointestinal symptoms varies between 30% and 50% of sufferers (Maser C, 2006).

INTESTINAL PERMEABILITY OR LEAKY GUT

Leaky gut accompanies autoimmune disorders of the thyroid; Hashimoto’s and Grave’s. Tight junctions are a type of cell. They make up the continuous intercellular barrier which separates tissue spaces and regulates selective movement of molecules. The purpose of tight junctions is to keep liquid from escaping between cells, allowing a layer of cells, such as a lining an organ, to act as an impermeable barrier. For example, the tight junctions between the epithelial cells lining the bladder prevent urine from leaking out into the extracellular space. Tight junctions regulate the permeability of the gut, which is meant to remain ‘closed’ to the rest of the body.

What we eat is digested, nutrients are absorbed through the gut lining into the body and then the waste is excreted through the anus. What we put into our mouths is not meant to go directly into the bloodstream to circulate. If this happens and molecules, proteins and toxins can get into the blood circulation, then leaky gut exists. The immune system sees these unexpected molecules leaking through the gut lining as foreign invaders and mounts an immune response attack. Because the gut is leaky, this will happen over and over multiple times.

The immune system eventually goes into high alert from so many invaders and becomes overactivated. It then starts to attack own tissue and the auto-attack of autoimmunity has begun. In the case of Hashi’s, the immune system is attacking thyroid tissue. We must heal the gut to ‘close’ the leaky gut in order to stop the autoimmune attack.

DYSBIOSIS

Dysbiosis, or imbalanced gut flora, is a risk factor for Hashi’s. This is when the pathogenic ‘bad’ gut bacteria outnumber the health-promoting ‘good’ gut bacteria.

This is when the 39 trillion gut microbes, referenced earlier, are dominated by unhealthy pathogenic species. Many health issues and symptoms can occur as a result of this gut dysbiosis.

Thyroid disorders are linked to the composition of the microbiota and an altered microbiota specifically increases the prevalence of Hashimoto’s (Fröhlich E, 2019). Gut bacteria influence thyroid hormone levels by regulating iodine uptake (Fröhlich E, 2019). Gut bacteria affect important minerals like selenium, iron and zinc. This can lead to sub-clinical nutrient deficiencies.

ABSORPTION ISSUES

In addition to potential poor absorption of important nutrients, dysbiosis of gut microbiota can impact the uptake of thyroid medication (Fröhlich E, 2019). The microbiota may alter the uptake, absorption and availability of the thyroid medication L-thyroxine used to synthetically increase levels of the thyroid hormone T4 (Fröhlich E, 2019).

CONSTIPATION, SIBO, SIFO AND ACID REFLUX

Decreased motility occurs when the MMC, or migrating motor complex, is not functioning well. The MMC is designed to move matter through the digestive tract. It pushes food and other molecules through the gut. This keeps things moving and helps to prevent gut infections. It is very important for gut health.

The motility generated by the MMC pushes digested food through the GI tract and is important for the digestion process. This breaks down food and nutrients and promotes

normal levels of bacteria in the small intestines. One reason for decreased motility is a lack of thyroid hormone (Fröhlich E, 2019). Thyroid hormone helps to increase intestinal motility. People with Hashimoto's are at increased risk for developing GI related issues due to slower motility (Fröhlich E, 2019).

With poor gut motility, there is a risk of constipation because things are working too slowly. There is a risk of other gut problems as well.

SMALL INTESTINAL BACTERIAL OVERGROWTH (SIBO)

Small intestine bacterial overgrowth (SIBO) is basically an overgrowth of bacteria in the small intestine. It damages the gut wall leading to malabsorption of nutrients. The main signs and symptoms of SIBO are bloating, abdominal pain, cramping, gas, weight loss and diarrhea or constipation or actually a mix of the two.

Slower reduced motility is a key risk factor for the development of SIBO (Patil, 2014). Hypothyroidism is also associated with altered GI motility (Patil, 2014). Hypothyroidism is connected to SIBO because gastric motility is decreased in hypothyroidism. SIBO may be present in more than half of patients with hypothyroidism whose condition is primarily caused by Hashimoto’s (Patil, 2014).

The main causes of SIBO are hypothyroidism, proton pump inhibitors and antacids, Helicobacter pylori, autoimmune disease, malnutrition and immune dysfunction.

Thyroid hormones, especially T3, are involved in the process of peristalsis. This is when the MMC moves food through the intestines for elimination. In hyperthyroidism, people

tend to have diarrhea. In hypothyroidism and Hashi’s, people tend towards constipation due to too much or too little thyroid hormone.

T4 => T3 HORMONE CONVERSION

The thyroid hormone T4 is the inactive form of thyroid hormone. It must be converted into T3 to be used by the body. The gut bacteria convert inactive T4 into the active form of thyroid hormone, T3.

If the conversion of T4 to T3 is not working well, then common hypothyroid symptoms may result. About 20% of T4 is converted to T3 in the gut (Kharrazian D, 2018). T4 to T3 conversion can be impaired for different reasons.

If there are not enough healthy bacteria, as in the case of dysbiosis for example, then T4 => T3 conversion in the gut is impaired. Gut bacteria produce enzymes that convert T4 to T3 so if gut dysbiosis is present this can cause a conversion issue (Virili C, 2015).

LPS, or lipopolysaccharides, are toxins produced by gram-negative pathogenic bacteria. LPS can inhibit the enzyme involved in T4 -> T3 conversion so again, gut dysbiosis is a cause (Yu J, 2000). Inflammation from dysbiosis, as measured by cytokines like IL-6, have been shown to induce major changes in thyroid hormone metabolism and specifically, T4 -> T3 conversion (Corssmit EP, 1995).

Selenium and iron are crucial to T4 -> T3 conversion (Arthur JR, 1993). If a deficiency exists in these nutrients, then conversion will be impaired (Arthur JR, 1993). Finally,

high cortisol, as a result of chronic stress and/or inflammation, also inhibits T4 to T3 conversion (Stratakis CA, 1995).

CELIAC DISEASE

There is an association between Hashimoto’s and celiac disease (Krysiak R, 2019). In fact, autoimmune thyroiditis is the most prevalent co-existing autoimmune disorder in patients with celiac disease (Krysiak R, 2019).

One study investigated how a gluten-free diet might affect thyroid autoimmunity and function (Krysiak R, 2019). The major finding of the study is that the gluten-free diet reduced thyroid autoimmunity and slightly increased thyroid hormone output in women with Hashimoto’s (Krysiak R, 2019). In 62% of these patients, the decrease in thyroid antibodies and changes in thyroid function tests were accompanied by the disappearance of anti-tissue transglutaminase antibodies. Anti-tissue transglutaminase antibodies are the marker for celiac disease so seeing these disappear means that the celiac disease also improved on the gluten-free diet.

In addition, both vitamin D and selenium levels increased in people on a gluten-free diet. Both D and selenium play an important role in thyroid function and the rise in both is one reason why thyroid AI decreased in these study subjects. It was also found that the gluten-free diet reduced inflammation (Krysiak R, 2019). It has been found that Hashi’s patients often produce anti-gliadin and anti-transglutaminase antibodies, which would indicate some degree of celiac disease (Fröhlich E, 2019).

GLUTEN & MOLECULAR MIMICRY

Even if a Hashi’s patient does not have celiac, gluten is still problematic for people with thyroid conditions. This is due to the concept of molecular mimicry. Molecular mimicry is when the molecules of two substances in the body look extremely similar. The body can get confused and attack the wrong molecule, which is what happens in autoimmunity.

Gluten is an issue in Hashimoto’s and other thyroid conditions. This is because the gluten molecule looks like thyroid hormone producing cells, on a molecular level. When the gut is leaky, gluten molecules can escape from the GI tract and get into circulation in the body. The body sees the gluten and attacks it as a foreign invader. Because gluten looks like thyroid cells, the body may mistake thyroid tissue for gluten and attack thyroid cells. This is partially why thyroid antibodies decrease on a gluten-free diet.

In addition, we know that gluten is a large contributing factor to developing leaky gut in the first place.

H pylori is a common and contagious type of bacteria that infects the gut. It lives in the mucus lining of the stomach. H pylori infections can often be usually harmless. In more serious cases, it can lead to sores and ulcers in the stomach lining or the small intestine. For some people, an infection can lead to stomach cancer.

There may be a link with thyroid disease but there is not full consensus on the possible association between H pylori infection and autoimmune thyroid diseases (Figura N,

HELICOBACTER PYLORI (H PYLORI)

2019). Some studies have reported an increased prevalence of H pylori infection in people with AI thyroid disorders (Papamichael KX, 2009).

H pylori infection can be associated with Hashimoto’s, due to increased inflammation and molecular mimicry (Figura N, 2019). In fact, H pylori infection prevalence was significantly increased in 64.4% of the Hashimoto’s patients in one study (Figura N, 2019). There appears to be a relationship between H pylori infection and the presence of thyroid auto-antibodies, such as thyroglobulin antibodies (Tg Ab) and thyroperoxidase antibodies (TPO Ab) (Papamichael KX, 2009).

Another study showed a significant decrease in Free T3 and Free T4 in people with H pylori compared to people who tested negative for H pylori (Papamichael KX, 2009).

Low FT3 and FT4 are part of hypothyroidism and Hashimoto’s.

FOOD INTOLERANCES

As a result of the leaky gut associated with AI and Hashi’s, food intolerances can exist. This causes inflammation and over-activates the immune system response. Food intolerances are essentially a gut issue and can dramatically improve once leaky gut is healed.

In research, it has been found that testing for food intolerances is very important for patients with AI disease (Coucke, 2018). Eliminating food intolerances from the diet could decrease symptoms and ‘probably stop or slow the progression of the autoimmune disease’ (Coucke, 2018). The study concludes that food is probably an important trigger for autoimmunity in vulnerable patients (Coucke, 2018).

OTHER POTENTIAL CAUSES AND TRIGGERS OF HASHIMOTO’S

In addition to gut issues, there other potential causes and triggers of Hashimoto’s are:

INFECTIONS

Many types of infections can trigger Hashi’s (and other AI conditions) but the most common include both viruses and bacterial infections. There is evidence that hepatitis C virus may contribute to Hashi’s (Ajjan RA, 2015).

Epstein-Barr Virus (EBV) infection can be a significant contributory factor and cause autoimmune diseases. EBV has been found to either cause or be linked to multiple autoimmune diseases, including Hashimoto’s (Dittfeld A, 2016).

EBV, more commonly known as mono or ‘the kissing disease’, is a virus that can live dormant in a person for years. EBV can re-activate or flare and recur later in life in some individuals.

TOXIN OVERLOAD

The thyroid is very sensitive to environmental toxins. Many environmental pollutants have toxic effects on the thyroid (Duntas LH, 2016). These numerous toxic chemicals are in the environment and have long-term damaging effects not only on the thyroid but also on general health (Duntas LH, 2016).

• Compounds widely used in pesticides affect the hypothalamic-pituitary-thyroid axis and disrupt thyroid function (Duntas LH, 2016).

• PCBs (polychlorinated biphenyls) and PBDEs are two classes of persistent organic pollutants that are able to resist degradation and can bioaccumulate through the food chain. PCBs are highly toxic industrial compounds which negatively impact thyroid function (Duntas LH, 2016).

• PCBs and PBDEs bind to thyroid transport proteins and disrupt thyroid function (Duntas LH, 2016).

• Endocrine disrupting chemicals, such as Bisphenol A (BPA), polychlorinated biphenyls PCBs, pphthalates, phenol, plastics, lead, cadmium, DDT, and some other pesticides, are a particular issue. These chemicals disrupt iodine transport and TPO enzyme action to make thyroid hormones (Calsolaro V, 2017). They can contribute to Hashi’s or exacerbate existing conditions by interfering with hormones and immune function.

• Various types of agricultural chemicals (pesticides, insecticides, fungicides) have been found to be strongly associated with Hashi’s (Goldner WS, 2010).

One study looked at women living on farms in the Mid-West and found that these chemicals appear to be the cause for a higher incidence of thyroid disease including both Hashi’s and hypothyroidism (Goldner WS, 2010).

Another study looked at people of both sexes living near a petrochemical plant and discovered an increased incidence of both Hashi’s and thyroid antibodies in these people (de Freitas CU, 2010). There was both a higher prevalence and a higher risk of Hashimoto's and thyroid antibodies (de Freitas CU, 2010).

Glyphosate, the active ingredient in the herbicide Roundup, can lead to a depletion of selenium, an important nutrient in thyroid health. Selenium is important for making

thyroid hormone and helps to lower thyroid antibodies (Drutel A, 2013). Glyphosate harms gut health as it can cause intestinal dysbiosis (Ackermann W, 2015). Furthermore, glyphosate can disrupt the barrier properties of intestinal cells and might cause a leaky gut, increasing the risk of developing an autoimmune condition such as Hashimoto’s (Vasiluk L, 2005).

MERCURY

The heavy metal, mercury, is found in many items including cosmetics, pesticides, fish and dental fillings. Mercury is released into the air through coal burning or other polluting activities and accumulates in the water supply.

The mercury molecule looks very similar to iodine (The National Academy of Hypothyroidism, 2020). Due to molecular mimicry, the body can get confused and deposit mercury, instead of iodine, in the thyroid. This accumulated mercury can disrupt the conversion of T4 to T3, which can contribute to Hashimoto’s (The National Academy of Hypothyroidism, 2020).

Mercury depletes selenium, an important nutrient used in making thyroid hormone (The National Academy of Hypothyroidism, 2020). There is a correlation between high mercury levels in the bloodstream and thyroid antibodies levels (The National Academy of Hypothyroidism, 2020). Increased thyroid antibodies is a key factor in developing Hashimoto’s.

Finally, cell damage caused by mercury may encourage autoimmune activity (The National Academy of Hypothyroidism, 2020).

DIET & NUTRITION

Certain nutrients are critical for proper thyroid function. Nutrient deficiencies in some of the thyroid specific vitamins and minerals will impair thyroid function. Certain foods are particularly helpful for the thyroid and others can be damaging to thyroid function. An inflammatory SAD (Standard American Diet) will worsen any health conditions or susceptibilities.

The minerals and vitamins selenium, zinc, iron and vitamin D are important for thyroid health. Thyroid problems are linked to abnormal levels of these minerals (Fröhlich E, 2019).

For example, the thyroid gland contains the highest amount of selenium per mg of tissue in the body (Fröhlich E, 2019). Sufficient selenium levels are a prerequisite to prevent thyroid disease (Ventura M, 2017). Selenium is needed as an antioxidant and to produce thyroid hormones (Ventura M, 2017).

Zinc is critical for the conversion of T4 to T3 and the production of TSH. It also helps to tighten the intestinal tight junctions in cases of intestinal permeability (Fröhlich E, 2019).

Iron deficiency decreases T4 and T3 levels, reduces T4 to T3 conversion and decreases T3 metabolism (Ashraf TS, 2017).

Studies have found that vitamin D can reduce thyroid antibodies, especially TPO Ab (Chao G, 2020). It is thought that vitamin D may influence the effect of T4 on autoimmune diseases (Chao G, 2020). People with Hashimoto’s typically have a reduced vitamin D level and higher TSH (Chao G, 2020).

As mentioned earlier, gluten is an issue both for autoimmunity and for Hashimoto’s. One study found that a 6-month gluten-free diet reduced thyroid autoimmunity and slightly increased thyroid function in women with Hashimoto’s thyroiditis (Krysiak R, 2019). Both types of thyroid antibodies, TPO Ab and Tg Ab, levels were lower after a gluten free diet (Krysiak R, 2019). Part of the improvement in thyroid function is thought to be due to improved nutrition. People on the gluten free diet had higher vitamin D and selenium levels at the end of the 6 months (Krysiak R, 2019).

IODINE

Excess iodine consumption is a key risk factor of Hashimoto’s. Studies report excess iodine intake leads to an increase in both the incidence and prevalence of Hashi’s (Liu J, 2019). The specific mechanism linking excess iodine intake and Hashimoto’s is unclear (Liu J, 2019).

Iodine is required to make thyroid hormone. It is also a component of the thyroid hormones T4 and T3. We need just the right amount of iodine. Either too low or too high iodine intake can lead to thyroid diseases, such as hypothyroidism and Hashimoto’s.

Excess iodine is associated with the production of antibodies specific to thyroid hormones, which indicates an immune attack on the thyroid tissue is happening (Liu J, 2019). It is important to perform a urine test for iodine levels to be sure if this is an issue for a particular case of Hashi’s.

ESTROGEN DOMINANCE AND OTHER HORMONAL IMBALANCES

High estrogen levels increase thyroid binding globulin which binds thyroid hormones and blocks their uptake (Mazer, 2004). This can lead to hypothyroidism (Mazer, 2004). Estrogen dominance may also occur when progesterone falls, making estrogen dominant relative to progesterone. This would also inhibit thyroid hormones and contribute to hypothyroidism.

STRESS / HPA (HYPOTHALAMUS-PITUITARY-ADRENAL) AXIS DYSFUNCTION

Dysregulation of the HPA axis can cause excessive levels of glucocorticoids. The primary glucocorticoid is cortisol. High cortisol has many effects on the body and one is to suppress the 5' deiodinase enzyme, which converts T4 to T3 (Tsigos C, 2002). Impaired T4 to T3 conversion contributes to suppressed or lowered thyroid function (Tsigos C, 2002).

PARIETAL CELL ANTIBODIES

Parietal cells are located in the stomach. They make stomach acid and intrinsic factor. Stomach acid helps digest protein and metabolize minerals. Intrinsic factor helps absorb vitamin B12. Vitamin B12 deficiency can lead to fatigue, neuropathy and other

symptoms. Low stomach acid can lead to heartburn, poor digestion, feeling bloated and difficulty digesting high protein meals in particular. Low mineral levels can also be a consequence of low stomach acid.

Parietal cell antibodies are frequently associated with other autoimmune diseases such as autoimmune thyroiditis. This is indicative of an autoimmune attack on parietal cells. Parietal cell antibodies (PC-ab) are elevated in a significant percentage of thyroid cases. This is thought to be because the thyroid gland and the stomach share structural and biochemical properties (Boutzios G, 2022). Thyroid cells and stomach cells they have a common origin in the embryo (Boutzios G, 2022).

One study found over 20% of people with Hashi’s also had positive parietal cell antibodies (Utiyama SRR, 2018). Another study found between 10-40% of people with Hashimoto’s thyroiditis had positive PC-ab (Rodriguez-Castro Kryssia I, 2018). Parietal cell antibodies can also contribute to oral symptoms like mouth sores, sore tongue, dry mouth and more.

CAN HASHIMOTO’S CAUSE ANY OTHER DISEASES?

OTHER AUTOIMMUNE CONDITIONS

There is a tendency for a person with one autoimmune disease to develop other autoimmune diseases. This is because there is already excessive inflammation, leaky gut and other root causes in place. In addition, the immune system is already overactivated and attacking own body tissue. In the case of Hashimoto’s, the body is attacking thyroid tissue. It is certainly possible that the immune system starts to attack another type of tissue, which would result in another autoimmune condition.

Polyautoimmunity is the term for having more than one diagnosed autoimmune disease. The combination of three or more diagnosed autoimmune disorders in one person is called Multiple Autoimmune Syndrome (MAS). In one study, polyautoimmunity was observed in 34.4% of the autoimmune patient population (Rojas-Villarraga A, 2012).

As mentioned above, we see antibodies for parietal cells, indicative of an autoimmune attack on the parietal cells, in 10-40% of people with Hashimoto’s thyroiditis (Rodriguez-Castro Kryssia I, 2018).

HASHIMOTO'S ENCEPHALITIS (HE)

A condition called autoimmune encephalitis is related to Hashimoto’s. It is a condition of brain inflammation caused by a mistaken autoimmune response. The exact cause of Hashimoto's encephalopathy is not known. Hashimoto’s is one possible cause of encephalitis. The other common cause is infection. It is thought that, like Hashimoto's

thyroiditis, HE is an autoimmune condition. The immune system mistakenly targets own body tissue as if they were a virus or bacteria. In the case of HE, the target is the brain.

Hashimoto's encephalitis is rare. It is generally associated with a background of Hashimoto's thyroiditis. The patient has high levels of antithyroid antibodies, especially anti TPO antibodies (Uy CE, 2021).

Symptoms include seizures, stroke-like episodes, fatigue, encephalopathy meaning it alters brain function, dementia, jitteriness or nervousness, poor appetite, confusion, altered consciousness, and loss of contact with reality (psychosis).

In Hashimoto's encephalitis, there are brain symptoms and an overlap with mental health. We have just written a comprehensive E book about mental health. In it, we describe how mental health issues are very much driven by gut health issues. If the gut is not healthy, we can see mental health issues appear in people. Hashimoto’s encephalitis is another example of how a condition with mental health symptoms can be driven by gut health.

HOW TO TEST FOR HASHIMOTO’S?

It is fairly simple to test for Hashimoto’s. A blood test showing high levels of TPO Antibodies and Thyroglobulin Antibodies will indicate Hashimoto’s disease.

Unfortunately, the vast majority of conventional doctors only look at TSH when assessing thyroid health. They pick up hypothyroidism through TSH and prescribe a medication. They don’t look at the thyroid antibodies so they don’t catch Hashi’s or the AI element of the condition. This is a great shame because AI, in the form of Hashi’s, needs to be treated differently than just prescribing Levothyroxine. Solutions need to focus on gut health, resolving leaky gut and if possible, identifying the environmental trigger.

Some Hashimoto’s patients do not have measurable antibodies. Between 5-10% of Hashimoto’s patients do not have increased levels of thyroid antibodies (The National Academy of Hypothyroidism, 2018). In this case, the condition can get overlooked if antibodies are the only marker used for diagnosis (The National Academy of Hypothyroidism, 2018). A skilled practitioner will always look at symptoms in addition to lab tests and should treat based on symptoms.

An ultrasound can sometimes visually identify damage to a thyroid gland from an autoimmune attack without the presence of any antibodies. This, however, is not routine screening so much thyroid dysfunction with a root in autoimmunity may not be properly diagnosed or treated.

ARE THERE SOLUTIONS FOR HASHIMOTO’S?

Fortunately, there are many things within Functional Medicine that can be done to treat and improve cases of Hashimoto’s.

The solution to Hashi’s lies in healing the gut, finding the environmental trigger(s) and addressing ALL causes of inflammation to calm the immune system and prevent the auto-attack.

WHAT ARE KEY ELEMENTS OF TREATMENT FOR HASHIMOTO’S?

DIET CHANGES

There are a few diets that could work for Hashi’s. Essentially, the diet should be high in whole, unprocessed foods, including lots of vegetables and fruit with healthy fats and proteins. It can be quite individual and people with Hashimoto's often end up experimenting with different diets until they find one that makes them feel best.

The Auto Immune Paleo diet or AIP diet is a good option. One study trialed this diet on a group of Hashi’s patients (Abbott RD, 2019). After 10 weeks symptoms decreased significantly and inflammation, as measured by the blood marker hs-CRP, significantly declined by 29% (Abbott RD, 2019). Thyroid markers, TSH and thyroid antibodies, did not go down at the 10-week point. However, the decline in hs-CRP suggests a modulation of the overall immune and inflammatory response underlying autoimmune thyroiditis. The authors of the study think that eventually, there would have been a decrease in thyroid antibodies, a decreased need for thyroid hormone medication and

improvements in immune and inflammatory markers in the participants if they followed the AIP diet for a longer period of six to 12 months (Abbott RD, 2019).

Another very small study was performed with one participant, a 34-year-old woman with Hashi’s (Dolan K, 2018). She did not take thyroid hormone replacement medication and was able to manage her Hashi’s with diet and supplementation (Dolan K, 2018). She followed a diet rich in phytonutrients (brightly colored fruits and vegetables, like berries, tomatoes, carrots, peppers, eggplants, purple grapes, squash, sweet potatoes, peaches, dark green leafy vegetables, etc.). She avoided gluten and soy as they are harmful to thyroid health. Her diet included good quality fats, fermented foods and clean filtered water. She included supplements: vitamin B complex, D, alpha lipoic acid, coenzyme Q10, magnesium, omega 3 oil (DHA/EPA) and probiotics (Dolan K, 2018).

We recommend a few possible diets for Hashimoto’s:

• Auto Immune Paleo diet

• Paleo diet

• Gluten-free Mediterranean diet

WHAT ARE THE SPECIFIC DIET RECOMMENDATIONS TO FOLLOW FOR HASHIMOTO’S?

ELIMINATE GLUTEN

We have discussed above how gluten cross-reacts with thyroid tissue and causes an attack on the thyroid. Gluten also increases zonulin which causes leaky gut. A 6-month

gluten-free diet increased thyroid function in women with Hashimoto’s and led to a reduction in both types of thyroid antibodies, TPO Ab and Tg Ab (Krysiak R, 2019).

ELIMINATE SOY

Some studies show that soy isoflavones reduce thyroid function (Nakamura Y, 2017). In fact, genistein in soy inhibits the TPO enzyme needed to make thyroid hormones, thus reducing the amount of thyroid hormones (Nakamura Y, 2017).

GO COMPLETELY ORGANIC

This will help to reduce pesticides, endocrine (hormone) disruptors and chemicals toxins found in the conventional food supply.

CONSIDER ELIMINATING LECTINS

Lectins are a protein found in most plants. The highest levels are found in nuts, seeds and beans. Lectins create certain antibodies which have molecular mimicry with thyroid tissue so they will inhibit thyroid function. It is not always necessary to avoid lectins with Hashi’s. But if your Hashimoto’s is severe you might want to avoid lectins. If you just want to feel better quickly, try avoiding lectins.

COOK GOITROGENS AND EAT IN MODERATION

Certain foods contain goitrogens. Goitrogens can interfere with iodine uptake in the thyroid gland. Goitrogens are cruciferous vegetables such as bok choy, broccoli, brussels sprouts, cabbage, cauliflower, Chinese cabbage, collard greens, horseradish, kale, kohlrabi, mizuna, mustard greens, radishes, rapeseed, rutabaga and turnips.

It is usually not necessary to completely avoid goitrogens. But we do recommend cooking these goitrogen foods and not eating them raw. Avoid juicing or making green smoothies with large amounts of raw crucifers like kale if you have a low thyroid condition. Adequate intake of iodine can offset the negative effect of goitrogens. For those with low thyroid hormone, it may be helpful to make sure that iodine is sufficient when consuming goitrogenic foods. But don’t take in too much iodine as excess iodine is a problem for Hashi’s.

Going very low carb can be harmful to thyroid function. Insulin, which is triggered by eating carbohydrates, is necessary to convert T4 to T3. Removing or drastically reducing carbs from the diet can lead to issues with T4 => T3 conversion. Insufficient conversion could lead to hypothyroidism. If you are hypothyroid, then we recommend eating a moderate carb diet. Aim for about 100 grams per day, or about 30 - 35% of total daily calories.

AVOID THE KETOGENIC OR VERY LOW CARBOHYDRATE DIETS

STARVATION DOWNREGULATES THE THYROID

Chronic starvation, as seen in anorexia nervosa, can lead to changes in thyroid hormone levels (Douyon L, 2002). There is a decrease in T4 and T3 and an increase in Reverse T3 (which binds up T3) (Douyon L, 2002). It is important to eat adequate calories in cases of low thyroid function like Hashimoto’s.

GET ENOUGH OF THE ESSENTIAL MINERALS AND VITAMINS FOR THYROID FUNCTION

Iodine, selenium, zinc, iron and vitamin D are all very important for thyroid health. A certain amount is needed but it is also important not to have excessive amounts, especially with iodine. It might be best to work with an experienced FM practitioner to help get the balances right of these vitally important nutrients.

IDENTIFY FOOD INTOLERANCES AND REMOVE THOSE FOODS

Food allergies and intolerances are an indicator of gut issues, inflammation and an overactive immune response. It is important to identify the food triggers you may have, eliminate these foods at least in the short term to reduce inflammation, then treat the gut. Later you can experiment with reintroduction and see how you react to these foods once the gut is healed. In our clinic, we can help with precise details to follow for an Elimination and then Re-introduction diet to identify food intolerances or allergies.

SUPPLEMENTS

There are a number of supplements for Hashimoto’s:

THYROID GLANDULARS OR NATURAL DESICCATED THYROID (NDT)

Thyroid glandulars are made of bovine or porcine thyroid gland extract. This used to be considered standard treatment for low thyroid conditions. Brands of NDT are Armour Thyroid, Nature-Throid and NP Thyroid. They can be beneficial and prevent taking a pharmaceutical drug (some pharmaceutical drugs are glandulars but most contain synthetic thyroid hormone). These brands of prescription NDT provide a bioidentical form of T4 and T3.

The pharmaceutical medication Levothyroxine (and others like it) contain a synthetic version of T4 only. Some people do better with the bioidentical form and others do better with the pharmaceutical form.

One study comparing NDT and Levothyroxine (synthetic T4) found that 49% of patients preferred NDT, 19% preferred Levothyroxine and 33% had no preference (Hoang TD, 2013). A case study of one patient found that treatment with a glandular thyroid supplement significantly decreased symptoms of severe hypothyroidism and autoimmune thyroiditis (Wellwood C, 2014).

Which medication works best for which person is very individual. Work with an experienced FM practitioner to find the best approach for you. We do not recommend that anyone take a thyroid glandular without being under the guidance of a skilled medical professional as too much thyroid hormone is a problem and some autoimmune thyroid issues can be triggered/worsened by some glandular products. Regular lab testing for thyroid function during glandular administration, even non-prescription glandulars, is strongly encouraged.

ALOE VERA JUICE

In one study on women with Hashimoto’s, aloe vera juice was found to decrease thyroid antibodies (Metro D, 2018). Women in the study drank 50 ml of aloe vera juice for 9 months (Metro D, 2018). The result was a decrease in thyroid autoimmune inflammation and both TSH and TPO antibodies declined significantly by the end of 9 months (Metro D, 2018).

SPECIFIC MICRONUTRIENTS FOR THYROID FUNCTION

IODINE, ZINC, IRON, VITAMIN D AND SELENIUM

Iodine, zinc, iron, vitamin D and selenium are all nutrients that support thyroid health. You may be low in one or more of these. Work with a FM practitioner to test your levels properly to see if you need to supplements these nutrients.

Remember too much or too little iodine can be a problem. Be careful with iodine supplements! Iodine can worsen Hashimoto’s and hyperthyroidism. Do not self-diagnose and take iodine yourself, without testing for iodine levels and having a full thyroid panel properly interpreted. The most accurate way to test iodine is through urine, not serum blood testing. Anyone with hyperthyroidism should not use iodine except under the guidance of a skilled practitioner, because it could over-activate the thyroid and worsen the condition if not used properly.

PROBIOTICS AND PREBIOTICS

Probiotics and prebiotics all promote good gut health and feed the good bacteria in the gut. We recommend a high dose probiotic supplement. Also eat fermented foods such as sauerkraut, kimchi, kefir, miso, apple cider vinegar, yogurt, etc. But be cautious because if you have SIBO, as defined above, fermented foods can aggravate the condition and may make you feel worse. This is why it is always best to work with an experienced FM practitioner.

You can either take a supplement or simply eat Prebiotic foods. These include raw garlic and onion, green banana, dandelion greens, asparagus, leeks, oats, apple and flaxseeds.

GUGGUL AND ASHWAGANDHA

Guggul and Ashwagandha herbs help to optimize T4 to T3 conversion and work to increase T4 and T3.

LOW DOSE NALTREXONE (LDN)

Low Dose Naltrexone (LDN) is a generic drug originally designed for withdrawal from opioids. It is now also used off-label for other conditions, often autoimmune in nature (Toljan K, 2018). LDN re-balances the immune system and reduces the inflammatory response by modulating immune system cells (Toljan K, 2018). At a dose of 2-3mg per day, it can be helpful in many cases of Hashimoto's or Grave's.

OTHER WAYS TO SUPPORT

THYROID HEALTH AND HASHIMOTO’S

WHAT ARE OTHER WAYS TO SUPPORT THYROID HEALTH AND ADDRESS HASHIMOTO’S?

HEAL THE GUT

Work with a FM practitioner to improve gut health. Identify any infections, overgrowths, parasites, dysbiosis or other issues and resolve them. It is critical in autoimmunity to resolve leaky gut. This can be done with a comprehensive gut healing plan using diet and supplements. Once the gut is healed, nourish the good gut bacteria with a healthy diet, lifestyle habits and pro and prebiotics.

BOOST IMMUNITY

By healing the gut, you will automatically be boosting immunity as 70-80% of the immune system is located in the gut. You can further boost your immune strength by testing vitamin D levels. The ideal level is around 50-60 ng/ml.

ADDRESS INFECTIONS

It is critical to address any underlying chronic infections like Epstein Barr Virus, or other viral or bacterial infections. This includes other potential inflammatory issues like Lyme Disease and mold illness.

STRESS MANAGEMENT

We can never eliminate all stress. But we do need to learn to manage it through mindfulness practices like meditation, yoga, tai chi, deep breathing exercises, other types of movement, listening to music and other ways to get into the parasympathetic state of the nervous system.

HPA AXIS SUPPORT

With your FM practitioner, you can assess for HPA axis dysregulation. The HPA axis may contribute to the existence of low thyroid symptoms (Wellwood C, 2014). It is important to treat the adrenals and thyroid in combination. When the adrenals have been weakened, it can interrupt signaling and hormone levels (Wellwood C, 2014). Over time, this can reduce TSH and T4 =>T3 conversion and increase conversion to Reverse T3 (Wellwood C, 2014). This causes even more fatigue and exhaustion. If you are very stressed, the HPA axis will likely be dysregulated and will require some support.

REDUCE TOXIN EXPOSURE

Decrease the amount of toxins that come into your body. Don’t smoke, drink minimal alcohol, eat an organic diet and reduce exposures to chemicals and pesticides. Clean up your personal care and cosmetic products & household products; use the EWG skin deep website to check products at: https://www.ewg.org/skindeep. Use clean cookware and not Teflon. Avoid the chemical fluoride in tap water and toothpaste.

Drink filtered water and get a shower filter. Add houseplants to absorb chemicals in the environment. Reduce EMF’s exposure where possible. Reduce exposure to bromide, which is especially high in supermarket breads. Reduce exposure to chlorine with a shower filter and minimal exposure to swimming pools.

SUPPORT THE LIVER & DETOXIFICATION

This is an important step to help detoxify toxins and chemicals. You can work with an experienced FM practitioner to take steps to detoxify. If there is mercury toxicity or other toxic exposure, this will be a key step to healing Hashi’s. There are supplements that can help like glutathione, chlorella and others.

Diet changes can help to reduce toxic load. Other practices like sweating, using a sauna or far infrared light exposure, drinking plenty of water and exercising regularly are important. You can test your liver function by looking at liver enzyme (AST, ALT, GGT) levels.

REMEMBER THE BASICS

Be sure to work on important lifestyle factors and ensure that you sleep well, exercise and mediate to manage stress!

SUMMARY AND SUPPORT FOR HASHIMOTO’S

HASHIMOTO’S SUMMARY

Hashimoto's disease, or Hashimoto's thyroiditis, is an autoimmune disease that damages the thyroid gland. It is the most common cause of hypothyroidism (underactive thyroid). In Hashimoto's disease, the immune system makes antibodies that attack the thyroid gland. This damages the thyroid gland, so it does not make enough thyroid hormone. Hashimoto's disease often leads to hypothyroidism and the symptoms of low thyroid.

Hashimoto thyroiditis affects 1 to 2% of the population in the US (NIH US National Library of Medicine, 2020).

ROOT CAUSES OF HASHIMOTO’S

• The Triad of Autoimmunity: Genetic predisposition, Environmental trigger + a Leaky gut

• Gut health

o Intestinal permeability or leaky gut

o Dysbiosis

o Absorption issues

o Constipation, SIBO, SIFO and acid reflux

o SIBO

o T4 => T3 conversion

o Celiac disease

o Gluten & molecular mimicry

o Helicobacter pylori (H. pylori)

o Food intolerances

• Infections

• Toxins

• Mercury

• Nutrition & Diet

• Gluten

• Iodine

• Hormonal Imbalances

• Stress

• Parietal Cell Antibodies

TESTING FOR HASHIMOTO’S

It is fairly simple to test for Hashimoto’s. A blood test showing TPO Antibodies and Thyroglobulin Antibodies will indicate Hashi’s.

FM SOLUTIONS TO HASHIMOTO’S

The primary FM Solutions for Hashimoto’s include diet and supplementation. Good diet options to follow are:

• Auto Immune Paleo diet

• Paleo diet

• Gluten-free Mediterranean diet

SPECIFIC DIET RECOMMENDATIONS FOR HASHIMOTO’S

• Eliminate gluten

• Eliminate soy

• Eat a fully organic diet

• Consider eliminating lectins

• Cook goitrogens and eat them in moderate amounts

• Avoid the ketogenic or very low carbohydrate diets

• Starvation downregulates the thyroid

• Be sure to eat enough of the essential minerals and vitamins for thyroid function

• Identify food intolerances and remove those foods

SUPPLEMENTS THAT HELP HASHIMOTO’S INCLUDE

• Thyroid glandulars or Natural desiccated thyroid (NDT)

• Aloe vera juice

• Iodine, zinc, iron, vitamin D and selenium

• Be careful with iodine supplements!

• Pro- & prebiotics

• Guggul and Ashwagandha

OTHER WAYS TO SUPPORT THE THYROID & ADDRESS HASHIMOTO’S

• Heal the Gut

• Boost immunity

• Address infections

• Stress management

• HPA (hypothalamus-pituitary-adrenal) Axis Support:

• Reduce toxin exposure

• Support the liver & detoxification

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WE WORK WITH PEOPLE LOCAL TO DENVER, CO AREA AND ALL OVER THE US

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