Levothyroxine is one of the most commonly prescribed medications in the United States.  In fact, a few years ago synthetic thyroid hormone was THE MOST commonly prescribed medication, while in 2017 it was the second most popular prescription, followed by hydrocodone-acetaminophen (1).  While millions of people take synthetic thyroid hormone, more and more people are taking desiccated thyroid hormone (i.e. Armour, Nature-Throid, WP Thyroid).  Although many people need to take thyroid hormone replacement, there are also people who shouldn’t be taking it.  If you’re unsure whether or not you should be taking thyroid hormone replacement, hopefully you’ll have a better idea after reading this blog post.

Having healthy levels of thyroid hormone is essential.  But why is thyroid hormone so important?  Thyroid hormone not only plays an important role in metabolism, but it also regulates many bodily functions.  As I discussed in an article entitled “Why Is Thyroid Hormone So Important To Our Health“, thyroid hormone has some of the following roles:

• Thyroid hormone plays an important role in regulating gene expression
• Thyroid hormone plays a key role in brain development
• Thyroid hormone is important in the metabolism of proteins, carbohydrates, and lipids
• Thyroid hormone plays a role in peripheral nerve regeneration
• Thyroid hormones are required for optimal bone health
• Thyroid hormone plays a role in reproductive health

Overt Hypothyroidism vs. Subclinical Hypothyroidism

Overt hypothyroidism is when one or both thyroid hormone levels are below the lab reference range.  On the other hand, subclinical hypothyroidism is when the TSH is elevated, but the thyroid hormone levels are within the lab reference range.  The name “subclinical” can be misleading, as many people who are classified as having subclinical hypothyroidism are symptomatic, while others with subclinical hypothyroidism don’t experience any hypothyroid symptoms.

Subclinical hypothyroidism is considered to be mild when the TSH levels are between 4.0 and 10.0 mIU/l.  On the other hand, when the TSH is greater than 10.0 mIU/l it is considered to be severe.  This has limitations, as the TSH can fluctuate, and different labs will have different reference ranges.  It’s also important to understand that the severity of symptoms doesn’t always correlate with how high the TSH is.  For example, I’ve worked with patients who had a TSH greater than 10 mIU/l and didn’t feel too bad, but I’ve also consulted with patients whose TSH were within the lab reference range but felt lousy.

This brings up another discussion on the “lab” reference range vs. the “optimal” reference range.  For example, according to many functional medicine practitioners the “optimal” reference range for the TSH would be between 1 and 3 mIU/l.  But some labs don’t consider the TSH to be elevated unless if it is above 5.0 mIU/l.  The same concept applies with the thyroid hormone levels, as many people have thyroid hormone levels that are within the lab reference range, but are suboptimal.

What Causes Subclinical Hypothyroidism?

The most common cause of subclinical hypothyroidism is Hashimoto’s thyroiditis.  As discussed in other articles and blog posts, this is characterized by an elevated TSH and elevated TPO and/or thyroglobulin autoantibodies.  Other potential causes of subclinical hypothyroidism include a genetic polymorphism of the TSH receptor, transient TSH elevation during recovery from severe illness, untreated primary adrenal insufficiency, taking various drugs (i.e. lithium, amiodarone), and the presence of heterophile antibodies (2) (3).

What Are The Risks of Untreated Hypothyroidism?

If someone needs to take thyroid hormone replacement but chooses not to take it, what are the potential risks?  Well, one risk is that they might have to deal with symptoms that they wouldn’t otherwise experience if they were to take thyroid hormone.  I’ve worked with patients over the years who had moderate to severe hypothyroid symptoms but refused to take thyroid hormone replacement for various reasons.  But besides helping to decrease hypothyroid symptoms, remember that thyroid hormone has many important functions, as earlier I mentioned how it plays an important role in brain development, bone health, reproductive health, regulating gene expression, the metabolism of proteins, carbohydrates, and fats, and peripheral nerve regeneration.

In addition, there is some evidence that untreated subclinical hypothyroidism can increase the risk of developing cardiovascular disease.  In an article I wrote entitled “LDL Particles, Lipoprotein A, and Thyroid Health”, I discussed how having high LDL particles and lipoprotein a, which is also known as Lp(a), can increase one’s cardiovascular risk.  And having low thyroid hormone levels can lead to increases in LDL particles and Lp(a).  I also came across a study which showed that high blood pressure was more common in those with subclinical hypothyroidism, although a few studies showed that there wasn’t a reduction of blood pressure upon taking thyroid hormone replacement (4) (5).

If you are pregnant and have subclinical hypothyroidism then there is an even greater risk of not taking thyroid hormone.  Some studies have shown that pregnant women with mild subclinical hypothyroidism have an increased risk of gestational hypertension and pre-eclampsia (2).

What Are The Risks of Taking Thyroid Hormone Unnecessarily?

Perhaps the greatest risk of taking thyroid hormone replacement if you don’t need it is becoming hyperthyroid.  This can also occur if you need thyroid hormone replacement but take too high of a dosage.  For example, if someone has a mild case of subclinical hypothyroidism and they start with a dosage of 150mcg of levothyroxine, this very well might be too high.  But even if they had a severe case of subclinical hypothyroidism it probably would be wise to start with a lower dosage and gradually increase it.

Why Do Some People Who Need Thyroid Hormone Refuse To Take It?

There are a few reasons why people refuse to take thyroid hormone replacement, even if their blood tests indicate that they can benefit from it.  First of all, some people simply don’t think they need to take any type of exogenous hormone replacement.  While this is debatable if someone has subclinical hypothyroidism, if someone has overt hypothyroidism then there is a greater concern with not taking thyroid hormone.  Of course either way one needs to address the cause of the problem, and if someone has primary adrenal insufficiency that is causing overt hypothyroidism they need to address this first.  On the other hand, if someone has overt hypothyroidism that is caused by Hashimoto’s, although you still want to address the cause of the problem and restore the health of your immune system, while doing this it might be a good idea to take thyroid hormone replacement.

Another reason why some people don’t take thyroid hormone replacement is because they consider it to be a drug.  While it’s true that levothyroxine, as well as desiccated thyroid hormone, require a prescription, you shouldn’t put them in the same category as prescription drugs such as antibiotics, statins, acid blockers, etc.  The reason for this is because while people don’t have a deficiency of a statin or an acid blocker, they of course can have a deficiency of thyroid hormone.  I’m not trying to talk anyone into taking thyroid hormone, but if you truly need it but are avoiding it because you don’t want to take any “drugs”, I wouldn’t classify thyroid hormone as being a “drug”.

That being said, some forms of thyroid hormone replacement are superior to others.  For example, while a lot of people take Synthroid, this probably is the lowest quality form of thyroid hormone replacement available due to the fillers and artificial ingredients.  If you need to take synthetic T4 then consider a more hypoallergenic form such as Tirosint, or perhaps a more natural form such as Nature-Throid or WP Thyroid.

Another concern people have is that they will become dependent on thyroid hormone replacement.  In other words, once they start taking it they won’t be able to wean off of it.  The truth is that a “hormone dependency” can happen when taking any type of hormone, but I’ll also add that I’ve had many patients who were taking thyroid hormone replacement for many years prior to working with me who were able to wean off.  While it’s true that some people do need to remain on thyroid hormone replacement permanently, this isn’t the case with everyone.  And even if this were the case, you need to weigh the risks and benefits.

When Should You Take Thyroid Hormone Replacement?

Just in case you’re still unsure whether or not you should take thyroid hormone replacement, I’ll list a few situations when you will want to consider taking it.

1. If you have overt hypothyroidism.  If your thyroid hormone levels are below the lab reference range then you should strongly consider taking thyroid hormone replacement.

2. If you have a severe case of subclinical hypothyroidism.  Earlier I mentioned how the research considers a TSH greater than 10 mIU/ as being severe.  However, if someone in this situation has both thyroid hormone levels within the optimal reference range, then it is questionable if they should take thyroid hormone replacement.

3. If you have a mild case of subclinical hypothyroidism during pregnancy.  Of course the reasoning behind this is to decrease the risk of complications during pregnancy, as well as to reduce the risk of impaired cognitive development of the fetus.

4. If you have a mild case of subclinical hypothyroidism but experience severe hypothyroid symptoms.  This also is debatable, but I’ve had some patients who had a mildly elevated TSH and felt much better when taking thyroid hormone.

I’m not suggesting that there aren’t other scenarios when you would want to consider taking thyroid hormone replacement, but these are some of the situations when you should strongly consider taking it.

In summary, millions of people take thyroid hormone replacement.  And while there is a good argument that most people with overt hypothyroidism should take thyroid hormone, it’s more controversial when discussing whether people with subclinical hypothyroidism should take it.  Just as is the case with anything else, one needs to look at both the risks and benefits.  Some scenarios that might warrant someone with subclinical hypothyroidism taking thyroid hormone replacement are if their TSH is very high, if they are pregnant, and/or if they are very symptomatic.

Statins are one of the top medications recommended, as many people take it to lower cholesterol levels.  While many doctors are concerned about high cholesterol levels, very rarely do medical doctors express any concern over low cholesterol levels.  But it is possible for your cholesterol to get too low.  In this blog post I’ll discuss some of the common causes of low cholesterol, the risks associated with low cholesterol, and what you can do to increase it.

But what level of total cholesterol is considered to be optimal?  Before revealing this, I’d like briefly discuss what cholesterol is, and why it’s important.  Cholesterol is a waxy substance that is manufactured by the liver, although we obtain some cholesterol from certain foods, including meat, poultry, and full-fat dairy products.  Cholesterol has many important functions, as it is a vital component of cell membranes, it’s a precursor to all of our steroid hormones, as well as to vitamin D and bile acids, and it has other important functions.  But even if we focus on the roles I specifically mentioned here, it should be easy to understand why having healthy cholesterol levels is important, and why it can be harmful if your cholesterol gets too low.

For example, regarding the steroid hormones, pregnenolone is a precursor to both progesterone and DHEA.  As a result, if pregnenolone is low, then both progesterone and DHEA will also be low.  Progesterone in turn is a precursor of 17-OH progesterone, which is a precursor of cortisol, whereas DHEA is a precursor of testosterone, which converts into estradiol.  So if someone has low or deficient pregnenolone levels, then they can be deficient in all of these hormones I mentioned.

The reason why I’m bringing this up here is because cholesterol is converted to pregnenolone in the mitochondria.  Thus, if someone has very low cholesterol levels, they very well might have low pregnenolone levels.  And while having the person take pregnenolone may help to increase the other hormones, the primary goal should be to increase the cholesterol levels.

Why Are Many People Concerned About High Cholesterol Levels?

Although the focus of this blog post is on the risks associated with low cholesterol levels, I think it’s important to discuss why many people, including most medical doctors, are concerned with cholesterol being too high.  Of course the answer is that many are concerned about high cholesterol causing cardiovascular disease.  Keep in mind that elevated levels of total cholesterol and LDL alone aren’t strongly associated with heart disease.  On the other hand, low HDL levels are a concern, and LDL particles (LDL-P) and lipoprotein a LP(a) are superior markers for determining if someone is at risk for cardiovascular disease.  The point here isn’t to completely dismiss high total cholesterol and LDL as being risk factors, but if these are high you should consider additional testing.

Other Risks of Low Cholesterol

Earlier I mentioned the important role cholesterol plays, and thus the consequence of having low cholesterol levels.  However, I also want to dive into some of the research.  Cholesterol seems to play a role in the neuron membranes, specifically regarding the function of the 5-HT1A serotonin receptor (1).  The significance of this is that a large decrease in total cholesterol and other lipid markers (LDL, VLDL, and triglycerides) is associated with depression and suicide attempt (1).  Another study looked at the relationship between low cholesterol and mortality, and found that low cholesterol was related to high mortality, while high cholesterol was not a risk factor for mortality (2).  A case-control study showed that low cholesterol is a risk factor for primary intracerebral hemorrhage (3).  Yet another study showed that low cholesterol was strongly associated with criminal violence, as violent criminals had significantly lower cholesterol than others identical in age and sex (4).

What Are The Causes of Low Cholesterol?

There are two main types of hypocholesterolemia.  Primary hypocholesterolemia is due to genetic factors, as there can be genetic defects that affect cholesterol absorption, as well as genetic defects affecting cholesterol biosynthesis or metabolism (5).  If you have always had low total cholesterol and LDL-C levels on a lipid panel, then there is a good chance that genetics is the main factor.

Secondary hypocholesterolemia is acquired, and here are some of the common causes (1):

• Hyperthyroidism.  It is very common for people with hyperthyroidism and Graves’ disease to have low total cholesterol and LDL levels.   Cholesterol 7 alpha hydroxylase is an enzyme that plays a role in the metabolism of cholesterol.  In hyperthyroidism this enzyme is increased, which is what leads to lower serum cholesterol levels (6).
• Statins.  Not surprisingly, taking statins can lead to low cholesterol levels.  This of course is the main reason why statins are prescribed.
• Liver disease. Since cholesterol is manufactured by the liver, it makes sense that liver disease can result in low cholesterol levels.
• Malabsorption.  The intestine plays an important role in the regulation of cholesterol absorption.  Pancreatic insufficiency is one condition that can cause cholesterol malabsorption (7).  Bile acid malabsorption can also lead to lower cholesterol levels (8).  Celiac disease is also associated with hypocholesterolemia, although if someone has Celiac disease then a gluten free diet can help to normalize cholesterol levels (9).
• Acute or chronic infection. Acute and chronic bacterial, viral, and parasitic infections all might induce hypocholesterolemia due to the chronic effect of proinflammatory cytokines on lipoprotein metabolism (10).  In addition, parasites feed on host cholesterol, which is another way that parasitic infections can cause low cholesterol levels (10) (11).
• Anemia.  Although I can’t say that every patient I’ve worked with who had anemia also has had high cholesterol levels, the research does show a correlation (12) (13).

How Is Hypocholesterolemia Diagnosed?

Both high and low cholesterol levels are typically measured through a standard lipid panel.  This looks at the following markers:

• Total cholesterol
• Low-density lipoprotein (LDL)
• High-density lipoprotein (HDL)
• Very low-density lipoprotein (VLDL)
• Triglycerides

Regarding high cholesterol levels, keep in mind that an elevated total cholesterol and/or LDL doesn’t mean that you are at an increased risk of developing cardiovascular disease.  There are other “advanced” lipid markers that can help with this, and I discussed this in an article entitled “LDL Particles, Lipoprotein A, and Thyroid Health”.  On the other hand, a standard lipid panel can help determine if your cholesterol levels are too low.

What Is The Optimal Level of Total Cholesterol?

For total cholesterol, most labs have a reference range of <200 mg/dL.  Because they don’t give a lower limit, this gives many people (including doctors) the impression that the lower their cholesterol levels the better.  But as I presented in the research earlier, there are risks of cholesterol being too low.  Many natural healthcare practitioners, including myself, don’t want to see the total cholesterol below 150 mg/dL.  And I’d say that the “optimal” reference range is around 180 to 200 mg/dL.  I should also add that I don’t get too concerned when someone’s total cholesterol is above 200 mg/dL, especially if it’s less than 250 mg/dL.

Can Cholesterol Levels Be Increased Through Diet?

Many people still believe that eating foods high in cholesterol (i.e. red meat, eggs) will have a big impact on our cholesterol levels, and perhaps even lead to elevated cholesterol.  The truth is that the body does a great job of regulating cholesterol production, as if we consume a lot of dietary cholesterol the liver will make less, and vice versa.  So for someone who has low cholesterol levels, eating foods that are higher in cholesterol may slightly increase total cholesterol levels, but it usually won’t have a significant impact.

So what can help to increase low cholesterol levels?  Assuming primary hypocholesterolemia isn’t the main culprit, then the goal should be to address the cause of the problem.  For example, if I’m working with a hyperthyroid patient who has low cholesterol levels, then we of course would want to decrease the thyroid hormone levels, and this in turn will usually result in the cholesterol levels increasing.  If malabsorption is the problem then the cause of the problem needs to be addressed, whether this is due to an infection, Celiac disease, or another factor.

In summary, cholesterol has many important functions, which is why you don’t want it to be too low.  Some of the causes of low cholesterol include hyperthyroidism, statins, liver disease, malabsorption, infections, and anemia.  Eating foods high in cholesterol may slightly increase cholesterol levels, but if someone has low cholesterol they ultimately need to address the cause of the problem.

In 2017 I wrote a detailed article on oxalates.  One of the focuses of the article was how high oxalates are a risk factor for the development of kidney stones, although there was plenty of other information, including a list of some of the common foods higher in oxalates.  This past weekend I attended a conference on organic acids, and since oxalates were one of the topics discussed I figured it would be a good time to write an updated blog post on this.  While it won’t be as comprehensive as the article I wrote in 2017, there will be a few new things I discuss in this blog post.

So here are five things you should know about oxalates:

1. There are three main sources of oxalates.  The number one cause of elevated oxalates is eating foods high in oxalates.  Some of the foods high in oxalates include spinach, soy, nuts, beets, Swiss chard, raspberries, and blackberries.  If you test high for oxalates then the first thing you should do is evaluate your diet, and if you have been eating a lot of high oxalate foods then you should follow a low oxalate diet for a few months.

An overgrowth of fungi can also result in high oxalates.  This can include Candida albicans, other types of yeast, and mold.  A lot of people with thyroid and autoimmune thyroid conditions have an overgrowth of Candida.  If you have a Candida overgrowth and/or mold is responsible for elevated oxalate levels, then this obviously needs to be addressed in order to lower oxalates.

The third main source of high oxalates is cell metabolism.  In other words, your body will endogenously produce some oxalates, and certain genetic defects can increase the likelihood of you having high oxalates, even if you don’t eat high oxalate foods and/or don’t have a yeast or mold overgrowth.  But under normal conditions, and assuming you don’t have type 1 or 2 primary hyperoxaluria (I’ll discuss these conditions shortly) your oxalate levels shouldn’t be elevated.

2. In some cases oxalates can directly affect thyroid health.  I spoke about this previously in the article I wrote, as oxalate crystals can deposit in different areas of the body, including the thyroid gland.  And while I can’t say that oxalates are commonly detected on a thyroid ultrasound, the deposition of oxalates in the thyroid gland might be more common than we think.  This is backed up in the research, which confirms a high percentage of oxalate crystals in the thyroid glands of autopsied adults (1) (2).  And it’s not just adults that have high oxalates.  In fact, one of these studies showed 20% of human infants at autopsy were found to have oxalate crystals deposited in the thyroid gland.

In addition to the thyroid gland, oxalates can deposit in other areas of the body, including the following:

• Kidney
• Bone
• Brain
• Skin
• Nervous tissue

Depending on where the oxalates are deposited, this can lead to muscle and joint pain, and can even be a factor in some cases of fibromyalgia.  Although elevated oxalates don’t always result in pain, if you do have elevated oxalates that are resulting in muscle and/or joint pain, then it shouldn’t be a surprise that decreasing the oxalates should help to reduce the pain.  However, if you switch from a high oxalate diet to a low oxalate diet too quickly you can experience “oxalate dumping” symptoms.  In order to avoid these oxalate dumping symptoms you would want to slowly decrease the oxalates from your diet.

3. Organic acids testing can detect the presence of oxalates.  The urinary organic acids test from Great Plains Laboratory measures three specific oxalate metabolites.  This includes gylceric, glycolic, and oxalic.  The one most commonly high on an organic acids test is oxalic, but I’d like to briefly discuss the other two metabolites.

Glycolic relates to primary hyperoxaluria type 1, which is caused by a deficiency of the enzyme alanine glyoxylate aminotransferase (AGT).  This enzyme breaks down oxalates.  It’s important to keep in mind that AGT is dependent on vitamin B6, which means that if someone is deficient in vitamin B6 this can sometimes be a factor in high oxalates.  Some people with high oxalates can benefit from taking 100mg of vitamin B6 daily, although it might be a good idea to start with lower doses (i.e. 10 to 20mg per day) and then gradually increase.  Children with high oxalates might also require vitamin B6, but should take lower doses than adults.

High glyceric levels on an organic acids test usually relates to primary hyperoxaluria type 2.  In this condition there is a deficiency of glyoxylate reductase/hydroxypyruvate reductase (GRHFR).  Whereas primary hyperoxaluria type 1 can lead to kidney failure, primary hyperoxaluria type 2 is more likely to cause the formation of kidney stones.  Of course neither one of these conditions are good to have, and while there is a genetic component, you can support these conditions by making sure you have healthy vitamin B6 levels, and you also want to make sure you’re not eating a lot of high oxalate foods (you should eat between 40mg to 60mg of oxalates per day).

Earlier I mentioned that a Candida overgrowth and/or mold exposure can also cause an increase in oxalates.  The good news is that the organic acids test from Great Plains Laboratory not only tests for the oxalate metabolites, but also is a wonderful test for determining if someone has yeast and mold.  And while you can test for a Candida overgrowth in the stool and/or blood, I find the organic acids test to be more reliable.  In addition, the organic acids test not only looks at metabolites related to Candida, but other fungi that can produce oxalates.  For example, Aspergillus niger is a fungus that can lead to black mold, and the research shows that it can produce oxalates (3) (4).

4. Consuming calcium and magnesium citrate right before meals can help to prevent oxalate absorption.  The research shows that citrate inhibits the formation and growth of calcium crystals (5).  Since approximately 80% of stones are calcium based, it would seem counterproductive to take calcium, but supplementing with calcium can actually inhibit the intestinal absorption of oxalates (5).  If you choose to take a calcium supplement for high oxalates, 200 to 400mg of calcium citrate would be a good option (5).  Taking an equivalent amount of magnesium citrate also can be beneficial.

5. Cooking isn’t a solution for high oxalate foods.  Although cooking will reduce oxalates, it usually won’t lower the oxalates enough to safely consume high oxalate foods.  So for example, spinach is very high in oxalates, and while cooking spinach will reduce the amount of oxalates, it still won’t be low enough to consume if you are following a low oxalate diet.  So if you have high oxalates it really is a good idea to avoid all high oxalate foods.  Click here for a comprehensive list of foods that are low, moderate, and high in oxalates.  FYI, I got this list from the website of Great Plains Website, as Dr. William Shaw linked to it in an article he wrote on oxalates and autism.

Other Things You Should Know About Oxalates

Earlier when I was talking about vitamin B6 I mentioned how children shouldn’t take very high doses of this vitamin.  And while most of my patients are adults, it’s not uncommon for children to have high oxalates on an organic acids test.  This is especially true for those who are avoiding common allergens, such as gluten and casein.  The reason for this is because a lot of children and teenagers (and adults) who are gluten free will eat high amounts of foods with almonds, which are high in oxalates.  For example, someone who is gluten and dairy free might drink a lot of almond milk, eat almond butter, and frequently consume baked goods with almond flour.

And while I’m a big advocate of smoothies, if you’re not careful these can also be high in oxalates.  Spinach is very high in oxalates, and some people load up their smoothies with spinach.  I’m not suggesting that you should never eat spinach, as without question it has some good health benefits, but if you are adding a cup or two of spinach to your smoothie this is too much.  I personally add a lot of lettuce to my smoothie, as this is lower in oxalates.  Blackberries, blueberries, and raspberries are also high in oxalates, and while I do add these to my smoothies daily, I only add ¼ of a cup.  You also can add some calcium and magnesium citrate to your smoothie, as I mentioned earlier how this can help prevent oxalate absorption.

A few studies also mention that taking high dose probiotics can help with oxalates.  For example, VSL#3 is a high dose probiotic supplement, and a few studies have shown that taking VSL#3 can reduce gastrointestinal oxalate absorption, which in turn can decrease the risk of kidney stone formation and other conditions related to high oxalate levels (6) (7).

Action Steps To Take If You Have High Oxalates:

If you have tested high for oxalates on an organic acids test then I would recommend to take the following action steps:

Step #1: Gradually make the transition to a low oxalate diet

Step #2: If you tested high for fungi then address this

Step #3: Consider supplementing with vitamin B6

Step #4: Take calcium and magnesium citrate when consuming foods higher in oxalates (while gradually making the transition to a low oxalate diet)

Step #5: Consider taking high dose probiotics

So hopefully you learned a few new things about oxalates that you didn’t know before.  Eating foods high in oxalates is the number one reason for elevated oxalates, although having high levels of fungi can also cause this.  Supplementing with vitamin B6, high dose probiotics, and calcium/magnesium citrate can be beneficial for those who have high oxalate levels on an organic acids test.  While I don’t recommend an organic acids test to all of my patients, if you’re concerned that you have elevated oxalates then you might want to consider ordering such a panel.  If you are unable to obtain one from a local practitioner you can contact our office and order one.

In 2016 I wrote a blog post entitled “5 Essential Oils That Can Benefit People With Thyroid Conditions”.  It was a very popular post, and so in 2017 I decided to write another well-researched article that focused on the benefits of Myrrh and Frankincense.  Perhaps I’ll write another blog post or article in the near future that focuses on other essential oils, but I’d like to know whether you have used essential oils, and if so, what has been your experience with them?

If you have had a positive experience when taking essential oils please let me know!  Or if for any reason you had a negative experience please let me know!  Of course it would be great if your experience relates to thyroid health, but even you used essential oils to improve your health in other ways feel free to share your comments below.

I’d also like to mention that a few months ago my friend Dr.  Eric Zielinski released a new book called “The Healing Power of Essential Oils“, and so if you want to learn even more about essential oils you might want to check this out.

When it comes to managing the symptoms of hyperthyroidism, many people rely on antithyroid medication such as methimazole or PTU.  But some people are unable to take antithyroid medication due to the side effects.  Others can tolerate antithyroid medication fine, but it might not be effective in lowering their thyroid hormone levels.  Bugleweed is an antithyroid herb that can help many people who experience side effects from antithyroid medication, but in some cases this herb isn’t effective either.  And when someone is unable to lower their thyroid hormone levels, the person’s endocrinologist is very likely to recommend radioactive iodine or thyroid surgery as the only option.

Of course the ultimate goal should be to address the cause of the underlying condition.  Although this is true, it takes time to accomplish this, and in the meantime it’s important to manage the hyperthyroid symptoms.  After all, there are numerous risks associated with uncontrolled hyperthyroidism, including arrhythmias, atrial fibrillation, and thyroid storm.

Some people who are unable to tolerate antithyroid medication will take beta blockers.  And while beta blockers can help to manage the cardiovascular symptoms commonly experienced by those with hyperthyroidism and Graves’ disease, they don’t lower thyroid hormone levels (although some beta blockers can affect the conversion of T4 to T3).  So while beta blockers decrease the risk of developing arrhythmias and atrial fibrillation, there still is a risk of thyroid storm, and elevated thyroid hormone levels can also lead to decreased muscle mass and bone density.  The point I’m trying to make is that while it’s important to manage the cardiac symptoms associated with hyperthyroidism, it’s also important to lower the thyroid hormone levels.

What Is Cholestyramine?                                                                                       

Cholestyramine is a bile acid sequestrant.  It binds to certain components of bile, which in turn disrupts the enterohepatic circulation of bile acids.  Bile acid sequestrants are commonly used for lowering cholesterol or for the treatment of chronic diarrhea (when the cause is due to bile acid malabsorption).  Cholestyramine can also bind to mycotoxins, and thus can be used as a treatment for toxic mold, although it of course is also important to remove the source of the mold.

How Can Cholestyramine Help With Hyperthyroidism?

Cholestyramine has been shown to interfere with the enterohepatic circulation of endogenous thyroid hormones, which is increased in hyperthyroidism (1).  Simply put, it binds to thyroid hormones and then the hormones are excreted by the body.  In fact, this is why those people with hypothyroidism and Hashimoto’s don’t want to take cholestyramine around the same time they take thyroid hormone replacement (i.e. levothyroxine).

 What Does The Research Show?

One study evaluated the efficacy and safety of high-dose cholestyramine added to antithyroid medication in order to control hyperthyroidism (2).  This was a small study, involving only five patients, all who took at least 30 mg of methimazole.  They were put on 4 grams of cholestyramine three times a day for four weeks.  When compared to a control group consisting of patients who only took methimazole, the group who took both the methimazole and cholestyramine showed a more rapid reduction of the T3 and T4 levels in nearly all subjects.

In another study, this one a randomized, double-blind, placebo-controlled trial involving 45 patients newly diagnosed with Graves’ disease, the patients were randomly assigned into three treatment protocols (3).  Group one took 2 grams of cholestyramine twice per day, group two took one gram of cholestyramine twice per day, and group three took a placebo powder.  All three groups took 30 mg of methimazole and 40 mg of propranolol each day.  The length of the study was 4 weeks, and the thyroid hormone levels decreased more rapidly and to a greater extent in the cholestyramine-treated groups.  In addition, all of the patients in group one had normal thyroid hormone levels at the end of the study.

These studies, along with a few case reports (4) (5), showed that cholestyramine can decrease thyroid hormone levels more rapidly when combined with methimazole.  But how about if cholestyramine is taken without any antithyroid medication?  I was able to find a case report involving a 36-year old woman who was diagnosed with Graves’disease, and was unable to take antithyroid medication due to side effects (6).  Four grams of cholestyramine was given every six hours, and while unfortunately the woman ended up receiving radioactive iodine, prior to receiving this treatment her free T4 levels improved significantly within five days.  Although this is only a single case study, it did provide some evidence that cholestyramine might be an effective monotherapy for those with hyperthyroidism who are unable to take antithyroid medication.

Can Cholestyramine Be Effective When Combined With Bugleweed?

As of writing this blog post I haven’t had any patients take cholestyramine along with bugleweed, and so I honestly don’t know if it would be effective when combined with this antithyroid herb.  However, earlier I did mention a case study that showed that cholestyramine was effective when taken without any antithyroid medication.  So it’s possible that you might not need to take either antithyroid medication or antithyroid herbs in combination with cholestyramine, but my guess is that combining it with bugleweed might help to lower the thyroid hormone levels quicker than just taking cholestyramine alone.

What Dosage Is Commonly Used?

In most cases the dosage of cholestyramine used was 4 grams three times per day.  This was the case when both antithyroid medication was used, as well as in the study where cholestyramine was taken without antithyroid meds.  However, another study involved taking either 1 or 2 grams of cholestyramine, and all of the patients who took 2 grams of it achieved a euthyroid state (normal thyroid hormone levels) by the end of the study.  It’s worth mentioning that the patients in the study also took 30 mg/day of methimazole, along with 40 mg/day of propranolol.

What Are The Side Effects of Cholestyramine?

There are a few downsides of cholestyramine.  First of all, it is only available in a powder form and doesn’t taste too good.  This of course isn’t a side effect, but I did want to mention it, as compliance might be an issue in some cases.  This is especially true with children and teenagers, but with some adults as well.  The main side effects of cholestyramine include constipation and abdominal discomfort.  One of the main concerns with antithyroid medication is that it can put stress on the liver and lead to elevated liver enzymes.  Although I’m not aware of evidence which shows that cholestyramine causes significant liver damage, mild elevations in the liver enzymes sometimes will occur (7).

How Can You Convince Your Doctor To Prescribe Cholestyramine?

I have been working with hyperthyroid patients since 2009, and I have never had an endocrinologist recommend cholestyramine to their patients.  My guess is that many aren’t even aware that it can be an effective treatment for hyperthyroidism, and as a result, it might be challenging to get a doctor to write a prescription for this.  Keep in mind that an endocrinologist doesn’t need to write a prescription, as any medical doctor can do this, and it usually is easier to find an open-minded primary care physician than an open-minded endocrinologist.

Either way, if your doctor has never heard of cholestyramine as a treatment for hyperthyroidism, then I would suggest showing them the research presented in this blog post.  Make sure you let them know that the research is from published journal articles, and they of course can access the studies by clicking on the links in this blog post.  If your doctor is strongly opposed to natural treatment options you can choose not to present the entire blog post but just show them the research.  After all, cholestyramine isn’t a natural treatment option, but is just a different option than antithyroid medication.

For those who are able to tolerate methimazole but find it to be ineffective in managing hyperthyroidism, you also might want to let the endocrinologist know that you would be willing to take the cholestyramine in combination with the antithyroid medication.  The reason I bring this up is because they might be more likely to prescribe cholestyramine if they know that you will continue taking the methimazole.  If anyone reading this is successful in getting a prescription for cholestyramine to help manage their hyperthyroidism, I ask you to please come back to this blog post to share your experience in the comments section below.

In summary, cholestyramine is a bile acid sequestrant, and it might be a treatment option in some people with hyperthyroidism and Graves’ disease.  This is especially true when antithyroid medication isn’t effective in lowering the thyroid hormone levels, although cholestyramine might also be effective when used as a monotherapy.  The main side effects of cholestyramine include constipation, abdominal discomfort, and in some cases it can cause mild elevations of the liver enzymes.  But everything comes down to risks vs. benefits, and if taking cholestyramine can help someone to avoid radioactive iodine or thyroid surgery then in my opinion the minor side effects would definitely be worth it, although while taking it you of course would want to continue to address the cause of your condition.

For those with thyroid and autoimmune thyroid conditions, nutritional supplements and herbs can be an important part of a natural treatment protocol.  But while many people greatly benefit from taking supplements, sometimes people don’t receive optimal results. In fact, some people don’t notice any improvement in their condition at all.  Sometimes this can be because the person isn’t taking the appropriate supplements, and the quality of the supplement is also something to consider.  In this blog post I’ll discuss seven reasons why the supplements you’re taking aren’t working.

Reason #1: You’re not eating a healthy diet.  Fortunately many of my new patients have already been eating a pretty healthy diet prior to seeing me for the first time, as many of them are gluten free, and some of them have followed an autoimmune Paleo diet for awhile.  On the other hand, others eat a very poor diet, and some of these people take many different nutritional supplements.  But if you want to achieve optimal results then you really need to eat well.  While one can make the argument that taking nutritional supplements is important for most people to receive great results, if funds are limited and you have a choice between spending money on healthy food or spending money on good quality supplements, there is no question that you should choose to spend the money on eating healthy food.

Reason #2: You’re not taking a high enough dosage.  While I would be cautious about taking massive doses of nutritional supplements and herbs, sometimes people are too conservative with the dosing of their supplements.  For example, many people take vitamin D supplements, and while labs commonly use a reference range of 30−100 ng/mL, you want the levels to be above 50 ng/mL, and some sources suggest for it to be between 60 and 80 ng/mL.  While some people are able to increase their vitamin D levels primarily through sun exposure, many others need to supplement with vitamin D.  And when this is the case, higher doses are usually required to get the levels above 50 ng/mL.

It’s the same concept with other nutrient deficiencies.  Of course you need to exercise caution, as it’s possible to overdose with certain nutrients and herbs.  On the other hand, some nutrients are relatively safe to take in higher doses, including magnesium, chromium, vitamin C, and vitamin B12.  That being said, it probably is a good idea to work with a competent healthcare practitioner before taking large doses of any nutrient or herb.

Reason #3: You’re not taking the supplements consistently.  While many of my patients do a great job of following the recommendations, it’s not uncommon for a patient of mine to tell me that they haven’t been taking some or all of the recommended supplements on a consistent basis.  For example, if I recommend for someone to take a specific supplement three times per day, they might only take it once or twice per day.  Or sometimes they will completely skip a day.  Of course this doesn’t describe everyone, and so if you’re reading this and are diligently following the supplement recommendations given by your healthcare practitioner then of course keep up the good work!

The truth is that missing a dose of a supplement every now and then might not be a big deal in some people.  On the other hand, for others it can make a difference in their progress.  And since there is no way of knowing which category you fall into, it is best to play it safe and take the supplements as recommended.

But what if you can’t afford to take the supplements as recommended?  Well, I would be honest with the practitioner you’re working with, as perhaps he or she can make modifications to the supplements you are taking.  For example, if someone has had ten different supplements recommended to them, and they are unable to take all of them as recommended, they might be tempted to take a reduced dosage of all of them, when a better option might be to take the full doses of four or five of the supplements.

Reason #4: You’re not taking the supplements correctly.  For example, some supplements are best taken with meals, while others are best taken on an empty stomach.  L-glutamine is an amino acid that is commonly recommended by healthcare practitioners for gut healing, and for this purpose it is best taken in between meals.

Reason #5: You haven’t taken the supplements long enough.  Although many people reading this blog post understand that it takes time to see results, some people have unrealistic expectations, as they expect to notice positive changes in their symptoms within a few days of taking supplements.  Don’t get me wrong, as some people do feel better quickly after taking supplements, but sometimes it can take a few days or weeks before there is symptomatic improvement.

As an example, let’s take a look at how someone with small intestinal bacterial overgrowth (SIBO) might respond when taking an herbal approach.  First of all, with SIBO, higher doses of certain antimicrobials very well might be needed to get significant results.  And in many cases the person with SIBO will need to take the herbs for at least a few weeks before they experience any positive changes.  The same concept can apply with a Candida overgrowth, as while some people who choose to take antifungal herbs notice positive changes in their symptoms sooner than later, for others it will take a few weeks or months before they start feeling better.

Let’s look at another example.  Some people with hyperthyroidism and Graves’ disease take the herbs bugleweed and motherwort for symptom management.  And while some people will notice a decrease in their hyperthyroid symptoms quickly, for others it will take a few weeks before they notice any positive changes.

How about if you are taking nutritional supplements to correct a nutrient deficiency?  In this situation it also can take some time before you notice an improvement in your symptoms.  One reason why some people have unrealistic expectations is because we are basing these expectations off of the results other people have had.  For example, you might visit a forum or Facebook group and see someone who took the same supplement you’re currently taking, and they noticed an improvement almost immediately, whereas you have been taking the same supplement for a few weeks and haven’t noticed any positive changes.  While it certainly is possible that the supplement isn’t effective in your case, it is also possible that biochemical individuality is accounting for the rapid symptomatic improvement of that person.

Reason #6: Your supplements are interacting with other supplements or medications.  Some medications can interfere with the supplements you’re taking, and sometimes there are also “supplement-supplement” interactions.  For example, if you’re taking any type of a binding agent, such as Cholestyramine or activated charcoal, this can bind to toxins, but these binding agents also can interfere with the absorption of certain supplements.  This is just one example of how your supplements might interact with other supplements or medications you’re taking.  While I can’t say I commonly see this with my patients, it does happen from time to time, and it’s something you need to be aware of.

Reason #7: You’re taking fake supplements.  This is a big problem, especially for those who purchase their supplements on online sites such as Amazon and Ebay.  This isn’t to suggest that there aren’t reputable sellers on these and other websites that sell supplements, but you need to be very careful.  After all, with all of the different products sold on Amazon and Ebay it is almost impossible for them to tell which supplements being sold are authentic and which ones are counterfeit.

What exactly do I mean by a “fake” supplement?  This simply means that the ingredients being used aren’t the ingredients being advertised on the label.  And the obvious reason why counterfeiters do this is to make a greater profit.  By the way, while it’s possible that the suppliers of these fake supplements will use harmful ingredients, in most cases this isn’t an issue, as they want to put fake ingredients that are safe so that you will continue buying their supplements.  But of course there is always the chance there can be harmful ingredients substituted as well, which is yet another reason to be cautious about buying your supplements through a random seller on Amazon or Ebay.

So when can you feel comfortable buying supplements on Amazon or Ebay?  Well, the only way I would feel comfortable purchasing supplements on these sites is if they are sold directly by the supplement manufacturer.  I suppose if someone has an online supplement store on Amazon and has hundreds of five star reviews then there is a good chance you can trust their supplements, although I’d still be cautious.

Other Reasons Why Your Supplements Aren’t Working

There can be other reasons than the ones I listed in this blog post.  For example, in the opening paragraph I mentioned that it’s important to take the appropriate supplements, and of course the quality of the supplement is also important.  Hopefully you’re taking the correct supplements, but there are circumstances when people are taking the wrong ones, or at the very least aren’t taking the ones that should be a priority in their situation.

For example, someone might have been told they have a leaky gut, and so they are taking supplements to improve their gut health.  And so perhaps they are taking L-glutamine, probiotics, digestive enzymes, and other supplements to support their gut.  But if they have a chronic infection that caused the leaky gut, they should focus on herbs to eradicate the infection, and then focus on healing their gut.

Earlier I mentioned how taking fake supplements is a concern, although some people are taking “authentic” supplements, but unfortunately it’s from a company that uses low quality ingredients.  Some examples of lower quality ingredients include magnesium oxide, cyanocobalamin, and synthetic folic acid.  Another thing to keep in mind is how the supplements are stored, as if you or the manufacturers aren’t storing the supplements properly then this can reduce the effectiveness.  This is especially true with probiotics and fish oils, although it can affect other supplements as well.

In summary, while nutritional supplements and herbs can be an important part of your recovery, there are times when supplements people take aren’t effective.  There can be numerous reasons for this, but some of the reasons discussed in this post include 1) you’re eating too much junk food, 2) the dosage isn’t high enough, 3) you’re not taking the supplements consistently, 4) you’re not taking the supplements correctly, and 5) your supplements are fake.

I’ve written about thyroid nodules in the past, as many people with thyroid and autoimmune thyroid conditions have nodules.  I’ve also written about insulin resistance, as this is also commonly seen in people with thyroid imbalances.  This is especially true for those people with hypothyroidism and Hashimoto’s thyroiditis, although it can also affect those with hyperthyroidism and Graves’ disease.  But there is also evidence that insulin resistance can be a factor in the development of thyroid nodules, which of course will be the focus of this blog post.

I’m frequently asked how to shrink thyroid nodules by patients and non patients.  The truth is that there is no specific natural treatment approach for all thyroid nodules.  The obvious goal should be to find and address the cause of the thyroid nodules, which isn’t always easy to do.

Other Causes of Thyroid Nodule Formation                                                  

Although the focus of this blog post will be to discuss the relationship between insulin resistance and thyroid nodules, there can be other causes.  Two of the more common ones are an iodine deficiency and problems with estrogen metabolism.  As a result, it makes sense to determine if someone has these imbalances.

There is no perfect method of determining whether someone has an iodine deficiency, although urinary testing is preferred by many healthcare practitioners, including myself.  For example, when I was diagnosed with Graves’ disease I ordered an iodine loading test.  The downside of this test is that it requires ingesting a 50mg tablet of potassium iodide, and not everyone does well when taking this.  Another option that doesn’t involve consuming iodine is an iodine spot test, which is a one-sample urinary iodine test.  Although some people test for iodine in the blood, normal serum iodine levels doesn’t rule out an iodine deficiency.

As for determining whether or not you have problems with estrogen metabolism, blood testing of course is one method that can be used to measure the estradiol levels.  Saliva and urine testing is also an option, and without question are superior options for cycling women.  The reason for this is because a cycling hormone panel allows cycling women to collect multiple saliva or urine samples throughout their cycle.  This is more accurate than collecting a single sample in the second half of the cycle, although it also is more expensive.

However, measuring the estradiol levels won’t always indicate whether someone has estrogen metabolism issues.  For example, the enzyme catechol-o-methyltransferase (COMT) is involved in estrogen metabolism.  As a result, if someone has a genetic polymorphism of the COMT gene then this can affect estrogen metabolism.  Having elevated levels of an enzyme called beta-glucuronidase can also prevent the excretion of estrogen.

What Is Insulin Resistance?

Although I would recommend to read other articles I’ve written on insulin resistance for more detailed information, I’ll briefly explain what this is here.  Insulin is a hormone that is produced by the beta cells of the pancreas.  As the name implies, insulin resistance is when the cells are no longer sensitive to insulin.  So this is actually a high insulin state, which is why this is associated with pre-diabetes and type 2 diabetes.  Although some doctors rely on a fasting glucose test to determine if someone has insulin resistance, other testing is recommended to make a diagnosis, including a fasting insulin and a hemoglobin A1C.  Sometimes a glucose tolerance test will also be used.  Elevated triglycerides on a lipid panel are frequently a sign of insulin resistance.

As for how insulin resistance develops, there is no question that eating a diet consisting of high amounts of refined carbohydrates and sugars is a factor.  A high intake of fructose can especially be problematic, as this can lead to an increase in fat deposition in the liver and skeletal muscle, thus increasing the risk of insulin resistance and type 2 diabetes (1).  And when I say that high amounts of fructose can be a factor in the development of insulin resistance, this is especially true when fructose is used as a sweetener in processed foods and beverages.  This doesn’t mean that you can’t overdo it with fruit, but eating a few servings of fruit per day isn’t going to cause insulin resistance in most people.

While one’s diet can play a big role in the development of insulin resistance, there can be other factors.  Inflammation is a big factor, and there are many different causes of inflammation.  Since the mitochondria play a role in glucose homeostasis, mitochondrial dysfunction can also be a factor.  There is even evidence that intestinal dysbiosis can cause insulin resistance (2), which is yet another reason to do everything you can to improve the health of your gut.

What Does The Research Show?                          

One study examined the prevalence of insulin resistance in a case-control study of patients with benign thyroid nodules (3).  These patients lived in an iodine-sufficient area, and as a result, an iodine deficiency was unlikely to be the culprit, although in my opinion it still would have been worth testing to determine if they had an iodine deficiency.  In any case, the study showed that there is an association between insulin resistance and benign thyroid nodules.  Another study looked at the association between insulin resistance and the vascularization of thyroid nodules (4).  The authors of the study concluded that there is a vital role of insulin resistance in the distribution, construction, and density of thyroid nodular vascularization, and that this in turn might contribute to the growth and the progression of thyroid nodules.

Yet another study looked at the relationship between insulin resistance in those with euthyroid nodular goiter (5).  For those who are unfamiliar with the term “euthyroid”, this refers to someone who has normal thyroid hormone levels.  In any case, the results showed that insulin resistance may cause an increase in thyroid cell proliferation and nodule volume, as well as nodule formation.  I’ll mention one more study that looked to see if there was a correlation between insulin resistance and thyroid nodules in those with type 2 diabetes (6).  The results of the study demonstrated that insulin resistance was a risk factor for thyroid nodule formation in patients with type 2 diabetes.

3 Steps You Should Take If You Have Thyroid Nodules

Based on the information presented in this article, if a thyroid ultrasound reveals that you have one or more thyroid nodules then you should take the following steps:

Step #1: Modify diet and lifestyle factors.  Regardless of what imbalances you have, it will benefit your overall health if you eat a healthy diet.  This is especially true if you have insulin resistance, although it can help with other health issues as well.  And of course it won’t hurt to address other lifestyle factors, which includes improving your stress handling skills and getting sufficient sleep.

Step #2: Do the appropriate testing.  In this blog post I discussed three factors that can lead to the formation of thyroid nodules, including an iodine deficiency, problems with estrogen metabolism, and insulin resistance.  I also discussed how to test for these imbalances.

Step #3: Correct any imbalances found through the testing.  You of course would want to correct any imbalances that show up on the testing.  Sometimes this is easier said than done.  For example, if you have an iodine deficiency, then you might need to improve other aspects of your heath before correcting this deficiency.  I’ve spoken about this in an article I wrote entitled “An Update on Iodine and Thyroid Health”.  As for how to correct a problem with estrogen metabolism, I would recommend reading an article I wrote entitled “7 Ways To Positively Influence Estrogen Metabolism”.

But of course the focus of this blog post is on insulin resistance as being a factor in the development of thyroid nodules.  And while many times following the first step will help with this, other times this won’t be sufficient.  Earlier I mentioned some of the other factors that can play a role in the development and perpetuation of insulin resistance, including inflammation, mitochondrial dysfunction, and intestinal dysbiosis.  I’ve discussed all of these factors in different articles and blog posts.

Will following these three steps result in the shrinking of your thyroid nodules?  Perhaps, although you need to keep a few things in mind.  First of all, it’s not always easy to find and correct these imbalances.  You need to find the imbalances that are responsible for the formation of thyroid nodules, which can be challenging at times.  And then even if you find the imbalances, correcting them can also be a challenge.  For example, I briefly mentioned the challenges of correcting an iodine deficiency earlier.

I also mentioned that there can be numerous causes of insulin resistance.  So even if you have confirmed that you have insulin resistance through testing, it isn’t always easy to find what specifically is causing the insulin resistance.  This doesn’t mean that you shouldn’t attempt to find out the cause, but just remember that doing so can be challenging at times.

So hopefully you have a better understanding of the relationship between insulin resistance and thyroid nodules.  Some of the common causes and contributing factors of insulin resistance include poor diet, inflammation, mitochondrial dysfunction, and intestinal dysbiosis.  Two other common causes of thyroid nodules include an iodine deficiency and problems with estrogen metabolism.  As a result, it makes sense to do the appropriate testing to find out what imbalances might be causing or contributing to your thyroid nodules, and then correct any imbalances that are found.

The oral cavity is home to billions of microorganisms (that’s right…billions!), including an estimated 750 different species of bacteria (1).  Problems with oral health can lead to numerous health issues, including cardiovascular disease, and even diabetes mellitus (2).  But while there is no question as to whether oral health is important to one’s overall state of health, some still question the claims that oil pulling can improve oral health.  I’m a big proponent of oil pulling, which is why I decided to put together this blog post.

I’d like to start out by discussing what oil pulling involves.  Essentially oil pulling involves taking a small amount of oil (i.e. coconut oil, sesame oil) and swishing it around your mouth for 10 to 20 minutes.  By swishing the oil in your mouth it is “pulled” between your teeth.  After you’re done you want to spit it out in a trash can or paper towel.  Don’t spit the oil in your sink…unless if you want to clog it!  Some sources also suggest to swish some warm water in your mouth a few times after oil pulling, and you can then brush your teeth afterwards.

When Should Oil Pulling Be Done?                                                

Some suggest that oil pulling should be performed in the morning, before your first meal, and prior to brushing your teeth.  This is when I usually will do it, as I will swish 1 tablespoon of coconut oil in my oil in my mouth while preparing green tea and making my smoothie.  I’ve had some patients tell me that they do oil pulling in the shower while getting ready for work.  I suppose you can even do oil pulling while you drive to work, and bring along some type of container to spit the oil in after you’re done.

Although some suggest that oil pulling should be performed before meals, I wonder if doing it after certain meals would be more beneficial.  For example, it might be beneficial to do oil pulling after eating fermented foods.  The reason for this is because fermented foods such as sauerkraut have Lactobacilli.  Lactobacilli are gram-positive, lactic acid bacteria, and they are very important for the health of the gut, along with the urinary system and vaginal tract.  However, some Lactobacillus species can cause dental cavities (3), as the lactic acid they produce can corrode the teeth.  Because of this, an argument can be made to incorporate oil pulling after eating fermented foods.

How Frequently Should You Do Oil Pulling?

Some sources suggest to do oil pulling daily, and perhaps even multiple times per day.  I can’t say that I do oil pulling on a daily basis, as I do it 3 or 4 times per week.

Which Oils Should You Use?

The truth is that you can use any type of oil for oil pulling, but of course it makes sense to use healthier types of oils, along with oils that have been shown in the research to have antimicrobial properties.  I’m going to discuss three specific oils:

Coconut oil.  Coconut oil contains lauric acid, which has antimicrobial and anti-inflammatory properties.  In vitro studies have shown coconut oil to be effective against Streptococcus mutans and Candida albicans (4).  The monolaurin in coconut oil has been shown to be effective against microorganisms such as Staphlococcus aureus, Candida, Helicobacter pylori, and Enterobacter spp (5).

Olive oil. The constituents of olive oil have antimicrobial, immunomodulatory, and antioxidative effects (5).

Sesame oil.  Sesame oil contains sesamin, sesamolin and sesaminol and has detoxification, antioxidant, and antibiotic actions (5).

Health Conditions That Can Benefit From Oil Pulling

While I’m sure you can understand how oil pulling can improve conditions directly related to oral health, it might also benefit other health conditions.  Here are some of the different health conditions that can benefit from oil pulling (6):

• Dental caries
• Plaque-induced gingivitis
• Halitosis (bad breath)
• Oral thrush
• Headaches and migraines
• Asthma
• Diabetes mellitus
• Eczema
• Thrombosis

What The Research Shows         

Let’s take a look at a few research studies which show the benefits of oil pulling.  You’ll notice that most of these studies focus on oral health benefits.

General antimicrobial effects.  One small study compared oil pulling using sesame oil with chlorhexidine mouthwash, and the results showed a statistically significant reduction in the Streptococcus mutans (S. mutans) count in the oil pulling group (7).  It’s important to mention that the chlorhexidine mouthwash group had a greater reduction in S. mutans, but of course we also need to consider the chemicals in the mouthwash.

Another study looked to assess the reduction in S. mutans and Lactobacillus species count in the saliva after ten minutes of oil gum massage therapy for three weeks with sesame oil, olive oil, and coconut oil (8).  The results of the study showed a significant reduction in mean S. mutans count, Lactobacillus count, plaque scores, and gingival scores.

Halitosis (bad breath).  One study evaluated the effect of oil pulling on halitosis and the microorganisms that could be responsible for it (9).  Sesame oil was used, and it was compared to chlorhexidine mouthwash.  The study showed that oil therapy is equally effective as chlorhexidine on halitosis and reducing the microorganisms associated with halitosis.

Another study compared the efficacy of oil pulling and chlorhexidine in reducing oral malodor and microbes (10).  The results showed that oil pulling with sesame oil is as effective as chlorhexidine in reducing oral malodor and microbes causing it.

Plaque-induced gingivitis.  One study evaluated the effect of oil pulling with sesame oil on plaque-induced gingivitis (11).  The study showed that oil pulling resulted in a reduction in the plaque index, modified gingival scores, and the total colony count of aerobic microorganisms.

Another study evaluated the effect of coconut oil pulling on plaque formation and plaque induced gingivitis (12).  There was a statistically significant decrease in the plaque and gingival indices, and thus the authors concluded that oil pulling using coconut oil could be an effective adjuvant procedure in decreasing plaque formation and plaque induced gingivitis.

Can Oil Pulling Benefit Those With Graves’ Disease and Hashimoto’s?

Not surprisingly, there are no studies demonstrating that oil pulling can directly benefit thyroid health, as well as autoimmune thyroid conditions such as Graves’ disease and Hashimoto’s thyroiditis.  So I can’t say that oil pulling is an essential component of restoring your health back to normal.  On the other hand, having good oral health is important for overall optimal health.

In addition, the research shows that proinflammatory cytokines are found in diseased periodontal tissues (13), and some of these same proinflammatory cytokines are a factor in autoimmunity.  There is also an increase in Th17 cells in periodontitis (14), and these are also present in autoimmune conditions.  And as I mentioned earlier, problems with oral health can have systemic effects.  So for example, if someone has an elevated C-reactive protein (CRP) marker, there is always the possibility that their oral health is responsible for this elevation, and if this is the case, then oil pulling may help, depending on the cause.  Keep in mind that there are many other factors that can cause an elevated CRP as well.

Doing Oil Pulling With Essential Oils

Although using the oils I mentioned earlier can benefit your oral health, some healthcare practitioners suggest that mixing in essential oils can be of further benefit.  Although I couldn’t find any studies showing this, it makes sense when you think about it, as certain essential oils also have antimicrobial properties.  So for example, you can mix one drop of tea tree oil with coconut oil.  Dr. Eric Zielinski is an expert when it comes to essential oils, and in an article he wrote he suggested adding one drop each of clove, orange, lemon, and peppermint with 1 to 2 tablespoons of coconut oil.  In the past I wrote an article on the benefits of Frankincense and myrrh oil, and Dr. Zielinski also mentioned how these can be mixed with essential oils.

Are There Any Risks of Doing Oil Pulling?

If you read the research it seems that oil pulling is very safe, and that there are no risks involved.  The only concern I have is whether it possibly can also affect some of the good bacteria in the mouth.  In other words, is it possible to overdo it with oil pulling?  I’m not sure what the answer is, as it might be fine to do oil pulling once or twice per day, but as I mentioned earlier, I do it 3 or 4 times per week.  And perhaps this also is overdoing it, but I’ll add that there is no evidence I’m aware of demonstrating that doing oil pulling on a daily basis can cause any type of oral dysbiosis.  I’m sure there is a greater risk of this happening with chemical mouthwashes.

It’s also important to mention that after you oil pull, you don’t want to swallow the oil.  The reason for this is because you want to spit out any bacteria or toxins that are in the oil.  Of course swallowing the oil isn’t going to kill you, but it’s best to spit it out.

Final Thoughts:

I started doing oil pulling a few years ago, and while I haven’t had any cavities since, because I brush and floss regularly it’s hard to say if the oil pulling has been the primary factor.  But based on some of the research I presented it does seem to help reduce some of the harmful microorganisms in the mouth.  In addition, oil pulling is easy to do and is inexpensive, and so I do recommend trying to get into the routine of doing this.  And of course if anyone has a positive (or negative) experience to share regarding oil pulling please feel free to post a comment below.

Most people reading this probably have heard of a leaky gut.  But many people don’t truly understand what causes a leaky gut, how to determine if they have it, and how to heal their gut.  Many people just assume they have a leaky gut, and then will attempt to repair their gut by drinking bone broth and/or taking gut repair supplements.  In the past I have written numerous articles and blog posts on leaky gut syndrome, but since a leaky gut is something that impacts those with Graves’ disease and Hashimoto’s I’ve decided to put together an updated blog post that focuses on five things you should know about a leaky gut.

1. According to the triad of autoimmunity, everyone with Graves’ disease and Hashimoto’s has a leaky gut.  The triad of autoimmunity involves a genetic predisposition, an environmental trigger, and an increase in intestinal permeability, which is also known as a leaky gut.  It’s common to work with an autoimmune thyroid patient who wonders if they have a leaky gut, although according to this theory, EVERYONE with any type of autoimmune condition has a leaky gut, at least initially.  In other words, according to this theory a leaky gut is one of the three factors necessary for autoimmunity to develop, but this doesn’t mean that a leaky gut can’t be healed.  In fact, in order to reverse the autoimmune component it is necessary to find and remove the environmental trigger and heal the gut.

2. Gluten causes a leaky gut in everyone.  Speaking of environmental triggers, recent evidence shows that gluten causes a leaky gut in everyone.  This is a very good argument for everyone with Graves’ disease and Hashimoto’s to avoid gluten while restoring their health, and to also try to your best to avoid it after you have achieved a state of remission.  I was diagnosed with Graves’ disease in the fall of 2008, and I achieved a state of remission in 2009.  And while I avoid gluten most of the time, I can’t say that I’ve been 100% gluten free since restoring my health.  So if gluten causes a leaky gut in everyone, why haven’t I relapsed?

There are a few potential reasons for this.  First of all, I do minimize my exposure to gluten.  Second, I’m pretty sure that I don’t have Celiac disease or a non-gluten sensitivity.  So while gluten causes a leaky gut in everyone, in my case it wasn’t the direct trigger of my Graves’ disease condition.  A third reason is luck, as if I were to overindulge in foods with gluten for a prolonged period of time, and at  the same time I was exposed to a certain environmental trigger, then there is a very good chance I would relapse.  So every time I’m exposed to gluten I’m playing with fire.  And to be honest, there is a risk even with a single exposure to gluten.  So in no way am I encouraging anyone to consume gluten after getting into remission.

By the way, I think another reason why I haven’t relapsed is because I do a lot of other things to maintain a healthy state.  Even though I’m not perfect with the diet, I eat well most of the time.  And just like most people, I deal with a lot of stressors, but I’m confident that I do a good job of dealing with them, as I block out time for stress management each day, and I also make sure to get sufficient sleep each night.  In addition, I’m always doing things to reduce my toxic load, including doing a 21-day liver detox a few times per year, as well as infrared sauna therapy a few days per week.  Don’t get me wrong, as there is always room for improvement, but it’s also important to understand that perfection isn’t necessary to maintain a state of wellness after achieving a state of remission.  If this were the case then everyone would eventually relapse.

3. Leaky gut testing is available.  Some people aren’t aware that there is testing available to find out if you have a leaky gut.  One option is the lactulose-mannitol test, which is a urine test that requires someone to swallow a sugary solution of lactulose-mannitol.  Lactulose is a larger molecule, and therefore it’s poorly absorbed in someone who has a healthy gut.  As a result, if someone who does this test has high levels of lactulose in the urine then this usually indicates that they have an increase in intestinal permeability.

Cyrex Labs also has a leaky gut test.  The name of the test is the Intestinal Antigenic Permeability Screen, also known as their Array #2.  This tests for a few different antigens associated with a leaky gut, including actomyosin, occludin/zonulin, and lipopolysaccharides.

I used to recommend leaky gut testing frequently, most commonly the Array #2 from Cyrex Labs.  And there are times when I still recommend this test to my patients, but in most cases I assume that the person has a leaky gut.  And there are a few reasons why I take this approach.  First of all, according to the triad of autoimmunity, everyone with Graves’ disease and Hashimoto’s has a leaky gut.  Second, when I used to recommend the Array #2 more frequently I found that most people did test positive.  And when someone tested negative I would wonder if the results were accurate since everyone with an autoimmune condition has a leaky gut, at least according to the triad of autoimmunity I mentioned earlier.

Of course there is always the possibility that someone initially had a leaky gut but then took the necessary steps to heal it.  So for example, in some people gluten is the sole leaky gut trigger, and if someone has eliminated gluten from their diet, yet hasn’t found and removed the “direct” autoimmune trigger, then conceivably this can cause someone to have a normal leaky gut test, even in the presence of positive autoantibodies.  Stated differently, it’s possible to remove the “leaky gut” trigger and heal the gut, yet still have elevated thyroid antibodies if the “direct” environmental trigger hasn’t been removed.

4. A leaky gut can lead to multiple food sensitivities.  I’m not a big fan of food sensitivity testing, but there are times when I have had patients order a food sensitivity panel.  And it’s common for those who have a leaky gut to have many different food sensitivities.  The good news is that healing the gut usually will help to resolve most, if not all of the food sensitivities.

5. In order to heal your gut you need to follow the 5-R protocol.  The five components of the 5-R protocol include 1) remove, 2) replace, 3) reinoculate, 4) repair, and 5) rebalance.  It is imperative to remove the leaky gut trigger, and while this may sound like common sense, I commonly see people focusing on replacing, reinoculating, and repairing before they find and remove the factor that caused the leaky gut.  Admittedly it can be challenging at times to find the leaky gut trigger, and while you can incorporate the different “Rs” of the protocol simultaneously, you won’t heal a leaky gut if you don’t remove the factor that is causing it.

So how can you find the leaky gut trigger?  I talk about this in great detail in my book Hashimoto’s Triggers, and the same process of finding and removing triggers also applies to those with Graves’ disease.  While many times testing is necessary to find your leaky gut trigger, this isn’t always the case.  For example, if gluten is someone’s sole leaky gut trigger, then simply eliminating gluten can allow someone’s gut to heal.  If taking a course of antibiotics were the leaky gut trigger, then of course you removed the trigger as soon as you stopped taking the antibiotics.

Sometimes it’s not so simple, and testing may be necessary to find your leaky gut trigger.  And even if testing isn’t necessary to detect your “leaky gut trigger”, it very well might be necessary to find your “direct trigger”.  If this is confusing to you then I’d recommend reading my blog post on the triad of autoimmunity.  It’s also important to keep in mind that someone can have multiple leaky gut triggers.  So for example, if someone is eating gluten and has a gut infection, both of these can cause a leaky gut, and thus both of these “leaky gut triggers” would need to be removed in order for the gut to heal.

So let’s summarize this blog post.  According to the triad of autoimmunity, everyone with an autoimmune condition has a leaky gut, which of course would include those with Graves’ disease and Hashimoto’s.  Although gluten isn’t a “direct” environmental trigger in everyone, it does cause a leaky gut in everyone.  A leaky gut can also cause multiple food sensitivities, and while leaky gut testing is available, it’s not something that I commonly recommend to my patients.  Finally, in order to heal your gut you need to remove the leaky gut trigger, which is the first “R” of the 5-R protocol.

Methimazole (brand name Tapazole), is commonly prescribed to those who have hyperthyroidism and Graves’ disease.  In most cases it is effective in reducing thyroid hormone levels, and while it’s not doing anything for the cause of the problem, it can help to prevent someone from receiving radioactive iodine (RAI) or thyroid surgery while the underlying cause of the condition is being addressed.  However, not everyone is able to tolerate Methimazole, and if someone has a negative reaction to Methimazole, there is a good chance the endocrinologist will recommend RAI or thyroid surgery.

Methimazole, along with other thionamide-derived antithyroid drugs, have been used for over half a century.  A common starting dosage is 20 mg per day, although if someone has a more severe case of hyperthyroidism then larger doses might be prescribed (i.e. 40 mg/day).  Most endocrinologists will recommend Methimazole for 12 to 18 months, assuming the person isn’t experiencing any severe side effects, or other problems, including elevation of the liver enzymes.

As for how Methimazole works, it inhibits an enzyme called thyroperoxidase, which is important in the synthesis of thyroid hormone.  It specifically inhibits the metabolism of iodide and the iodination of tyrosine residues, which in turn prevents the synthesis of both T4 and T3 (1).

Potential Side Effects of Methimazole

Here are some of the side effects people can experience when taking Methimazole (2) (3):

• Changes in taste
• Dizziness
• Hair loss
• Headaches
• Hives
• Itching
• Joint pain and swelling
• Nausea
• Rashes
• Vomiting

More serious side effects include the following (3):

• Blood in your urine or stools
• Clay-colored stools
• Dark urine
• Fever
• Jaundice (yellowing of the skin or eyes)
• Loss of appetite
• Severe blistering, peeling, and red skin rash

Two Additional Complications Associated With Methimazole

Agranulocytosis.  This is a term used to describe a severe reduction in the production of white blood cells. This is more likely to affect those who take high doses of Methimazole.  Some patients with agranulocytosis will present with signs and symptoms of an infection, including a high fever and a sore throat (4).

Elevated liver enzymes.  This is more commonly associated with Propylthiouracil (PTU), but over the years I’ve had numerous patients with hyperthyroidism whose liver enzymes were elevated when taking Methimazole or Carbimazole.  You might want to check out an article I wrote entitled “How To Decrease Elevated Liver Enzymes In Hyperthyroidism and Graves’ Disease“.  In the article I discuss when you should be concerned about elevated liver enzymes, and some strategies to decrease them.

What Alternatives Are There To Methimazole?

As I mentioned in the opening paragraph, if someone is unable to take Methimazole, it’s common for their endocrinologist to recommend radioactive iodine or thyroid surgery.  However, there are three treatment options you should consider before getting your thyroid gland ablated or surgically removed:

Option #1: Try to get a prescription for Propylthiouracil (PTU).  The downside of PTU is that it can be harsher on the liver than Methimazole, and approximately 50% of those who are unable to tolerate Methimazole will also be unable to tolerate PTU.  That being said, it still might be worth giving PTU a try, as while it might produce similar side effects as Methimazole, there is also a chance that you might be fine taking it, and at the very least it can buy you some time while you are trying to address the underlying cause of your condition.

Option #2: Consider natural antithyroid agents.  Many reading this know that when I was diagnosed with Graves’ disease I didn’t take antithyroid medication.  Instead, I took an antithyroid herb called bugleweed to manage my hyperthyroid symptoms.  Although bugleweed isn’t always potent enough to lower the thyroid hormone levels, it’s definitely worth a try before resorting to extreme treatment methods such as RAI and thyroid surgery.  It’s also important to mention that the quality of the herb is important, and you should consider taking a stronger extract ratio.  For more information on bugleweed and other herbs that can help manage the hyperthyroid symptoms, I would read a blog post entitled “Which Are The Best Herbs For Managing The Symptoms Of Hyperthyroidism & Graves’ Disease?”.

Option #3: Low dose naltrexone (LDN).  This option should be considered for those people with Graves’ disease, and not other types of hyperthyroid conditions (i.e. toxic multinodular goiter, subacute thyroiditis, etc.).  Naltrexone is an FDA-approved medication, and it was discovered that low dose naltrexone (LDN) has immune-modulating effects that can benefit many people with autoimmune conditions.  While there are no studies I’m aware of that specifically show that LDN can help people with Graves’ Disease, over the years I have had some people with Graves’ disease successfully use LDN to manage their symptoms while addressing the underlying cause of their condition.

If LDN can modulate the immune system and effectively manage the hyperthyroid symptoms, then why don’t I recommend it more frequently to my patients with Graves’ disease?  There are a few reasons for this.  The main reason is because while it’s not harsh on the body like Methimazole, it’s also not as effective in managing the hyperthyroid symptoms.  I also find bugleweed to be more effective than LDN.  And if someone has an elevated resting heart rate due to high thyroid hormone levels, then it’s important to get the thyroid hormone levels down as soon as possible.

Another reason why I don’t commonly recommend LDN to my patients is because it can be challenging to get a prescription.  Unfortunately most endocrinologists aren’t open to prescribing LDN, and many aren’t even aware of the benefits regarding its immune-modulating effects.  However, recently I’ve had a few patients get a prescription remotely by working with a medical doctor online at www.ldndoctor.com.  The way this works is that you schedule a consultation with a medical doctor, and they will write a 6-month prescription for LDN.  I must warn you that I don’t personally know any of the LDN-prescribing doctors, although so far the feedback from my patients have been positive.

Another website to check out is www.ldnscience.org, where you can find a local doctor who prescribes LDN.  The upside is that you not only can search for a doctor who prescribes LDN in the United States, but in other countries too.  The downside is that there are some locations that don’t have an LDN-prescribing doctor.  For example, I live right outside of Charlotte NC, but as of writing this blog post, the closest doctor who prescribes LDN practices approximately 2 hours away.  However, if I was facing either radioactive iodine or thyroid surgery I would gladly drive a few hours to get a prescription for LDN, although I also would consider scheduling a consultation with someone through www.ldndoctor.com.

Which Option Should YOU Choose?

If you had a negative reaction to Methimazole and are currently facing a situation where your endocrinologist is pressuring you to receive radioactive iodine or thyroid surgery, you might be wondering which of these three alternatives to consider.  It’s not an easy decision to make, as while I listed PTU first, this doesn’t mean that you can’t try a natural approach such as bugleweed.  And even though I gave a few reasons why I don’t initially recommend LDN to my patients with Graves’ disease, you might decide to start with this option.

One of the benefits of LDN is that unlike antithyroid medication and herbs, LDN actually modulates the immune system.  However, even if LDN effectively modulates your immune system, keep in mind that it’s not addressing the underlying cause of the problem.  Of course neither is antithyroid medication or bugleweed, and so regardless of which of these three options you choose, you would still want to address the cause of your condition.  If someone has a non-autoimmune hyperthyroid condition, such as toxic multinodular goiter, then they will want to consider the first two options I mentioned.

In summary, many people with hyperthyroid conditions take Methimazole to manage the hyperthyroid symptoms.  However, not everyone with hyperthyroidism can take Methimazole, as some people experience side effects.  When this is the case you might want to look into other options, including PTU, bugleweed, and low dose naltrexone.