Recently I interviewed Dr. Nikolas Hedberg, as we chatted about infections in Graves’ disease and Hashimoto’s, and below is the written transcript. If you would prefer to watch the interview you can access it by Clicking Here:

With me, I have Dr. Nikolas Hedberg. Dr. Hedberg, we are going to discuss infections and thyroid health. How are you doing today, Dr. Hedberg?

Dr. Nikolas Hedberg: Great. Thanks for having me on.

Dr. Eric: You are welcome. Thank you for being on. Before we start, I am going to dive into Dr. Hedberg’s bio. He is a chiropractic physician, a board-certified chiropractic internist, board certified in nutrition by the American Clinical Board of Nutrition, and an herbal medicine fellow. Dr. Hedberg is also the founder of the Immune Restoration Center in Asheville, North Carolina, where he consults with patients worldwide. He is the founder of the Hedberg Institute, an online functional medicine education platform for practitioners of all types who want to build a highly effective and successful functional medicine practice. He has also been a speaker for many years in the functional medicine arena, presenting on autoimmune disease and the connection between infections and chronic illness, which is what we’ll be discussing here. He is also the author of the book The Complete Thyroid Health and Diet Guide, a comprehensive guide to understanding thyroid disorders from a functional medicine perspective.

Doc, if you don’t mind, I’d like you to start out by discussing your background, how you started working with people who have autoimmune thyroid conditions with more of a focus- Currently, you focus a lot on infections. Of course, with Hashimoto’s or Graves’, if they have infections, that’s a potential trigger. Why don’t you tell everyone how you got started?

Dr. Nikolas: I first started practicing 18 years ago. I was building my practice and giving lectures around Asheville. I realized that the thyroid lectures always drew standing room only crowds compared to all of the other illnesses I was talking about. I knew there was something there that I really had to look into. Patients started coming in who were taking Synthroid, and it really wasn’t working, not feeling much better. The combination of those two factors drove me into the direction of focusing on thyroid.

Once you start to focus on thyroid, you realize the vast majority of people with hypothyroidism have Hashimoto’s Disease. There really is no medical treatment for Hashimoto’s. Those patients are really left without many answers from the conventional side of medicine. As you dig deeper into Hashimoto’s, you find out that a lot of practitioners are overlooking chronic stealth infections as the driver of autoimmunity. A lot of practitioners are focusing on important things like gut health and Vitamin D, but the infectious aspect, I found over the years, is usually overlooked. That has just always been a main interest of mine, the immune system, chronic infections, especially viruses. I am most interested in chronic viruses.

Dr. Eric: The same applies with Graves’. Most patients with hyperthyroidism have Graves’ Disease. People with Graves’ Disease tend to have viruses. This is not just my clinical experience, but in the literature, too, there is a correlation with both Graves’ and Hashimoto’s for different infections. Of course, we’ll talk about some of the different infections here.

Why don’t we start out by discussing how an infection can trigger an autoimmune thyroid condition such as Graves’ or Hashimoto’s?

Dr. Nikolas: The immunological description is very complex. There are six potential different mechanisms. I will break it down so that people can understand it and not go into tremendous technical detail.

Basically, your immune system recognizes viruses, bacteria, parasites, fungi, things like that. Those immune cells attack those particular microbes. In autoimmunity, the immune system is unfortunately making antibodies against your own tissue. For the thyroid, it’s thyroid tissue. There are particular types of infections that can look similar to thyroid tissue. The immune system is looking at amino acids. What those look like on the surfaces of particular infections and on the thyroid. It makes antibodies against whatever has those same amino acid sequences. That is basically how it happens.

There are other ways it can happen, such as there can be a pretty strong infection in a particular organ like the thyroid. There is a lot of debris in that area due to inflammation. In that soup, the mix of debris and infection and self tissue, the immune system gets confused, and it starts to tag the self tissue and the microbe that is in that particular organ as foreign. Both get attacked. That is called molecular mimicry. We have known about that for quite some time. Actually in about 1972, it was discovered that cytomegalovirus was connected to lupus. That was the first discovery. It’s not something new. That’s almost 50 years we have known about it. That’s basically how it works.

Dr. Eric: Besides potentially causing autoimmunity directly through that molecular mimicry mechanism, some pathogens, such as H-pylori and parasites can increase the intestinal permeability of the gut. Could that also be a mechanism, through the triad of autoimmunity? Maybe it’s not a trigger, but it’s making the person more susceptible.

Dr. Nikolas: Definitely. There are studies on intestinal permeability and leaky gut and direct connection with Hashimoto’s and other autoimmune diseases. You mentioned H-pylori. That is going to have an impact on multiple factors, not just in the gut, but in what micronutrients are being absorbed and utilized. Some of these infections can definitely affect the gut and create dysbiosis and increased permeability, and that can lead to autoimmunity.

Dr. Eric: Why don’t we talk about some of the different infections that you see more commonly in your practice with your patients? Or you could also in addition to that bring up those in the literature. I know yersinia enterocolitica is one associated with both Graves’ and Hashimoto’s. I can’t say I see a lot of patients with yersinia when I do testing. What are some of the more common infections that you see with your patients?

Dr. Nikolas: I’ll start with yersinia because unfortunately it’s missed very often in stool analysis. It hasto be tested in blood as well. IgG, IgM, and IgA antibodies. Often, you will see the stool analysis misses it, but it’s active through blood testing. That’s one connected to Graves’ and Hashimoto’s. The connection there is the surface proteins of yersinia look just like thyroid tissue.

H-pylori is another one that is very common. The connections with H-pylori and Graves’ are stronger than they are with Hashimoto’s, but there is definitely a connection with both. You can pick up H-pylori pretty accurately with a stool test, breath testing, or blood testing. A lot of the studies on H-pylori and autoimmune thyroid disease are usually in stool.

If you get deeper  into the intestine, blastocystis hominis, there used to be just one case study published in the literature on this particular parasite and Hashimoto’s. A paper just came out either last year or the year before. A very good paper with direct connections showing blastocystis hominis is connected directly to Hashimoto’s. They went a little further and actually treated the blastocystis hominis, and the patient’s symptoms got much better. Their immune markers got much better. Their thyroid health got better by eradicating the parasite.

It’s one thing to identify a particular infection connection. The other is, can we actually do something about it? Will the patient get better if we get rid of it? Blastocystis hominis, in that case, it does. With H-pylori, there are some studies that show if you treat H-pylori, the patients can reduce their thyroid medication dose, and some of their thyroid markers can improve. That is another connection there as far as treating the particular microbe.

Outside of the gut, and sometimes inside, the main one is going to be Epstein-Barr virus. This is the most common virus in all types of autoimmune conditions. There is a lot of literature on Epstein-Barr virus and both Graves’ and Hashimoto’s. Those are the most common. There are a lot of other ones like HHV-6, Herpes 6. There are good studies on that with Hashimoto’s. Unfortunately, you can’t accurately test an adult for HHV-6 reactivation. It’s an ambiguous way to know if it’s reactivated or not. Viruses can transactivate each other, meaning if EBV reactivates, it can reactivate another virus like HHV-6 and vice versa. With all the herpes viruses, the functional medicine treatment for them, if you treat one, like Epstein-Barr, that will be effective for all types of herpes viruses. Even if you don’t know for certain if one of them is positive or not, if you treat one, you will be treating the other.

Dr. Eric: Do you usually treat the viruses with an antiviral herbal approach?

Dr. Nikolas: It’s a three-pronged approach. Especially the herpes viruses and Epstein-Barr, they rely on what’s called NF Kappa B, nuclear factor kappa B, which means there is inflammation. EBV relies on that to proliferate.

The first thing to do is to use some kind of anti-inflammatory that works on NF-Kappa B. The most common ones that I’ll use are curcumin, black cumin seed oil, resveratrol, quercetin. Those are all effective here.

The second prong is you want to support natural killer cells, CD8+ T cells, cytotoxic T cells that contribute things like EBV. To support those, you want to use a mushroom. I’ll usually use cordyceps and reishi. That’s the second way.

The third is with monolaurin, also known as lauric acid. This dissolves the fatty acid envelope around the virus, so it exposes it to the immune system, so it’snot as stealth without that.

Those are the three things I’ll do to approach chronic viruses like EBCV.

Dr. Eric: Regardless of whether it’s EBV or cytomegalovirus or another one like Parvo virus, that approach seems to help. With EBV on a blood test, if someone tests positive for EBV, the IgM antibodies, that’s more of an acute infection. Maybe when they first got it years ago, the IgM marker would show up. What’s your take on people who have IgG markers? Most people do have IgG. Do you pay attention to the three different IgG markers? I spoke with Dr. Kasia Kines, who wrote the book The Epstein-Barr Solution. She pays more attention to that early antigen antibody. Others are more focused on how high the antibodies are, like if they are in triple digits or undetectable. How do you interpret the EBV markers?

Dr. Nikolas: Let’s talk about what’s very clear in the literature on EBV diagnosis and interpretation. You’re right. The IgM is elevated during acute infection. On average, IgM is gone in about seven weeks. In the vast majority of people, that will not return for life.

The two IgGs that you’re talking about where people are looking for elevations, the nuclear antigen and the viral capsid antigen, those alone can’t tell you if there is reactivation. The only thing that can tell you there is a high viral load or high immune response. That doesn’t mean there is reactivation. You do have to mainly look at the IgG early antigen. Unfortunately, the major labs like Labcorp and Quest don’t have the early antigen on their standard panel. They just have the other three. You have to request to add the early antigen in. Labcorp used to include the early antigen for the last 16-17 years, and they just took it out a year or two ago. You do have to look at the early antigen.

A few caveats there: There are some individuals genetically who will just have elevated early antigen for life, IgG, even when the virus is no longer active. You do have to take that into account. Then it becomes more of a clinical diagnosis. You also have to look at the complete blood count, looking at the white blood count, neutrophils and lymphocyte ratios. If you see the lymphocyte screeping up toward neutrophils, that can be an indicator of chronic viral activity.

The early antigen, you could run it, and it could be high. But it takes about six months for the early antigen to calm down and become negative once the virus is successfully deactivated. You could also be in the middle of a successful deactivation of the virus, but it is still positive.

Those are all really important things to know, that alot of people aren’t looking at or don’t know. You don’t want to jump to conclusions if the early antigen is high.

Dr. Eric: Do you test for EBV and other viruses with pretty much all of your patients?

Dr. Nikolas: Not all of them. It depends on how ill they are. A lot of them come in and already have had EBV testing. 99.999% of the time, the early antigen is not included. A lot of times, if I am testing, I am just doing the early antigen, not looking at the other markers. I couldn’t give you an exact percentage, but the vast majority, I’m looking for viral activity in patients with autoimmunity. The vast majority come back positive.

Dr. Eric: Going back to the gut infections, you mentioned yersinia being positive more in the blood testing. When H-pylori is positive and you treat it, from what I understand, you don’t want to retest in the blood because those antibodies could take a while to get rid of. Is it the same with yersinia? If you detect that it’s positive in the blood, and you treat someone for it, do you just put them on the protocol for a specific amount of time? How does that work as far as the retesting for yersinia enterocolitica?

Dr. Nikolas: I had to call the lab. If you test yersinia through Labcorp, say, they send it out to a specialty lab called ARUP Lab. I called them and had a long conversation with a pathologist there. If you really want to know about laboratory diagnosis, you want to talk to pathologists. We talked about it for a while.

There is no real definitive way to be certain if the infection is successfully treated if any of the markers are still elevated or not. You run the IgG, the IgA, and IgM. Now you can be pretty confident with the IgM it will only be around for seven weeks. If you see that elevated, you know it’s arecent yersinia infection, so they got it from some contaminated food or water. Most of the time, you’re not going to see the IgM elevated. These people are chronic.

That leaves you with IgG or IgA. IgA can still be high if the yersinia is successfully eradicated. It can take a long time, over a year, for that to become negative.

The IgG is the last thing to look at. Once they have had it, that can actually go away completely. It’s different from a lot of IgG tests, where usually they’re elevated for life once someone has had it. Someone can have a negative IgG test in this case. The main purpose of the blood test is to identify if they have it, and if it’s relatively recent. If you see both the IgG and the IgA are both positive, that’s a really strong indicator that it is an active infection.

Dr. Eric: With H-pylori, how commonly do you see that in your patients?

Dr. Nikolas: It’s very common because of my patient population with Hashimoto’s. Probably anywhere from 60-80%, somewhere in that range, it’s positive. H-pylori is a little bit tricky with the interpretation. Especially if you are doing stool testing. I use the GI map from Diagnostic Solutions. I’ve had long conversations with the lab developers there. It becomes a clinical diagnosis if you see it. You will see a particular number. That does mean there is some H-pylori, there is some activity, which we would expect because such a large portion of the world has it.

The question is if it’s causing a problem. If it’s elevated, in the red, and the clinical picture fits with if they are having symptoms of H-pylori, then that’s the case where you would most likely want to treat it. But if they don’t have any gut symptoms at all and it’s high, I won’t do an extensive treatment for H-pylori just because of the lab tests if it doesn’t fit clinically. That’s how I approach those H-pylori markers.

Dr. Eric: When you do treat it, do you take more of a natural approach, or do you typically recommend the triple therapy consisting of antibiotics and the PPI?

Dr. Nikolas: I do a triple therapy approach with triple probiotics. I use a LactoBif blend, a saccharomyces boulardii, and a spore-based probiotic. I will use all three types. Strengthening stomach acid production, strengthening digestion, along with the probiotics is very effective for most people. If it isn’t, I would go in with a few herbal antibiotics for three or four weeks. That clears it out quite nicely.

Dr. Eric: Talking about symptoms, you mentioned that with H-pylori, you rely on the symptoms. Are there cases, when it comes to infections, where you don’t rely on symptoms, where it could potentially be a trigger, even if the person isn’t experiencing specific symptoms associated with that infection?

Dr. Nikolas: Yeah. Almost all of them, there could not be any symptoms.  So HHV-6 and EBV, they might not really have any strong symptoms related to those viruses, but they are active. Yersinia, you can have yersinia in the gut, and it’s not causing any major symptoms. Again, H-pylori, if they don’t have the symptoms of it, but they have a very strong autoimmune response, and we are doing a lot of the things we would normally do, and they are not moving along the way we would like them to, I might go in there and do a trial and knock it out in three or four weeks. See if there is some improvement. You’re not really going to do any harm treating H-pylori alternatively because we’re not using antibiotics to damage the gut micro flora.

Thinking of other infections that are connected there, like Hepatitis C, there is a really strong connection between Hepatitis C and Hashimoto’s. Hepatitis C actually has a stronger connection with Hashimoto’s than any other infection that we know of. In fact, Hepatitis C can leave the liver and set up in the thyroid. It’s called an extra hepatic reservoir. It can drive autoimmunity there. Some people with Hep C, especially early on, don’t have any symptoms. It’s always a matter of doing some extensive investigation.

Dr. Eric: As far as the research, I don’t think there are any other parasites in the literature associated with either Graves’ or Hashimoto’s, but have you seen from a clinical perspective where, maybe not blastocystis hominis, but maybe another parasite is present, the person’s symptomatic, and that seems like it might be a trigger? You treat the parasite, and there is a positive correlation with their immune markers going down.

Dr. Nikolas: Yeah. Blastocystis hominis really is the only one that I have ever been able to find in the literature connected to thyroiditis of any kind. But hypothetically there would be some similarities with other types of parasites if you look at the blasto mechanism. Blastocystis hominis is going to drive TH17, which drives autoimmunity. People with parasites, not always, but a lot of them tend to have a TH2 polarization. When you successfully eliminate any kind of infection that is driving TH17 or a TH2 polarization, then theoretically, you would help the immune system and help autoimmunity. Again, no strong evidence to support that other than blastocystis hominis. I’m sure you’ve seen it, and I’ve seen it, and other practitioners have seen it, where you treat the parasite, and they do get much better.

Dr. Eric: Definitely. Of course, to be fair, many times, we’re working on other things, too. It’s not just the parasite. Sometimes it’s then difficult to make the connection, but there have been cases where I’m pretty sure it was due to a parasite that is not in the literature. That greatly helped. Thanks for sharing that.

Speaking of parasites, you said you do the GI Map, which I do as well. Would you agree that stool testing, it can be helpful, but also with parasites, it’s not perfect? Even though the GI map again is DNA-based. Arguably, it might be more accurate than other testing. Still, there is always a chance for a false negative, correct?

Dr. Nikolas: Yeah. I mean the way I explain it to patients is you have the villi in the intestine. The stool analysis, it’s mainly going to pick up the stool that is passing over the brush border of the intestine. You can have deeper infections deep in between the villi. You can have parasites in there, all kinds of things. There is no way to pick up everything that is in someone’s gut ona stool analysis. It’s just impossible. We can’t go by that exclusively just because of the depth of the spaces in between the villi.

Dr. Eric: After you treat someone for H-pylori or a parasite, it’s a little bit different with viruses, but specifically with the gut infections, do you usually retest after treatment, or do you rely mostly on the presentation of the person and some other markers like blood markers?

Dr. Nikolas: Early in my career, I would retest. As the years went on, I tested less and less. If the patient is feeling good and their symptoms are gone, I leave it up to the patient if they want to retest or not. I have some patients who really want to see on paper that everything is cleared out and they are going to be okay going forward. Other patients are feeling great. There aren’t any indications that they have any ongoing infections. I say, “You’re fine. You’re good to go. We don’t have to spend the money and retest.”

Dr. Eric: Do you use any biofilm disrupting agents, like N- acetylcysteine (NAC), or proteolytic enzymes when treating infections?

Dr. Nikolas: N-acetylcysteine the main one that I use for biofilms. The herbal medicines that I use pretty much all disrupt biofilms, if I am using something for an intestinal parasite or H-pylori or fungi. The triple probiotic approach plus the herbs, if it seems like a difficult case, then we use NAC, is all more than enough. There are products out there designed for biofilms. I’ve used those in the past. I didn’t really find an amplified successful outcome using those. The fewer the supplements, the better, is how I approach things. The things I do usually work well without using those extra products. They can definitely work, but the question for me is always, do I really need them in this particular patient?

Dr. Eric: Makes sense. Thanks for sharing that. How about stealth infections such as Lyme disease? Viruses could be considered those, too. Or co-infections such as Bartonella, babesia. Can those be potential triggers of autoimmune conditions?

Dr. Nikolas: The literature is weak on all the tick-borne infections. But there are a couple papers on Borrelia, the bacteria that causes Lyme disease and thyroiditis. Those are ambiguous. Any kind of strong infection that drives an immune response can potentially trigger autoimmunity. There are a lot of anecdotal reports of rickettsia, which is also transmitted through ticks, and other biting vectors as being connected to Hashimoto’s.

You do find in the Lyme community a fair number of them have autoimmune thyroid disease. Whether those are particular microbes from the tick, or is it just because their gut is so messed up from all the inflammation? Is it because they have been on so many antibiotics, which has caused dysbiosis and gut problems? Whether it’s all the inflammation, the stress of having Lyme disease. It could be any of those things. I can just say that the literature is pretty weak on the connections there, but you do see it a lot.

Dr. Eric: That is true. I was diagnosed with chronic Lyme three years ago. I have a history of Graves’. I was concerned it might retrigger it. Fortunately, it didn’t. I tested all the thyroid antibodies, not just the thyroid stimulating immunoglobulins.

You mentioned stress. One question is the impact of stress on infections, especially viruses. Do you agree that to some extent they are more opportunistic, if you could talk about the importance of optimizing one’s immune system health, such as improving adrenals and stress handling, how much overall does that help in preventing certain infections? Maybe not the gut infections, or maybe them as well. Especially viruses, stealth infections, Lyme disease.

Dr. Nikolas: Huge factor, not just because of what it does to the gut and the immune system, but lymphocytes have cortisol receptors on them. Chronic stress drives cortisol elevations. That causes down regulation of cortisol receptors on lymphocytes. The immune response becomes weak over time, the longer someone is under stress. That allows these opportunistic infections to grow. Stress is #1 in my practice, figuring out every potential possible stress input to the system and figuring out how to mitigate that. You won’t really get great results unless you’re addressing all those factors.

Also, adrenaline drives histamine. Histamine drives chronic viral activity. Adrenaline and cortisol both drive TH2 polarization, which drives TH17. Unfortunately, TH17 cells are the major drivers of autoimmunity. Whenever it comes to the immune system, there are always multiple factors there. You can draw out all the connections, and it looks like a big web. Stress is one of the most important fundamental aspects of chronic infections and autoimmunity.

Dr. Eric: I definitely agree with that. I had a case of shingles a few years ago, too. I’m pretty sure that was just due to a ton of stress that summer. I agree. Stress management, getting proper sleep, extremely important. Diet, lifestyle factors, very important.

All right, thanks, Dr. Hedberg. I appreciate you sharing all this information. It was great chatting with you about infections. Could you share with the audience where they could find out more about you?

Dr. Nikolas:My website is DrHedberg.com. That is where I have my articles and my podcast. That’s for potential patients. The Hedberg Institute at HedbergInstitute.com is for functional medicine practitioners. I have functional medicine courses there that they can sign up for and learn how toeffectively treat all these conditions that we’ve talked about.

Dr. Eric: Again, thanks, doc. Appreciate you taking the time to talk about infections. Hope everyone learned a lot.

Dr. Nikolas: Great, thanks for having me. Enjoyed it.

Recently I interviewed Dr. Amie Hornaman, as we chatted about thyroid blood chemistry, and below is the written transcript. If you would prefer to watch the interview you can access it by Clicking Here:

Dr. Eric:

With me, I have a very special guest, Dr. Amie Hornaman, who is host of her own podcast The Thyroid Fixer. How are you doing, Amie?

Dr. Amie Hornaman:

I’m great, Eric. Thank you so much for having me on.

Dr. Eric:

Wonderful. Let’s dive into Dr. Amie’s bio here. She again is known as The Thyroid Fixer. She is a woman on a mission to optimize thyroid patients around the world and give them their lives back using her proprietary transformational program, the Fix Method. She is also the founder of the Institute for Thyroid and Hormone Optimization. After her own experience of unsufferable symptoms, misdiagnoses, and improper treatment, Dr. Amie set out to help others who she knew were going through the same set of frustrations and who were on the same medical rollercoaster. With a focus on optimizing thyroid and hormone function, and thus optimizing her patients, Dr. Amie looks at you as a unique individual, not just a lab value. She examines all factors that tie into thyroid dysfunction and thyroid symptoms and fixes you to get your life back, which I assume is why you’re called the Thyroid Fixer.

Dr. Amie:

And that’s the goal.

Dr. Eric:

Why don’t you start off by giving a little bit of your back story? How you started fixing other people’s thyroid glands. Obviously, you do more than just the thyroid. But let’s talk a little bit about your backstory.

Dr. Amie:

So many of us in this health space, it’s that pain to purpose story. It’s going through something ourselves that brings us into helping others. If we rewind to 20-something years ago, I was actually competing in figure competitions, which is like body building, but more softer, more feminine. You still have to get on stage in a bikini. I was doing fitness modeling, too. Listen, I do not come from a family of skinny minis. My family has obesity and Type 2 diabetes in it. I always would have to diet down and really work at it. I knew what to do. I knew how my body would respond. I had done it many times before.

I was getting ready for a show. The diet is chicken, broccoli, asparagus, fish. You’re going to the gym twice a day. This one particular show, I started gaining weight instead of losing weight. I mean 20+ pounds. I stopped weighing myself after I hit 20 pounds because I didn’t want to see the scale go up anymore. I was not myself. I was depressed, fatigued. My hair started falling out. I went from doctor to doctor saying, “Listen, I know my body. I know something’s off. Please do something and tell me what is going on.” They were all saying, “You’re ‘normal.’ You’re fine. Just eat less and exercise more.” Are you kidding me? There is no possible way to actually eat less or exercise more than I already am. They gave me the runaround. A lot of patients get the, “You’re just getting older. You have to live with it. Everything looks fine on your labs.” Back then, I didn’t know anything about labs. I didn’t know what they tested and didn’t test because I was just a patient, just like all of you, trying to figure out what the hell was going on with me.

Seventh doctor finally touches my throat and says, “Swallow.” She says, “You have a goiter. We’re going to ultrasound it. We’re going to run more tests, but you have Hashimoto’s.” I leave there and am like, “Yes! This is awesome! I have an answer and a pill. This will fix all my problems. I will lose weight and feel like myself again.” Five months later, nothing. No change whatsoever.

I always joke. I’m pretty sure, Eric, that we had Gateway computers back then, the big box ones. I went on there and found this thing called T3. I saw all this research that T3 works really well with T4. Of course, I was on Synthroid, like many people are stuck on in the beginning. I bring this information to my doctor and say, “Look at this. This T3 thing looks like it works really well with T4. How about we do that?” She goes, “I’m not going to do that.” I said, “I’m going to find somebody who will.”

I finally went into the functional, integrative medicine space. I kept hearing this guy’s name. When you hear it three times, it’s the universe telling you something. I go to this guy who changes my life. He is now my mentor. He got me on the path that literally gave me my life back: doing the right tests, doing the right treatments, supplements, nutrition, medication, the whole deal. That is when my career changed because I thought, “You know, if I went through that frustration,” I mean, I was crying in my car after the sixth doctor told me I was normal. I just wanted an answer. This is unacceptable. I needed to get out there and help other people who were going through these frustrations that I went through because I am just one little person in Erie, PA. There are plenty of other people out there suffering.

That’s why I’m here. I went to functional medicine training. Got my master’s and my doctorate. Now I am in this space helping others.

Dr. Eric:

Wonderful. Thank you for sharing that. In the bio I gave, one thing I mentioned is that you do more than just look at the labs. You want to treat the whole person. But we are going to focus on thyroid blood chemistry because we do look at labs. Same thing here on my side. I think labs are important; it’s just not the only thing. Unfortunately, medical doctors only look at labs; they may look at more than just TSH sometimes, but a lot of them just look at TSH and just give medication for Hashimoto’s, thyroid hormone replacement. For hyperthyroidism or Graves’, they will give antithyroid medication unless they resort to ablation or thyroid surgery. As far as thyroid labs, what do you do? TSH would be one. Discuss some of the labs.

Dr. Amie:

The must-dos. The must-haves with thyroid labs. If you don’t have these, we really can’t tell what’s going on. You start with the TSH. If you’re lucky, you will get a free T4. We might see those, but quite honestly, that doesn’t give me the whole picture whatsoever. We absolutely need a free T3 because T3 is the active thyroid hormone. I’m sure you talk a lot about that here. We want a free T3 level. We want the reverse T3 level, which is the antithyroid hormone. Of course, we want the TPO and TGA antibodies because I want to know if you have Hashimoto’s, even if you have your thyroid taken out. I have many patients who go, “I don’t have a thyroid anymore.” I go, “I know. I’m still going to check your antibodies because your antibodies can still be present even after thyroid removal or ablation.” Those are all of the thyroid labs that I like.

Of course, like you said, I look at the symptoms. I always say “both and.” Yes, we have to do the thyroid, but we also have to look at your hormones, insulin, nutrients, and all those other factors that come together so beautifully to help your thyroid medication work better, or if you still have it, your thyroid work better. We have to pair all of that up with your symptoms into one big, beautiful picture.

Dr. Eric:

That’s what I do, too. I definitely recommend a full thyroid panel. I will say reverse T3, and we can talk more about it, I don’t do it anymore on my Graves’ patients. With hyperthyroidism/Graves’, and most of my patient base has hyperthyroidism, because of the hyperthyroidism, pretty much everybody has an elevated reverse T3. It’s different in the hypothyroid world. We could talk about that. Pretty much I would say just about everyone who is hyper has that elevated reverse T3. When you correct the hyperthyroidism, often that will resolve.

Talking about TSH, thyroid stimulating hormone, can you explain why you don’t want to rely on TSH alone?

Dr. Amie:

I see so many patients in the hypo space, or they have gone through hyperthyroidism or Graves’, and they either had treatment with medication or removal or radioactive iodine. Now we are replacing with thyroid hormone replacement if they had removal or ablation. If we rely on the TSH, the TSH can basically lie. If we are replacing with medication, that is going to go down. Especially if we are replacing with medication that contains T3, because if you had your thyroid removed, guess what? We still have to replace with T4 and T3. If we are replacing with medication that contains T3, that is naturally going to go down. I have also seen it go down below a 1 with T4-only medication, which is more rare, but it does happen.

Then you are in a situation where you go to your conventional doc. That TSH is .5, .01, let’s say. Your doctor freaks out and thinks you’re hyper. Meanwhile, you’re like, “No, doc, I was hyper last year. Remember, we treated me. Now I’m gaining weight, and my hair is falling out, and I’m tired. I’m sure as hell not hyper.” If you rely on that TSH alone, that person will look hyper and not be. You have to look at the actual thyroid hormones since TSH is a pituitary hormone, not a thyroid hormone. You can’t rely on TSH alone to get the full picture of what is actually going on in a person’s body.

Dr. Eric:

Agreed. Thank you for explaining. That’s what I was looking for. The pituitary hormone, I knew you would get to that. Perfect explanation.

I mentioned that in hyperthyroid patients, I typically don’t test for reverse T3 anymore. Why do you recommend reverse T3 in your hypothyroid patients, which I do, too? I do see some patients with hypothyroidism and Hashimoto’s.

Dr. Amie:

If reverse T3 is high, let’s say we are using thyroid hormone replacement, NTD or T4/T3 combinations—because if they have had their thyroid removed or ablated, or if they have Hashimoto’s, so it’s slowly being destroyed and we are catching them in the later stages, we use that medication—that T4 can convert to reverse T3. If a person is on too much T4 medication, maybe not enough T3, or the other factors that cause reverse to go up like inflammation, high insulin, estrogen dominance, low iron status, anemia, or if you don’t have enough iodine, zinc, or magnesium, all of that can push up reverse T3. Reverse T3 is basically a survival mechanism of your body. But if that’s high, and you’re walking around trying to live life and do a job and raise a family and run a business, you will be in survival mode all the time. It might just mean that we need to adjust your medication or look deeper at what is causing that reverse T3 to be elevated and fix that so that your body is not walking around in a protective survival mode all the time.

When you’re in the ICU or ER, the reverse T3 can be high. If you’re a Graves’ patient, you’re in this autoimmune flare where your reverse T3 is going to go high because it’s saying, “Listen, we don’t need any more thyroid hormone. Stop, there’s too much anyway.” That makes sense. If you’re hypo or on the other side of Graves’, where you have already had the surgery or the RAI, then we don’t want you walking around in survival state anymore. Now we are replacing that thyroid hormone. We want that to work and your body to make you feel good. We no longer want you in that high reverse T3 state. You don’t need to be in survival mode anymore.

Dr. Eric:

Makes sense. Thank you for that explanation. Let’s talk a bit about optimal ranges. We both agree that we don’t want to rely on the lab ranges, which again, most medical doctors do. They will just test the TSH and maybe the free T4. But even if they look at free T3, they will usually say everything is okay if it’s not red flagged by the lab. Can you talk a little bit about lab ranges versus optimal ranges?

Dr. Amie:

This is a big thing for everybody. I heard Mark Hyman once describe that standard lab value ranges are like the side of a barn. If you stand 50 yards back, and I give you a ball and you throw it at the barn, you will hit the side of the barn. But if I put a target on the barn, it will be tougher to get in that target. That target is the functional optimal range. That is where we know as functional practitioners that you will feel better as a person. Your life will be much better if you are optimal.

Let’s take free T3. Free T3 is 2.4. The cut-off for the lab value range is 2.3. She didn’t get flagged. She didn’t get that L; it’s not red. If you don’t get the L or the H next to your lab value, your doctor is probably not paying attention to it and what it means. To me, as a thyroid practitioner, I am going, “This is bad. This is low. We want you at 3.5 or above.” For any listeners who might be out of the country, we want it in the upper quadrant of the range. Now, that being said, some people even do better when that free T3 is above range because most labs will cut it off at 4 or 4.5. Some people do really well at a 6. Some people do really well at a 10. That doesn’t mean they’re hyper because you have to look at the whole picture and how they feel and what we’re actually doing with them medication-wise. You cannot go by that standard lab value range, or you could be left feeling like garbage. You have to go by the optimal ranges. Then take it one step further and find your optimal.

Dr. Eric:

To clarify, for those with hyperthyroidism, you are talking probably more with hypothyroidism, if they are taking thyroid hormone replacement, you are not as concerned if they are hyper. But if someone with hyperthyroidism has a free T3 of 10, chances are their free T4 is elevated, too. Then of course we want to look at the whole picture. If TSH is depressed, and free T3/free T4 are elevated, and the person is hyper, that is a completely different story.

But you’re giving a situation where someone with Hashimoto’s might be on thyroid hormone replacement. I agree, some labs actually go as low as 2.0. Some might have a free T3 of 2.1. Most medical doctors, unless the TSH is elevated because the free T4 and free T3 are low enough to bring that TSH out of range, then they will pay attention to that TSH. If free T4 is .7 and free T3 is 2.1 and TSH is 4.2, which is within most lab ranges, they will usually ignore it. Maybe if the person presents with some symptoms, possibly. Thanks for that explanation as well.

Dr. Amie:

If I could expand a little bit, going off what you said, you really have to look at the whole picture. I’m sure you get this question a lot, too. People will go, “Dr. Eric, what should my free T3 level be?” 3.5 or above is the optimal range for me, but it’s the whole picture. Just like you said, if you’re walking around with a 3.5 or 5, and then your free T4 is a 7, and your TSH is .001, now you’re in a hyper state. You have to look at the whole picture and then ask the person those four important words that we normally don’t hear in conventional medicine, “How do you feel?” I know we are talking about optimal ranges, but it’s not just about one individual lab value. I get that question all the time: Where should my free T3 be? I can give you a general answer, but it’s about looking at how everything is working together.

Dr. Eric:

Getting back to the example of someone with Hashimoto’s, if they are on thyroid hormone replacement, and it’s a little bit on the higher side, but they are feeling great and everything else looks good, then you might be happy. On the other hand, if it’s on the higher side and they’re feeling hyper and not feeling good and experiencing hyper symptoms, then it might be a good idea to adjust the thyroid hormone.

You said you don’t take desiccated? You take actual T3, correct?

Dr. Amie:

Yes, I am a T3-only patient.

Dr. Eric:

You’re only T3?

Dr. Amie:

Ok.

Dr. Eric:

Many medical doctors only give T4. Here is a question. Going off track, if someone needs T3, but their doctor just refuses, I assume you would just say probably go to another doctor, maybe see a functional medicine practitioner. If they do test for free T4 and it looks good, but free T3 is a little bit low, you would say maybe see someone else?

Dr. Amie:

Yeah. You start with testing. My rule of thumb is if you ask your doctor for a full thyroid panel with all the tests that you and I just went over, and they say no, it’s time to get a new doc. That’s the first test. That’s a test for your doctor. If your doctor won’t test you as apatient to get that full picture, and you’re going in and saying, “Here’s my symptoms,” and they won’t even listen to you and see what’s on paper right in front of them and have answers to why you’re feeling the way you’re feeling, time to move on.

Part B is let’s say you do have a low free T3. You do the same thing that I did. “Hey, I was listening to this chick, and she is a thyroid expert. She said this thing about T3 being awesome. I’m on T4 only. Look, my free T3 is only a 2.1. By the way, I’m gaining weight, my hair is falling out, and I’mreally tired.” If your doctor says no, it is time to move on.

That being said, I do have patients who want to go the natural route. That’s fine. If you’re taking T4 and it’s not converting properly, and your T3 is low and your reverse T3 are high, we can do all of the other things to help that conversion happen. If you want to stay on your medication or you really are stuck- I have patients in Australia, the UK, and Canada where I can’t prescribe for them. We have to do it the natural route. We have to push that conversion of T4 to T3 and take out all the blocks that are impairing that conversion from happening. It can be done naturally. If you’re here in the States and you’re on the struggle bus, it’s definitely time to get a new doc.

Go the functional route. Yeah, you gotta pay out of pocket. Chances are insurance isn’t going to cover it. But guess what? You’re going to get more than five minutes with a functional doctor because that’s all you get with insurance at your current doctor at your PCP or endocrinologist. That’s absolutely what I would say.

Dr. Eric:

Let’s talk about thyroid antibodies. You mentioned for Hashimoto’s, there are thyroid peroxidase antibodies, anti-thyroglobulin antibodies. For Graves’, there is thyroid stimulating immunoglobulins, which is a type of TSH receptor antibody. How important are antibodies to you to look at initially and to keep track of? A lot of patients, I don’t want to say obsess over antibodies. Graves’ and Hashimoto’s are immune conditions. I like to look at antibodies, too, but I want to get your opinion when it comes to thyroid antibodies.

Dr. Amie:

We have to test for them because I want to know whether you have an autoimmune condition or not. I want to know whether you have Hashimoto’s or not or Graves’ or not. We have to test initially. We also want that baseline, where you are starting. Here’s the thing. Many times, doctors won’t test, so I will see patients after they have been through 10 years of testing or even 10 years of thyroid treatment, but they never had their antibodies tested. Or they had them tested once. The testing part is important, just to know whether or not there is an autoimmune condition present. With hypothyroidism, 90% of it is Hashimoto’s. It might not get flagged right away. Oftentimes, we see antibodies come up as a false negative. We want to test multiple times to check that.

We want to see if you’re doing big jumps. I don’t care about little jumps. You’re right. Patients will get kind of a little bit obsessed with antibodies. I will get messages like, “Oh my gosh, my antibodies went up by 50.” So? Maybe you were stressed out, or you got glutened at a restaurant. I don’t care about those little changes. If your antibodies go from 100 to 3,800, we need to pause and take alook at that. That’s why I like testing but not obsessing. It’s just knowledge. It’s just ongoing biofeedback for me and the patient. We don’t hang our hat on the antibodies.

It comes back to, “How do you feel?” those four words. If a patient is feeling great, obviously we want to get your antibodies to 0. But if you are feeling amazing, and you’re losing weight and are living life and have energy and your hair is growing, I don’t care if your antibodies are 100 or 200. We are going to keep working at it, but I’m not going to obsess over that number because I want you feeling good. Does that make sense? It was a long answer to a short question, but that ties all those pieces together.

Dr. Eric:

Yeah, it makes sense. It beats the opposite where if someone’s antibodies are looking great, and they are still feeling lousy, there could be other imbalances as well. It definitely makes sense.

When it comes to retesting, I have a couple of questions. One question is how frequently do you retest a thyroid panel? A second question that ties into it is do you test the antibodies every single time you recommend a thyroid panel?

Dr. Amie:

First question is how often. I get asked this a lot by my patients. General rule of thumb if we are doing an overhaul on their medication. Depending on how much we changed, in that beginning stage, we will retest in 4-6 weeks just to see what’s going on. Then after that, and after we get them more optimized, we can space it out. But I always tell them if you feel wonky, if anything is going awry, then we retest sooner. That three-month or four-month or six-month marketer of when we are going to retest you is not set in stone. If you are gaining weight or feeling crappy again, sometimes a patient will say, “I feel like I did before I started medication. What’s going on?” especially with that whole NP recall. I was getting messages left and right, being like, “Why do I feel like garbage? Why do I feel like I did before I started meds? Why do I feel hypo again?” It was the medication. We need to test again obviously. We need to test now. Something is going on in your body. We just retest sooner.

Antibodies, I space them out. Maybe every third test, we take a peek at them. Again, will we put them in a full panel if someone is feeling badly? Yes. If someone reaches out and is like, “What is happening?” then yeah, we test everything.

Dr. Eric:

I take a similar approach. I can’t say I recommend testing antibodies every single time.

Dr. Amie:

No.

Dr. Eric:

Endocrinologists differ. If they do test antibodies, it will just be the very first time, and that’s it. They will never test for them again. I do have some patients who are still working with an endocrinologist. Not that I’m complaining, but some test the antibodies every single time. It really varies. If they are getting testing through me, if they really want to test antibodies every single time, I won’t argue. But typically, it will be like every other time.

With hyperthyroidism, it might be a little bit different. Initially like you said, you might want to test more frequently. But with hyperthyroidism, you definitely want to keep an eye on them. if they are on antithyroid medication, there are other tests we will want to look at like liver enzymes, making sure the white blood cell count isn’t depressed.

Speaking of that, let’s talk about other tests that you do. As far as blood tests, I assume you do the basics like CBCs with differentials, comprehensive metabolic panels. Do you want to talk about that as well?

Dr. Amie:

Definitely. A long list. CBC with diff, CMP, obviously. I love looking at hemoglobin A1C and insulin because most thyroid patients, whether hyper or hypo, will have insulin resistance. Since the thyroid gland is the master, it will start throwing off your other hormones. We want to look at all the hormones. Insulin is a hormone; we want to look at that. We can’t hang our hat on glucose because glucose can lie. So we want to test A1C and insulin.

I like looking at a C-reactive protein for inflammation. Full hormone panel. Ladies, you have more than estrogen. You need a full hormone panel. That includes progesterone, free and total testosterone because testosterone is very important for my ladies. It is often overlooked by conventional medicine as being important. There is an optimal range for that, too, for you to feel good. Then we look at pregnenolone, DHEA. If we can get a four-point salivary cortisol panel to look at adrenals, I like to do that. Obviously all the nutrients: selenium, magnesium, iodine, Vitamin D. Vitamin D is a hormone. We look at that, too because that can get thrown off with hypo. I am probably missing some in there, but those are the ones that come immediately to mind. We will run an Epstein-Barr virus panel, Lyme Disease, tick-borne illness, all those things that could drive up reverse T3 and be co-infection.

Dr. Eric:

As far as Lyme, you will run a Lyme panel on everybody?

Dr. Amie:

No, I don’t. It depends on the symptoms. It’s obvious what’s going on with some people. It’s right here in black and white. As we get a little bit deeper, I had one patient that has long-haulers from C. I won’t say it out loud. She has long-haulers. As we look, what’s driving this? Epstein-Barr, less than 90% of us have that, too. Is it active or in its dormant stage? Is there a Lyme component, too, that is making her feel incredibly fatigued, or is it just her thyroid, or is it just the long-haulers? We want to rule that out when someone has that crushing fatigue.

If you look at their thyroid panel, and everything looks fine, or at least we have you optimized here, what else is going on that you’re so tired? Your Vitamin D is good. Zinc is good. You’re checking all those boxes. Then you think you better run Lyme and tick-borne here because there might be something a little bit deeper. So I don’t automatically run that. If I am working with a patient that is working with their own practitioner, good luck getting the full Lyme panel. It will just be the one marker. We have to do it on the side because this isn’t going to give us the information that we need.

Dr. Eric:

Yeah, I specifically asked you that question because I was diagnosed with chronic Lyme three years ago. I can’t say I run a Lyme panel on everybody. I do more frequently test Epstein-Barr in a lot of my patients. Also, with Lyme, the regular labs, Lab Corp, Quest Diagnostics, I don’t find reliable. You might get lucky, but usually if I’m testing, I’m using a specialty lab to look more at Lyme and co-infections.

I agree with the adrenal saliva testing. I’ve been doing that for years. I don’t know if you do DUTCH testing on patients. The last few years, I started doing dried urine testing on some patients. It depends. When you test for hormones, do you mainly do it through the blood? Or are you familiar with DUTCH?

Dr. Amie:

I’m familiar with DUTCH. I’m still on the fence with that, too. I’ll do it in patients I’ll feel like we need to compare both serum and urine and see the metabolites that we find in the DUTCH test. But I am all about saving patients money, too. If we can get the answers with a blood test that is by your insurance or you can get on the cheap from Ulta Labs, let’s go that route. That test is expensive. If we don’t need it, we’re not going to implement it and make you spend more money out of pocket. We can get a lot from blood. It is so split in our little world here of functional medicine, like the iodine controversy, the DUTCH hormone controversy. Dried urine is the best because we get the metabolites. No, that’s after the urine has already processed it; we have to use blood. You’re hearing both sides, and you know you need to land somewhere here. I go back and forth, too. Like you, I will use the DUTCH if it’s absolutely necessary to get a bigger picture.

Dr. Eric:

Saliva testing, you do use with most patients to look at adrenals?

Dr. Amie:

Yeah, that’s the gold standard. That’s the one where I will say, “We need to use something other than blood.” The four-point salivary cortisol panel, it gives us that look of what your cortisol is doing throughout the day. You can’t just go by blood and have one morning marker. It will give us some feedback, but I like to see what that cortisol half curve is doing. Is it actually in the right curve? Is it flatlined high? Is it flatlined low? That really requires saliva to get an accurate measure.

Dr. Eric:

Same here. I use more saliva testing than a DUTCH test. If I do recommend that, I add adrenals onto that. When I dealt with Graves’, I used the saliva test, and I have been using that for a long time. You definitely want to look at the circadian rhythm of cortisol and not just that single sample, which could again be influenced by like if someone is nervous going to a lab and they get that blood test, the withdrawal itself can cause the cortisol to spike up.

One other question that comes to mind for testing is thyroid ultrasounds. This obviously is straying from the blood or saliva tests. It’s different, but it does relate to thyroid. Do you recommend thyroid ultrasounds to your patients?

Dr. Amie:

I do recommend it. It’s that individual thing. Sometimes we can go off the blood, and we know what’s going on. There’s no palpable goiters, nodules. No one is having trouble swallowing. We don’t have those symptoms. On a case-by-case basis, if someone is having trouble swallowing, if they have a visual or palpable nodule, then we want to get an ultrasound. If they are in the latter stages of Hashimoto’s where that thyroid gland is being destroyed, we want to get an ultrasound.

I’m not sure where you use it with hyperthyroidism. But in those cases, yes. I have a patient right now who just got an ultrasound because she could actually feel that something has grown. Sure enough, one of her nodules has grown in size, so they are going to biopsy it. Okay, ultrasound. Good. In that case, really helpful. But not everyone needs one. I recommend it as a baseline if you can get it, if your insurance covers it. Coming back to the saving money part, if it’s black and white in front of me with the labs, and I know what’s going on, and I know what we’re going to treat and how we’re going to treatit, I won’t always say, “You must get an ultrasound” because they might end up with a $300 bill for that.

Dr. Eric:

I agree. I don’t think everybody needs it. When I was diagnosed with Graves’, I saw an endocrinologist at the time. She actually did not want to do an ultrasound, but I talked her into doing one. I was willing to pay out of pocket; I didn’t have insurance at the time. I wanted to know. I can’t say it’s necessary in every single person with hyperthyroidism or hypothyroidism.

This was a great discussion. I appreciate you sharing this information with my listeners. Any last words when it comes to any type of testing?

Dr. Amie:

The main thing is to get the full picture all at once, I know you probably see this in your patients, too, but I see conventional medicine do this willy nilly thing. We’ll test TSH first. If that’s bad, then we’ll do more testing, free T3 and free T4. If that’s a problem, then we’ll come over here and test your hormones. Why not do everything at once? Why not have everything right in front of you so you can look at it like a puzzle, and you’re putting the pieces of the puzzle together?

If I gave you a puzzle and said, “Hey Eric, do this puzzle, but I’m only going to give you a quarter of it,” you wouldn’t know if this was a corner or a middle piece. You have no idea. You don’t even know what the picture is. We need the whole thing. We need all the information at once.

You have to be your own patient advocate sometimes. Sometimes you have to order your own testing to get the full picture if there are pieces missing in your puzzle. Demand it. Testing gives us answers. We can compare that testing up with how you feel. Things can change. That is where the magic happens. Unless we have everything in front of us, how do we know? We don’t want to throw darts. We don’t want to say, “Maybe you have low testosterone. Maybe you’re estrogen dominant.” Then we start treating that, and it’s wrong. No, let’s get some numbers, some answers.

Dr. Eric:

I agree. When I recommend testing to my patients, I do take into consideration not everybody can afford everything. I will give options, too. Ultimately, it’s up to the patient. Even if I think something is not optional, it really is optional because they might- If we need to further prioritize, of course we will do so. We want to get answers. We don’t want to just rely on basic blood tests. Same thing with adrenals. I like to do saliva testing there. I think we’re on the same page with that.

Again, thank you so much for getting together. You shared some wonderful information. Where can people learn more about you? I know your podcast is one place.

Dr. Amie:

Yep, The Thyroid Fixer podcast on all podcast platforms. They can also find me by going to my website, DrAmieHornaman.com. If they are interested in booking a call, they can book a free discovery call. You can talk to a member of your team about how we can work together if you are in that hypo state. I know a lot of your patients do swing from hyper to hypo, from Graves’ to Hashi. Do you see that a lot?

Dr. Eric:

Over time. People do it quickly because they are on the antithyroid medication. A lot of people with Graves’ also have the thyroid peroxidase antibodies. A lot of them also have anti-thyroglobulin antibodies. Over time, some people do become hypo. That’s also why we want to try to address that immune system component to prevent them from getting to that state.

The Thyroid Fixer is the podcast on all platforms. The website is DrAmieHornaman.com. Thanks again. Appreciate your time, Dr. Amie. We’ll have to have a part two in the future.

Dr. Amie:

Definitely. Thank you, Dr. Eric for having me on.

***

Dr. Eric:

Thanks again for listening. One thing I wanted to mention is that my optimal reference ranges differ slightly from Dr. Amie’s. Part of this is probably because I work more with people who have hyperthyroidism. For the free T4, I like to see the levels between 1 and 1.5. For the free T3 levels, I like to see them between 3 and 3.5. As for the TSH, I like to see it between 1 and 2. 1 and 1.5 would be even better. As Dr. Amie mentioned, everyone is different. If your numbers are slightly higher or lower, and if you’re feeling great, and everything else is looking good, you shouldn’t get too caught up with the numbers.

Recently I wrote a series of blog posts discussing the ketogenic diet, Paleo diet, and carnivore diet (I’ve discussed the AIP diet in the past and so I didn’t include it as part of this series).  When I was dealing with Graves’ disease in 2008/2009 I followed a restrictive diet during Thanksgiving and the rest of the holiday season.  And many of my patients with hyperthyroidism/Graves’ disease and hypothyroidism/Hashimoto’s also avoid certain foods during this time of year (as well as other times).  It’s never fun to restrict foods, especially during the holiday season, although keep in mind that even if you’re following one of the diets mentioned above, you can still enjoy the holidays while eating whole, healthy foods.

The truth is that there will always be reasons you can come up with to stray from whatever diet you’re following.  There are birthdays, anniversaries, other holidays (i.e. Valentine’s day), summer cookouts, etc.  No matter what time of year you’re trying to follow a strict diet it isn’t easy.  And I realize that not everyone reading this will be following a specific diet, but the goal of this blog post is to give some encouragement to those who are following a restrictive diet.

Whether you are following a strict diet or plan on indulging more than you probably should, I want to wish you a Happy Thanksgiving!!!

Note: this is the third blog post in a series of diet-related posts. Please check out my previous posts on the ketogenic diet and Paleo diet.

I’d like to begin by letting you know that I currently don’t recommend a carnivore diet to my patients, and while I do eat meat, overall I eat more of a plant-based diet.  That being said, some of the concepts behind a carnivore diet make sense.  The carnivore diet is based on the premise that animal foods are more nutrient-dense and bio-available than plant-based foods, and they also have the smallest amount of toxins.  And I will admit that the latter statement is almost definitely true, as even many proponents of a plant-based diet agree that there are potentially harmful toxins in plant-based foods.

Two examples include lectins and oxalates.  In fact, well-known cardiologist Dr. Steven Gundry recommends more of a plant-based diet, yet he realized that many plants have toxic compounds, which is what led him to write the book “The Plant Paradox”.  However, it’s also important to mention that not all plant-based foods are equivalent, and so while Dr. Gundry’s research shows that grains should probably be avoided, he does recommend certain types of nuts, as well as properly prepared legumes (i.e. pressure cooked).

What is a Carnivore Diet?

A strict carnivore diet involves eating only animal-based foods (i.e. red meat, poultry, organ meat, fish, eggs) while avoiding all plant-based foods (vegetables, fruit, nuts, seeds, grains, legumes).  The main reason why these foods are excluded is to avoid certain toxins, which include lectins, phytates, glycoalkaloids, and oxalates.  In his book “The Carnivore Code”, Dr. Paul Saladino discusses 5 different types of carnivore diets.  His “Tier one” diet involves eating mostly animal-based foods, but allows a small amount of the least toxic plant foods.  In his book he discusses the least and most toxic plant foods, although another excellent book that relates to this is “The Plant Paradox”, written by Dr. Steven Gundry.

I won’t discuss all five of the diets in Dr. Paul’s book, but I’ll mention that his “Tier five” diet excludes all plant-based foods.  Some of the foods he recommends to eat on this “Tier 5” diet include grass-fed muscle meat, connective tissue, seafood, and eggs.  It also involves eating a lot of organ meats.

Why Do People Choose To Follow a Carnivore Diet?

Many people choose to be a vegan or vegetarian because 1) they think that it’s healthier, or 2) they think it’s unethical to eat animals.  I don’t think that most people initially follow a carnivore diet because they think that all plant-based foods are unhealthy, and of course they’re not doing it because they think it’s unethical to eat plants.  The two main reasons are because 1) they are trying to lose weight and nothing else has worked, and 2) they have some type of health condition they’re looking to overcome.

How Can a Carnivore Diet Help with Graves’ Disease and Hashimoto’s?

Although I can’t say that I’ve had patients follow a strict carnivore diet, there are people with different types of autoimmune conditions who have found a carnivore diet to be life changing.   Obviously the same can be said for many other diets that involve eating whole foods, while avoiding refined foods and sugars, fast food, etc.  And while I’m sure there are people who haven’t done well on a Paleo or autoimmune Paleo (AIP) diet yet thrived on a carnivore diet, this is just proof that there is no diet that fits everyone perfectly.

An autoimmune Paleo diet involves avoiding most of the plant-based foods that are harsher on the gut and can potentially result in inflammation.  But without question there are people who don’t do well with the “allowed” plant-based foods, and thus they might do better on a carnivore diet.  It’s also worth mentioning that many of the AIP allowed foods are high in oxalates (i.e. spinach, sweet potatoes), which in some cases can cause pain, kidney stones, and other health issues. This doesn’t mean that you can never eat these foods, although it probably is a good idea to minimize your consumption of them.  For example, if you’re stuffing your smoothies with spinach like I used to do then you might want to reduce the amount of spinach you eat.

Can a Carnivore Diet Disrupt the Gut Microbiome?

In my recent blog post entitled “Can a Ketogenic Diet Benefit Those with Graves’ and Hashimoto’s?“, I discussed whether or not a ketogenic diet can negatively affect the gut microbiome.  I brought up a few different studies, and concluded that more research needs to be done, and to play it safe it might be a good idea to supplement with prebiotics when following such a diet.

Although there is no research I’m aware of that looks at the gut microbiome of people following a strict carnivore diet, one randomized controlled trial compared a vegan diet vs. a meat-rich diet, and after 4 weeks it showed that overall the gut microbiota was not remarkably altered between both diets (1).  So most of the participants showed a similar microbiota composition at the start and the end of the trial, which is encouraging for those who choose to eat mostly animal-based foods.  But of course four weeks is a short period of time.

One of the main concerns with avoiding plant-based foods is that there won’t be dietary fibers to support the flora of the gut.  Once again, this is disputed by advocates of the carnivore diet, as they claim that the body will adapt.  I’m not arguing this, but I still think more research needs to be done before we can conclude that a 100% animal-based diet won’t have any negative consequences on the gut microbiome when followed for a prolonged period of time (i.e. at least one year in duration).

Can a Carnivore Diet Cause Nutrient Deficiencies?

Advocates of the carnivore diet claim that eating a strict carnivore diet won’t result in nutrient deficiencies as long as you eat a variety of organ meats.  Although I can’t say I eat organ meats, I agree that they are very nutrient dense.  That being said, because of the lack of research demonstrating whether eating a diet consisting of 100% animal-based foods will result in nutrient deficiencies, even if one chooses to predominantly eat animal-based foods, I still think it would be wise to eat some plant-based foods as well.

Can a Carnivore Diet Increase Cardiovascular Risk?

While in the past there were some concerns about eggs increasing cardiovascular risk by raising cholesterol levels, this has been debunked (2) (3).  Currently most of the concerns with animal-based foods are with red meat, as there are numerous studies that show a relationship between red meat consumption and heart disease (4) (5).  While this might be attributed to eating unhealthy forms of red meat, one also needs to take into consideration that many people who eat “unhealthy” forms of red meat on a regular basis also incorporate other unhealthy habits.  For example, someone who eats non-organic, grain-fed beef probably is more likely to eat other lower quality foods than someone who regularly consumes grass fed/grass finished beef.

In 2015 I released an article entitled “Is Red Meat Harmful For Those With Graves Disease and Hashimoto’s Thyroidits?“.  In this article I argued that eating healthier forms of red meat (i.e. 100% grass fed beef) probably doesn’t carry the same health risks as unhealthier forms.  That being said, I can’t say that I eat red meat on a daily basis, but I’m not necessarily avoiding it on a regular basis, as I do eat it a few times per week.

Can other sources of animal-based foods increase cardiovascular risk? 

It’s important to mention that while most people who follow a carnivore diet probably eat red meat, those who follow this diet probably should eat other types of meat as well.  And the research seems to show a decreased cardiovascular risk when eating other forms of animal-based foods.  This includes poultry and fish (6) (7) (8).  Once again, none of these studies takes into account healthier forms of red meat.

Did Our Ancestors Follow a Carnivore Diet?

Although it does appear that some ancestral groups ate large amounts of animal-based foods, they didn’t exclusively eat this way.  They did eat some plant-based foods at times, and so while I do recommend more of a plant-based diet to my patients, if you eat a lot of meat I would still recommend to eat some vegetables.  You just want to try to avoid the least toxic plant-based foods while trying to restore your health.

Is It Safe To Follow a Strict Carnivore Diet Long Term?

Unfortunately I wasn’t able to find any long term studies involving people following a 100% carnivore diet.  On a short term basis it probably is fine to follow this.  But on a long term basis it is unknown.  I’m sure if you visit some of the carnivore diet Facebook groups there will be people who have followed this diet for many months, and probably some for years and who seem to be in a good state of health.  And if this describes you then please feel free to share your experience in the comments section below.

Have YOU Followed a Carnivore Diet?

If you have followed a carnivore diet, or are currently following one, then I’d love to hear from you! Whether you have followed a carnivore diet for a few weeks, months, or years, please share your experience in the comments section below.  If you followed a carnivore diet and it greatly improved your health please let me know! And if you followed a carnivore diet and you didn’t notice any improvements I’d also like to know!

Note: this is the second blog post in a series of diet-related posts. Please check out my previous post on the ketogenic diet.

In the last blog post I discussed the ketogenic diet, and I figured I’d go ahead and discuss the Paleo diet in this post.  In the past I’ve discussed the autoimmune Paleo (AIP) diet, and although the Paleo diet isn’t as restrictive as an AIP diet, this doesn’t mean that it can’t benefit people with autoimmune conditions such as Graves’ disease and Hashimoto’s.  In fact, it can be a great option for those who find an AIP diet to be too restrictive.

In this blog post I’ll mention how the Paleo diet is followed by many people looking to lose weight.  However, this isn’t the main reason I recommend this diet, and in fact, some people with hyperthyroidism are looking to gain weight.  Even when this is the case, following a Paleo diet can be a good option to consider, as the goal isn’t to restrict calories, but instead is to eat an abundance of whole healthy nutrient dense foods.

What is The Paleo Diet?

The Paleo diet is based on the diet that our Paleolithic ancestors followed.  As Dr. Loren Cordain mentioned in his book “The Paleo Diet”, there was no single Paleo diet, as our ancient ancestors made the most of their environment. In other words, they ate what was readily available.

Whereas the ketogenic diet is a high fat, low carbohydrate, low to moderate protein diet, the Paleo diet is a high protein, low carbohydrate, moderate fat diet.  Although I mention “low carbohydrate”, a Paleo diet usually isn’t as extreme as the ketogenic diet, which is a big reason why the ketogenic diet can be more effective for people looking to lose weight. That being said, many people who follow a Paleo diet for weight loss purposes also successfully shed unwanted pounds.

Why Do People Follow a Paleo Diet?         

Just as is the case with most other diets, many people choose to follow a Paleo diet to lose weight.  In the previous blog post I discussed how many people follow a ketogenic diet for the same purpose, but unlike a ketogenic diet, a Paleo diet is usually more sustainable long-term.  Of course not everyone follows this diet just to lose weight, as some follow it to improve and/or maintain other aspects of their health.  This is especially true for those with chronic health conditions, as many times it takes a life-changing event for people to start eating well.

Quite frankly, this described myself when I was diagnosed with Graves’ disease.  While I arguably didn’t eat as poorly as the average person, there definitely was a lot of room for improvement.  And after I was diagnosed with Graves’ disease I followed a Paleo diet initially, as back in 2008 the autoimmune Paleo diet didn’t exist, although there were similar “gut-healing” diets.  But even though I followed a Paleo diet to start off with, I didn’t really eat eggs, and I wasn’t a big fan of most of the nightshades (other than white potatoes, which I was avoiding).

However, I didn’t give up nuts and seeds, as I figured they were a nice healthy snack (which they are).  But when I hit a roadblock in my recovery I decided to give up nuts and seeds for a few months, and I do think it made a difference.  Perhaps if I properly prepared the nuts (i.e. soaked and sprouted them) I wouldn’t have had to stop eating them, and the same might be true of others reading this who have Graves’ disease or Hashimoto’s.

What Foods Are Allowed on a Paleo Diet?

When eating a Paleo diet there is no limit on the amount of lean meats, poultry, fish, seafood, fresh fruits, and vegetables (with the exception of starchy tubers) you can eat.  Eggs are also allowed, although not recommended to eat daily.  And nuts and seeds are also allowed in small amounts.  I’ll discuss why these should be limited shortly.

For those who eat meat, I of course would recommend to eat healthier forms of meat (i.e. organic, 100% grass fed, pasture raised).  And while I don’t agree that seafood should be eaten on a daily basis, if you do eat seafood you also want to choose healthier forms (i.e. wild vs. farm-raised salmon).  If you eat eggs they should be organic and/or pasture-raised.

So here is a bulleted list of foods that are allowed on a Paleo diet:

• Lean meats and poultry
• Fish
• Fresh fruits
• Vegetables
• Eggs
• Nuts and seeds
• Healthy oils
• Spices
• Honey

Why Should You Limit Eggs and Nuts?

First of all, not all advocates of the Paleo diet recommend to limit eggs and nuts.  Also keep in mind that eggs and nuts are excluded from an autoimmune Paleo diet because they include compounds that can be harsh on the gut.  But this isn’t the main reason why some recommend to minimize the consumption of these foods when following a Paleo diet.

In his book “The Paleo Diet”, Dr. Cordain gives a few reasons why eggs should be limited to a few times per week.  One reason is because they weren’t available all of the time to our Paleolithic ancestors.  He also mentions that eating too many eggs can promote weight gain and increase blood cholesterol levels. I honestly don’t think the latter reason is a concern with eating an egg or two per day…especially when it comes to affecting cholesterol levels.

As for nuts and seeds, the main reason why it’s recommend to minimize your consumption of them on a Paleo diet is because most nuts and seeds have a high omega 6 to omega 3 ratio.  Some nuts aren’t as high as others, as walnuts and macadamia nuts have a lower omega 6 to omega 3 ratio when compared to other nuts and seeds, including cashews, almonds, Brazil nuts, and sunflower seeds.  Dr. Cordain has a nice chart in his “Paleo Diet” book that lists the different ratios.  It’s also worth mentioning that nuts are higher in oxalates than other foods.

What Foods Should Be Avoided?

Just as is the case with any healthy diet, you of course want to avoid eating refined foods and sugars, along with unhealthy oils (i.e canola oil).  You also want to avoid grains and legumes due to the lectins, which can be harsh on the gut and in some cases result in inflammation.

Here is a bulleted list of the foods you should avoid when following a Paleo diet:

• Refined foods and sugars
• Dairy
• Grains
• Legumes
• Unhealthy oils
• Soda and sweetened beverages
• High amounts of salt

Can You Eat a Plant-Based Paleo Diet?

Although many advocates of the Paleo diet recommend to eat a lot of animal protein, some recommend to eat plenty of vegetables.  This includes Dr. Cordain, as while he does recommend for people to eat a lot of animal protein in his book, he also recommends eating plenty of fruits and vegetables.  In his book he mentioned that ancient Paleolithic groups ate an average of 55-60% animal foods as part of their daily caloric intake, although some ate a much higher percentage.

If you’re a vegan or vegetarian you might have stopped reading at this point, but I will say that in my opinion, people who follow a Paleo (or AIP) diet don’t need to eat a lot of meat.  The problem is that many people don’t eat enough vegetables and healthy fats (i.e. avocados), which is one reason why they are hungry throughout the day.  Of course there are other reasons, as many people with hyperthyroidism have a voracious appetite, and as a result they don’t feel satisfied unless if they eat larger amounts of meat.  If someone wants to eat more meat while following a Paleo or AIP diet that’s fine, but I just want to let you know that it’s not necessary.

When I dealt with Graves’ disease I ate a good amount of meat, but I also didn’t eat as many vegetables as I do today.  These days I eat plenty of vegetables (many as part of a smoothie), and I eat a small amount of meat on most days.

Does a Paleo Diet Negatively Affect The Gut Microbiome?

In my ketogenic diet blog post I discussed a few studies which showed the effects of this diet on the gut microbiome.  I concluded that more research needs to be done, and those who follow a ketogenic diet might want to consider supplementing with prebiotics, just to be on the safe side.  I came across a couple of studies on the effects of a Paleo diet on the gut microbiome (1) (2).

One of these studies showed that long-term adherence to the Paleo diet is associated with a different gut microbiota, and that a variety of fiber components, including whole grain sources may be required to maintain gut and cardiovascular health (1).  The other study concluded that “the consumption of Microbiota-Accessible Carbohydrates from plant-based foods–but not grains–at the expense of refined sugars, and the minimization of the intake of processed foods, both hallmarks of the Paleo diet, could indeed act synergistically in maintaining a eubiotic level of gut microbiome diversity.”(2).  However, they do advise that caution be taken in adhering to this diet in the long term.

How Long Should One Follow a Paleo Diet For?

Since getting into remission from Graves’ disease this is the diet that I follow most of the time, although I can’t say that I follow it strictly 100% of the time.  Occasionally I do eat dairy and grains.  And so I guess you can say that I follow a “modified” Paleo diet.  After presenting the research above related to the impact of the Paleo diet on the gut microbiome, some might be concerned about strictly following this diet on a long term basis.  I think if someone eats plenty of high fiber vegetables then there is minimal risk of following this diet for many months or years, as we don’t need to eat grains and legumes (or dairy) to thrive and survive.  That being said, if you’re concerned you can certainly try to eat some of these foods on an occasional basis, which is what I do.

Have YOU Followed a Paleo Diet?

If you have followed a Paleo diet, or are currently following one now, I’d love to hear from you!  How did you feel when following such a diet? Did you notice any positive changes in your thyroid panel results, or any other markers? If you happened to have had a negative experience with the Paleo diet of course please let me know as well, as the goal is to try to get both perspectives.