When taking a natural treatment approach it of course is important to eat a healthy diet.  Although most endocrinologists dismiss dietary factors as playing a role in thyroid or autoimmune thyroid conditions, the truth is that eating a lot of refined foods and fast food on a frequent basis can lead to many different health issues.  However, some people don’t improve even when eating a healthy diet, and while it’s possible that there can be other factors affecting their health (i.e. stress, lack of sleep, an infection, toxins, etc.), in order to achieve optimal health it is important to avoid eating any foods you might be reacting to.

An obvious question you might have is “what foods should I eliminate?”  Not surprisingly you will get different opinions from different healthcare professionals.  But most will agree that the most common allergens should be eliminated, along with a few other foods.  This includes gluten, dairy, corn, eggs, soy, shellfish, peanuts, and refined sugar.  And because most refined foods and fast food include one or more of these allergens it is best to stick with eating whole foods while on an elimination diet.  Some healthcare professionals will also recommend avoiding foods such as beef, pork, coffee, tea, citrus fruits, and chocolate during an elimination diet.

An Elimination Diet For Those With Autoimmune Thyroid Conditions

Many people reading this are familiar with the autoimmune paleo diet.  This recommends for people to avoid most of the common allergens I listed above (gluten, dairy, corn, eggs, soy, peanuts, refined sugar, coffee), but also recommends avoiding legumes, nuts and seeds, along with the nightshade vegetables.  This of course makes the diet even more challenging to follow, but because legumes, nuts, seeds, and the nightshades have compounds which can potentially increase the permeability of the gut it probably is a good idea for most people with Graves’ Disease and Hashimoto’s Thyroiditis to avoid these foods.

I do think following an autoimmune paleo diet as an elimination diet is a good idea for many people with Graves’ Disease and Hashimoto’s Thyroiditis.  And of course those who do well with this diet can choose to continue following it until their health has been restored back to normal.  However, there are a few issues with this diet.  One problem is that it’s a very restrictive diet, as it essentially allows the person to only eat vegetables, fruits, lean meats and fish, coconut products, and some healthy oils (i.e. coconut oil).  Even with these restrictions many people are able to follow such a diet, especially on a short term basis, although it can be very challenging.  This is true for most people, but it is especially true for vegans and vegetarians.  And regardless of whether someone eats meat or not, some people don’t do well on an autoimmune paleo diet, even when it’s followed for a short period of time.

The other dilemma is that it is possible for people to have an allergy or sensitivity to one of the “allowed” foods.  In other words, someone might be sensitive to chicken, avocados, or kale, which are all permitted on an autoimmune paleo diet.  While these sensitivities are much less common, it still is possible to be sensitive to these and other foods.  Of course one can do food allergy and/or sensitivity testing, but this can get expensive, and the accuracy of such tests is controversial.  Research shows that the ALCAT testing is controversial (1), and although I have done IgG testing in the past, it’s not something I do on everyone, mainly because they are very expensive tests and I still question whether such testing is completely accurate.  I do like the new Multiple Food Immune Reactivity Screen from Cyrex Labs, although this test is also very expensive and has some limitations.

What I personally do is have most of my patients follow a strict autoimmune paleo diet initially, and then after the first month if they are struggling I’m usually open to them reintroducing some foods that typically aren’t allowed.  For example, eggs aren’t typically allowed on an autoimmune paleo diet, and I discussed the reason behind this in my blog post entitled ” Can People With Graves’ Disease and Hashimoto’s Thyroiditis Safely Eat Eggs? “.  But many people do fine eating eggs, especially the egg yolks, and in most cases, those who don’t do well will experience some symptoms upon reintroducing eggs.  Although nuts, seeds, and grains (even gluten free) are also not part of an autoimmune paleo diet, there are some people who choose to reintroduce small amounts of these foods and have no problems.  On the other hand, there are also people who reintroduce these foods and don’t do well, and eventually need to eliminate them from their diet again.

Below I have listed some of the main foods I recommend to be avoided initially, and I also include which ones are allowed when following an elimination diet for those with thyroid and autoimmune thyroid conditions.  Once again, I realize this can be very challenging for many people, and in the next post I’ll discuss reintroducing foods.

FOODS WHICH SHOULD BE AVOIDED:                                           

Gluten

Dairy

Corn

Grains (even gluten free)

Eggs

Soy

Shellfish

Peanuts

Refined sugar

Coffee

Chocolate

Legumes

Nuts

Seeds

Nightshades

FOODS WHICH CAN BE EATEN:

Vegetables (excluding the nightshades)

Fruits (some elimination diets recommend to avoid citrus fruits)

Poultry (chicken, turkey, etc.)

Lamb

Other Meat

Wild fish low in mercury and other toxins

Some coconut products (i.e. unsweetened coconut milk and yogurt)

Healthy oils: olive oil, coconut oil

If you want a more complete list of the foods that are allowed and “forbidden” on an autoimmune paleo diet I would recommend reading the book “The Paleo Approach” by Sarah Ballantyne.  In this book she gives some comprehensive lists regarding the foods you can and can’t eat.  Although beef and pork are allowed on an autoimmune paleo diet, some elimination diets exclude these foods.  And while I didn’t discuss the quality of these foods, you of course want to try eating organic whenever possible, consider eating pasture-raised eggs and poultry, and if you eat beef then choose 100% grass fed.

Obviously if you have a known allergy or sensitivity to one of the “allowed” foods then I would avoid it.  Also, even though I listed coconut products here, keep in mind that many coconut products sold in health food stores have other added ingredients that might cause health issues (i.e. carrageenan).  As a result, if you are going to eat coconut products such as coconut milk and/or coconut yogurt during the elimination diet it is best to make your own.

How Long Should You Follow An Elimination Diet For?

You want to follow such a diet for at least three or four weeks.  The reason for this is because the antibodies take at least three weeks to significantly decrease.  So for example, if someone has a sensitivity to eggs and eliminates them for only one week, this won’t be a sufficient amount of time to reduce the antibodies, and thus the person who is sensitive to eggs probably won’t notice a difference upon reintroducing them.  On the other hand, after approximately three weeks of eliminating eggs the antibodies should greatly decrease, and so if the person with an egg sensitivity reintroduces eggs they most likely will experience some negative symptoms.  As a result, after three or four weeks most people can begin reintroducing some foods, which I will discuss in the next blog post.

Will You Experience Any Negative Symptoms While On The Diet?

Some people do experience negative symptoms when initially beginning an elimination diet.  These symptoms can include fatigue, headaches, lightheadedness, and gastrointestinal symptoms.  These symptoms usually only last for a few days, and not everyone experiences them.

Can I Expect Any Improvement In My Symptoms?

While some people experience a worsening of symptoms initially, many notice an improvement in their symptoms after a few days or a few weeks.  Some of the common symptomatic improvements reported by those following an elimination diet include an increase in energy, a decrease in brain fog, better sleep, a decrease in gastrointestinal symptoms, and a decrease in pain.  Keep in mind that just because you’re not noticing an improvement in certain symptoms doesn’t mean that you’re not benefiting from the elimination diet.  For example, you might have low energy levels and/or sleep issues due to weak adrenals and HPA axis dysregulation, and while eliminating certain foods might help to reduce inflammation, going on an elimination diet alone usually won’t restore the health of the adrenals.  Similarly, if someone has a leaky gut due to an infection such as H. Pylori, just following an elimination diet isn’t going to help with this.

Based on what I just said you might ask the question “why not just do some testing first to see if someone has problems with the adrenals, a leaky gut, an infection, etc?”  Although I do some testing initially, what you need to keep in mind is that it is common for someone to have more than one health issue.  And sometimes it can be challenging to know what is specifically triggering one’s condition.  For example, someone might have a leaky gut that was caused by chronic stress or an infection, but they might also have a food sensitivity such as dairy that is contributing to their gut inflammation.  And so the obvious goal would be to address all factors which can cause gut inflammation and thus is preventing the leaky gut from healing.

Is It Okay To Cheat Once Or Twice During The Elimination Diet?

While many people follow an elimination diet without a problem, for others it is a big challenge.  And it’s not uncommon for someone to ask me if they are able to cheat while following it.  Or sometimes they won’t ask me, but instead will send an email letting me know that they strayed from the diet.  For example, someone might be following an elimination diet and then have a piece of birthday cake to celebrate a family member’s birthday (or their own birthday).  Or they might have been invited to a wedding and ate some foods they weren’t supposed to eat.  Or perhaps they planned the elimination diet around the holiday season and they were invited to a party where it was almost impossible to strictly follow this diet.

Cheating even once can be an issue if you the food you consume has an ingredient you are sensitive to.  And one of the main reasons for following an elimination diet is to try to determine which foods you might react to.  As a result, you really do want to be 100% compliant during this time.  The best thing you can do is to plan ahead, as if there is a special occasion where you know you won’t be fully compliant and you can’t change your plans, then postpone the elimination diet if necessary.  For example, if you have a vacation planned in a couple of weeks, then it probably is best to hold off on following the elimination diet until after the vacation.  If there is a party or another special event coming up soon that you need to attend and you don’t think you will be fully compliant with the elimination diet, then wait until after the party is over with.

Do You Really Need To Stop Drinking Coffee?

Many of my patients find it difficult to give up drinking coffee.  It’s common for someone to say that they can strictly follow the elimination diet, but they can’t give up their coffee!  I know it isn’t easy for some people to stop drinking coffee, even if it’s only on a temporary basis.  And while some people do fine drinking coffee, not everyone does okay, which is why it’s a good idea to eliminate the coffee for at least three weeks, and preferably longer than this.  I realize that some people have problems going cold turkey, and so what you might need to do first is to gradually reduce the amount of coffee you drink until you have weaned off.  For example, if you drink three cups of coffee per day then perhaps you can reduce it to two cups per day for one or two weeks, and then cut it down to one cup/day for one or two weeks until you have weaned off of the coffee.  Another option is to drink half caffeinated and half decaffeinated coffee (organic preferred), and then after one or two weeks make it 3/4 decaffeinated and 1/4 caffeinated, and then once you are drinking decaffeinated coffee it should be much easier to wean off of it.

What are the potential consequences if you continue to drink coffee?  As I briefly mentioned earlier, some people do fine drinking coffee.  But the same can also be said for other foods that are eliminated.  Some people do fine with dairy, eggs, gluten free grains, etc.  The truth is that many people do much better when eliminating the coffee.  Obviously if you have a sensitivity to coffee then continuing to drink it can be a problem.  But even if you don’t have a sensitivity, if you have adrenal issues then drinking coffee usually isn’t a good idea.  And so if you choose to follow an elimination diet please try to do your best to eliminate the coffee, even if it means taking a few weeks to wean off of it before starting the elimination diet.

Remember That The Goal Isn’t To Restrict Calories

Some people think that the primary goal of an elimination diet is to lose weight, and they not only avoid the “forbidden” foods, but limit their consumption of the “allowed” foods.  Even if your main goal is to lose weight, restricting calories isn’t the best method of accomplishing this.  While it is common for people to lose weight while following the elimination diet, the main goal is to find out which foods you might be sensitive to.  And so you don’t need to restrict the amount of foods on the “allowed” list.

Should You Continue Taking Nutritional Supplements and Herbs?

In many cases I’ve had patients take certain nutritional supplements and herbs while following an elimination diet.  However, feel free to take a break from your supplements and herbs during this time, and if someone has a lot of known sensitivities it probably is best to avoid most supplements and herbs during an elimination diet.  After all, there is always the possibility that someone can be sensitive to one or more of the supplements they are taking.  Sometimes it’s not the actual nutrient or herb that they’re sensitive to, but one of the other ingredients (i.e. fillers, gums, etc.).  This of course can also be true with medication, as someone might be having gut inflammation due to the synthetic ingredients in the one or more of the prescription drugs they’re taking.  Obviously I’m not suggesting for people to stop taking their medication while doing an elimination diet, but this is something to keep in mind.

Should Everyone With Graves’ Disease and Hashimoto’s Thyroiditis Follow An Elimination Diet?

Although I think most people with an autoimmune thyroid condition can benefit from following an elimination diet, this doesn’t mean that everyone needs to do this in order to receive good results when following a natural treatment protocol.  Not all of my patients have followed an elimination diet, but those people who are experiencing symptoms such as gastrointestinal discomfort (bloating, gas, increased or decreased bowel movements, etc.), severe fatigue, headaches, muscle and/or joint pain, and other moderate to severe symptoms not related to their thyroid hormone imbalance should consider following an elimination diet.  Once again, this doesn’t mean that a food sensitivity is definitely the cause of these symptoms, but if a food sensitivity is the culprit then obviously this needs to be detected and then removed.

Other Important Tips

In order the get the most benefits from your elimination diet there are a few other things I would recommend.  First of all, I would try to eat as many organic foods as you can.  The main reason is because there are less toxins in organic food, and in some cases someone will have a negative reaction not because of the food itself, but because of a specific toxin.  For example, someone might feel lousy at times when eating non-organic apples, but at other times might be fine.  And while they might assume they have a sensitivity to apples, the problem could be due to the high amount of pesticides found on non-organic apples.

You also want to drink plenty of water each day.  Drink purified water, or a good quality spring water out of a glass bottle.  Try to get sufficient sleep each night.  Of course there are many people who have sleep issues and therefore have problems falling and/or staying asleep.  But there are also many people who fall asleep fine but intentionally stay up much later than they should.  This isn’t too big of a deal if done on an occasional basis, but you obviously want to get a good amount of sleep on a regular basis.  Some light exercise is usually fine, but you don’t want to exercise excessively, as this is common, and too much exercise can do more harm than good.

In summary, going on an elimination diet can help to determine which foods you have a negative reaction to.  Although taking this approach isn’t 100% reliable, the same is true with other methods such as food sensitivity testing, and of course an elimination diet is much more cost effective, although it does admittedly take time and discipline.  When I recommend an elimination diet to my patients with Graves’ Disease and Hashimoto’s Thyroiditis, I essentially have them follow an autoimmune paleo diet for three or four weeks before reintroducing certain foods.  I realize this makes the diet very restrictive, but doing so is essential in some cases, and after three or four weeks most people can start reintroducing some other foods.  Please remember that you don’t want to restrict calories while following an elimination diet, and you also should try eating as many organic foods as you can, drink plenty of water, get sufficient sleep, and not exercise excessively during this time.

Thyroid eye disease, which is also known as Graves’ ophthalmopathy, affects approximately 50% of those people with Graves’ Disease.  And while in most cases the condition isn’t severe, this isn’t always the case.  Common symptoms include eye swelling, eye bulging (exophthalmos), and sometimes even blurriness and double vision.  While steroids such as prednisone are commonly given to help with the inflammation, certain natural approaches can also benefit the patient, without them having the side effects of steroid medications.  Research shows that selenium can be very effective in helping with thyroid eye disease, which I’ll discuss in this post.

But why is selenium so effective in helping with thyroid eye disease?  In order to better understand why selenium can help it probably is a good idea to briefly talk about the pathophysiology of thyroid eye disease.  Research clearly shows that Graves’ ophthalmopathy isn’t due to the hyperthyroidism associated with Graves’ Disease, but instead is due to the autoimmune response (1).  The same autoimmune response involved in Graves’ Disease is also responsible for damaging the tissues of the eyes.  Some of the more common symptoms include a dry and gritty ocular sensation, sensitive to light, excessive tearing, double vision, and a pressure sensation behind the eyes (2). The most common clinical features of Graves’ ophthalmopathy are upper eyelid retraction, edema, and erythema of the periorbital tissues and conjunctivae, and bulging of the eyes (2).

Just to summarize, in Graves’ Disease it is the immune system which attacks the TSH receptors, which in turn leads to the excess production of thyroid hormone.  And in Graves’ ophthalmopathy the immune system also causes damage to the tissues of the eyes, which in turn cause the signs and symptoms associated with Graves’ Disease.  And so the obvious goal should be to modulate the immune system and decrease the TSH receptor antibodies.  Glucocorticoids are commonly prescribed by medical doctors to help reduce the inflammation associated with thyroid eye disease, as well as suppress the immune system, which in turn can lower the TSH receptor antibodies (3).  But there are negative health consequences of steroids, such as glucose intolerance, gastritis, hypertension, hepatitis, and depression (3).

How Can Selenium Specifically Help With Thyroid Eye Disease?

Although the focus of this post is on thyroid eye disease, selenium has been shown to be effective in the prevention and/or treatment of many other conditions including cardiovascular disease, osteoarthritis, rheumatoid arthritis, hypothyroidism, stroke, atherosclerosis, cancer susceptibility and treatment, HIV, AIDS, neuronal diseases such as Alzheimer’s disease and amyotrophic lateral sclerosis, pancreatitis, depression, and diabetes (4).  Selenium might even be able to decrease the progression of thyroid cancer (5) (6).  But how can one mineral have such a dramatic impact on these conditions?  Well, selenium has numerous functions, as it is a powerful antioxidant which in turn can help to reduce oxidative stress, it is involved in modulating the immune system, it is an enzymatic cofactor, and it is also involved in gene expression.  So it is very likely that a deficiency of this mineral will make someone more susceptible to developing other chronic health conditions.

As for how selenium can specifically help with thyroid eye disease, although the exact mechanism isn’t known, an increase in oxidative stress has been observed in both acute and chronic phases of thyroid disease with raised tissue concentrations of reactive oxygen species (7).  Selenium is important for the formation of selenoproteins.  These selenoproteins are powerful antioxidants and help to neutralize the effects of oxidative stress by reducing these free radicals (8).  Glutathione peroxidase and thioredoxin reductase are the two main seleno-enzyme systems which are responsible for the reduction of free radicals (7) (9).  These free radicals lead to an increase in proinflammatory cytokines, which as I have discussed in past articles and blog posts, are associated with autoimmune conditions (10).  So essentially what happens is that if someone has a selenium deficiency, this will result in a decrease in selenoproteins, and this in turn will result in the accumulation of hydrogen peroxide, which will cause tissue inflammation (11).  In addition, a deficiency of these selenoproteins can cause dysregulation of the immune system (12).  All of this can lead to tissue injury.

Remember that it’s the immune system attacking the TSH receptors which is responsible not only for the hyperthyroid symptoms of Graves’ Disease, but the immune system also attacks the fibroblasts of the orbit, which results in the symptoms associated with thyroid eye disease.  The TSH receptor antibodies are secreted by activated B cells due to immune system dysregulation.  But a sufficient amount of selenium can help to regulate the immune system, as it can help restore both innate and humoral immune functions (13) (14).

How Much Selenium Should You Take?

As for the dosage of selenium, it depends on the individual.  A typical dosage to help with these conditions is 200 mcg/day, as this frequently is sufficient enough to result in a therapeutic effect without causing a selenium toxicity.  Some people don’t respond unless if higher doses of selenium are taken (i.e. 400 mcg/day).  However, too much selenium can be toxic, and so you do want to be cautious.  Although you can try to get enough selenium through eating selenium-rich foods such as Brazil nuts, it might be best to take a selenium supplement.  The reason for this is because the dosage of selenium will vary in the food depend on the source.  For example, a Brazil nut that wasn’t grown in selenium-rich soil will of course have a lower amount of selenium than a Brazil nut that was grown in selenium-rich soil.

It also is a good idea to do other things to modulate the immune system, and not just rely on taking selenium.  Other nutrients which can decrease oxidative stress and suppress the autoimmune response include curcumin, resveratrol, fish oils, green tea, and vitamin D.  While taking supplements can help, in order to reverse thyroid eye disease one of course will need to remove the autoimmune trigger that is responsible for the elevated TSH receptor antibodies.

In summary, thyroid eye disease is common in Graves’ Disease, and this condition involves the immune system attacking the tissues of the eyes.  Selenium is a powerful antioxidant which reduces oxidative stress and can modulate the immune system, and it’s an important cofactor for glutathione production.  Essentially what selenium is doing is helping to regulate the immune system, which will decrease the damage caused to the tissues of the eyes.  Keep in mind that other nutrients can also help with this process, and it’s also essential to remove the autoimmune trigger.

There is no question that engaging in regular exercise is important.  Exercise has many benefits, as it can decrease the risk of developing cardiovascular disease, improve insulin sensitivity, increase bone density, etc.  However, while many people don’t exercise enough, there are some people who exercise excessively, which also isn’t a good thing.  As I’ll discuss in this post, too much strenuous exercise can have a negative effect on the immune system and might potentially be a factor in the development of an autoimmune thyroid condition such as Graves’ Disease or Hashimoto’s Thyroiditis.

Although the focus of this post will be on the risks of overtraining in those with autoimmune thyroid conditions, moderate exercise seems to offer a protective effect on the immune system (1).  For example, while strenuous exercise can theoretically make someone more susceptible to an upper respiratory tract infection by temporarily suppressing the immune system defenses, moderate exercise can actually protect against upper respiratory infections (2).  Exercise has effects on both the humoral and the cellular immune system (2).

What Are The Potential Consequences Of Excessive Exercise?

Although there are no studies confirming that excessive exercise causes thyroid autoimmunity, there is no question that overtraining does affect the cytokines of the immune system.  And as I have discussed in other articles, these cytokines play a role in different autoimmune conditions, including Graves’ Disease and Hashimoto’s Thyroiditis.  In a properly functioning immune system you ideally want to have a healthy balance between T-helper 1 (Th1) and T-helper 2 (Th2) activity.  But certain factors can affect these pathways, and make someone Th1 or Th2 dominant.  This in turn can increase the chances of the person developing either Graves’ Disease or Hashimoto’s Thyroiditis.

Most cases of Hashimoto’s Thyroiditis are Th1 dominant conditions, whereas most cases of Graves’ Disease are Th2 dominant conditions.  However, this isn’t always the case, and the only way to know for certain is to test the cytokines.  A few years ago such testing was more common, as some natural healthcare professionals would test the cytokines through the blood to determine if someone was Th1 or Th2 dominant and then they would recommend specific nutrients or herbs to balance these pathways.  Although some healthcare professionals continue to do such testing on their patients, this remains controversial, and isn’t as commonly practiced these days.

So how does exercise specifically affect the cytokines and the Th1/Th2 balance?  Well, exercise of moderate intensity seems to cause a slight shift towards a Th1 profile, thus reducing inflammation and reducing the risk of infections (3).  However, it appears that acute exercise, as well as chronic moderate exercise, shifts the immune response towards a Th2 profile (3) (4).  Prolonged intense exercise may shift the balance towards Th2 to an even greater extent (3) (4).

What this is saying is that short bouts of intense exercise and chronic moderate exercise slightly shifts the immune response towards a Th2 profile, and excessive exercise seems to shift the immune system balance too much towards Th2.  Since most cases of Graves’ Disease are Th2 dominant conditions, this would suggest that excessive exercise can potentially trigger Graves’ Disease in those people who have a genetic predisposition for this condition.  However, the Th1 immune response offers protection against pathogens (i.e. viruses), and so this shift towards Th2 can make the person more susceptible to an infection, which can be a factor with either Graves’ Disease or Hashimoto’s Thyroiditis.  So excessive exercise might trigger Graves’ Disease by shifting the person to a Th2 dominant state, but it also might indirectly lead to Hashimoto’s Thyroiditis by making the person more susceptible to viruses and other infections.  For example, if someone with a genetic predisposition to Hashimoto’s exercises excessively this can weaken their immune system defenses, making them more susceptible to an infection, which in turn can lead to the development of Hashimoto’s Thyroiditis.

More About Excessive Exercise and Infections

Since infections can play a role in the development of autoimmune thyroid conditions I’d like to further discuss how excessive exercise can make someone more susceptible to developing an infection.  Secretory IgA plays an important role in providing protection by binding to pathogens, including viruses (5).  In other words, it is a first line of defense against pathogens.  However, prolonged strenuous exercise can cause a decrease in secretory IgA (6), which in turn can increase the chances of the person developing an infection.

So there are two mechanisms in which overtraining can increase the risk of developing an infection, which in turn can trigger autoimmunity.  The Th1 pathway is important to help prevent someone from getting an infection, but excessive exercise can shift the immune system towards a Th2 dominant state, which will make someone more susceptible to developing an infection.  In addition, excessive exercise can also lead to a decrease in secretory IgA, which plays a big role in providing protection against pathogens, including viruses.

The Impact Of Excessive Exercise On The Cardiovascular System

Although the focus of this post is on the risks that excessive exercise can have on the immune system, and how it can potentially trigger an autoimmune thyroid condition, there are other risks of overtraining as well.  Although there is no question that moderate cardiovascular exercise has some great health benefits, and that high intensity interval training can also be beneficial, too much exercise can cause harm to the cardiovascular system.  Excessive exercise can cause oxidative stress and increase the risk of atrial fibrillation, coronary artery disease, and malignant ventricular arrhythmias (7) (8).  So while it’s important to exercise regularly, you don’t want to overdo it.

Overtraining and Adrenal Insufficiency

The chronic stress that results from overtraining can also cause problems with the adrenal glands, and can even lead to adrenal insufficiency in some cases (9).  However, it appears that excessive exercise alone isn’t the only factor, as in order for adrenal insufficiency to develop it takes a combination of chronic overtraining along with a triggering stressful event (9).  But of course many people deal with a great amount of stress in their lives, and sometimes they use excessive exercise as a way of managing their stress.  In other words, someone who is dealing with a great amount of stress might initially feel better when overtraining, not realizing that they are actually worsening their health.

How Much Exercise Is Too Much?

The question you might have at this point is “how much exercise is considered to be too much?”  Well, further research is still needed in this area, but if you are engaging in moderate aerobic activity then you should be able to hold a conversation while exercising.  However, you might not be able to hold a conversation while engaging in high intensity interval training, although you shouldn’t be working out at a very high intensity for longer than a few minutes consecutively.  Just as a reminder, high intensity interval training involves short bouts (i.e. 30 seconds to a few minutes) of high-intensity exercise separated by one to five minutes of recovery (which involves either no or low intensity exercise).  Although doing this is fine in most healthy individuals, if someone participates in continuous high intensity exercise for prolonged periods of time (i.e. five minutes or greater) then this will increase the risk of causing problems with the immune system, cardiovascular system, and possibly other areas as well.

In addition, if you have a condition such as Graves’ Disease or Hashimoto’s Thyroiditis then you probably need to be extra cautious about overtraining, and in some cases even engaging in moderate exercise can cause problems.  For example, if someone has Graves’ Disease and has an elevated heart rate, then they need to be very cautious when doing any type of cardiovascular exercise.  This might seem obvious to many people, but I have worked with patients who had an elevated heart rate who asked if it was okay to engage in high intensity aerobic exercise a few days per week.  On the other hand, while someone with Hashimoto’s Thyroiditis might not need to worry about an elevated heart rate, if they have compromised adrenals then they will want to be cautious about engaging in vigorous exercise, even if they aren’t overtraining.  I mentioned earlier how someone who engages in excessive exercise and deals with a high amount of stress has a greater risk of developing adrenal insufficiency, and so it shouldn’t be surprising that someone who already has compromised adrenals will be doing more harm than good by overtraining.

In summary, while exercising on a regular basis is important and can provide many health benefits, exercising too much can do more harm than good.  With regards to the immune system, excessive exercise can cause an imbalance of the cytokines and decrease secretory IgA, which can increase the risk of developing either Graves’ Disease or Hashimoto’s Thyroiditis.  In addition, overtraining can have a negative impact on cardiovascular health, as well as the adrenals.  And so you need to be very cautious about exercising too much, and this is especially true if you have an autoimmune thyroid condition.

Note: This is the transcript from an interview I conducted with Dr. Izabella Wentz.  Dr. Wentz is the author of the book Hashimoto’s Thyroiditis: Lifestyle Interventions for Finding and Treating the Root Cause.

Dr. Eric: Hello everyone. I’d like to introduce you to our special guest, Dr. Izabella Wentz. She is a pharmacist who has dedicated herself to addressing root causes of autoimmune thyroid disease after being diagnosed with Hashimoto’s in 2009. She’s the author of the New York Times bestseller patient guide, Hashimoto’s Thyroiditis: Lifestyle Interventions for Finding and Treating the Root Cause. And she is an ardent champion of incorporating lifestyle change and functional medicine into the treatment of autoimmune disease.

How are you doing today Dr. Izabella?

Dr. Izabella: I’m doing great Dr. Eric and thank you so much for having me.

Dr. Eric: You’re welcome, and it’s great to have you. I really do look forward to interviewing you, and before asking you some specific questions I’d like to start by having you take a few minutes and explain your thyroid story and what motivated you to write your bestselling book.

Dr. Izabella: It’s kind of a funny story because people will ask me if I always had this big interest in the thyroid and I didn’t. When I was going through pharmacy school we learned about the thyroid gland and thyroid medications but it was just something that we learned in one day.

It was basically if you have a thyroid condition you take thyroid medications and that was it. I think there was some mention about it being autoimmune but nothing else besides that. And I was commonly dispensing thyroid medications when I worked in the community pharmacy and never realized the amount of suffering and pain people went through when they actually had thyroid disorders.

So I was diagnosed myself in 2009 and at that point I was fatigued, losing my hair, having joint pains, I had irritable bowel syndrome and all of these really strange symptoms that made me feel like my life was slowly falling apart. I went from being a relatively healthy person to where slowly my health was deteriorating and I was still in my 20’s. I went to my doctor who basically told me that I was getting older and losing my memory and hair, and gaining weight, and all these other things were part of getting older. Of course, I was only 26 at the time.

I eventually kept pushing and asking questions and going to different doctors, doctor shopping and trying to get some answers for all the symptoms I was experiencing. Then I was diagnosed with Hashimoto’s. At first I was relieved because I thought “okay, I have an answer to my problem and I can start on medication and I won’t be so tired anymore, and maybe I won’t be losing my hair”. But at the same time, the medication only helped a little bit and I was also interested in figuring out what I had done to develop this condition at such a young age because I thought I was leading a really healthy life. I was eating whole grains, low fat dairy, I was exercising and not smoking or drinking and I was just shocked. I wanted to know if there were any lifestyle factors that brought this condition on and if I could do anything to reverse or slow its progression.

And that’s how I got on this journey, I wanted to figure out if there was anything I could do on my own and I started digging for some answers and some lifestyle changes. One of the first things I discovered was the gluten free diet, which can make a drastic change in people in how they feel and look, and some people can actually put their condition into remission with a gluten free diet.

We went from there and my mom saw some improvements in my health. She’s a medical doctor trained in Poland and she told me that I needed to start writing things down so we can get this information over to my cousins and family members in Poland who had also been diagnosed. That’s kind of how the Hashimoto’s Patient Guide came to be. I was writing down things, I was researching and working on this to get myself better and I’m just really glad it’s been able to help other people as well along the way.

Dr. Eric: That’s a great story, and so from what I understand you were writing the book not necessarily to write a book, but to just write your own experience to benefit others and then turned it into a book?

Dr. Izabella: That’s kind of what was happening. When I was first diagnosed I had this brain fog like a lot of people do and I would research things on the internet, I’d go to the medical journals and get all of this great information and then I would forget it the next day. So it was really important for me to keep all of these things in a central place.

So the guide was kind of my own healing guide as well, and now it’s turned into that for other people.

Dr. Eric: Fantastic! Let’s get rolling with some questions. One of the questions I wanted to ask you is if you think it’s possible for the thyroid gland to regenerate if someone is able to suppress the autoimmune component of the condition?

Dr. Izabella: Absolutely, and I’ve seen it over and over again. So in some cases when people remove the triggers and they remove the root causes, or whatever is causing their immune system to attack their thyroid gland, thyroid tissue can regenerate. The challenging thing is that in different people it happens at a different rate. So one person may go gluten free and within 3 months they may need to start reducing their thyroid medications and get completely off their thyroid medications.

I collect a lot of remission stories from people on my website and we have a few people like that who basically changed their lifestyle and were able to get off thyroid medications because their thyroid function returned. Then we have other people who will do all of the right things and will see a reduction or even a remission in their thyroid antibodies but still may require the use of thyroid medications.

I wish there was a magic formula, and I used to think that it was younger people who had the condition for a shorter amount of time that were more likely to regenerate their thyroid tissue, but I’ve also had some people in their 50’s who have had the condition for 20 years who treated an infection they had and were able to get off thyroid medication. I don’t think there are any hard and fast rules, but definitely eliminating your triggers and supporting your body will help.

Dr. Eric: I agree. You first have to find and remove the trigger. And like you mentioned, I also haven’t noticed a set pattern. It can be someone who had the condition for a couple of years and someone else who had it for 20 years. Like you said, the person on thyroid medication for 20 years might able to get off the medication, whereas the person taking it for only a couple of years might be unable to.

And the challenge too, as you know, is if even if someone thinks they only had their condition for two years, chances are they’ve had it for quite some time. It takes time for the autoantibodies to be present and most of the time, as you know, they don’t test for the autoantibodies and usually they just do a thyroid panel. And so the autoantibodies might have been present five years prior to the TSH being affected and the person went through that time unaware of the condition.

Dr. Izabella: Yes absolutely! Some things that I found to be helpful is making sure you have your ferritin levels optimized, and have your adrenals optimized so that you’re not in a fight or flight mode, and you’re in a rest and digest mode, and just making sure you’re nourishing yourself properly.

Those are the things that are going to be helpful no matter if they help you get off thyroid medication or not. But like you said, it’s hard to prove, and some people will have thyroid antibodies for 10 or maybe 20 years before they actually start seeing a change in the TSH.

Dr. Eric: Exactly. Since you’re a pharmacist I want to ask you a few pharmaceutical questions. First, do you have a preference when it comes to patients with Hashimoto’s taking Armour vs. a compounded T4 or T3 product?

Dr. Izabella: I found that most people do very well with a combination of T4 and T3, and with Armour in a very, very small percentage of people. Some people might see an increase in thyroid antibodies with Armour, and so in that case I’d recommend doing the T4 and T3 compounded medication. Then we also might have potential problems with some of the fillers used in Armour. Some of the Armour products used to be corn-based, and some people who are very corn sensitive weren’t able to tolerate it. So in that case doing a compounded T4 and T3 medication may be beneficial.

The problem with compounded T4 and T3 medications is that they have to be made by specially trained compounded pharmacists. And you want to make sure the compounding pharmacist uses something called PCCA as a starter because thyroid medications are dosed in micrograms and so that’s like 1/1000th of a milligram. Most pills out there if you take Ibuprofen or Advil that’s 200 milligrams. So thyroid medications are dosed in 1/1000th of that and so it’s really easy to get the dosage wrong if you’re not using these specific starters that have the starting material very, very diluted. So that makes it very difficult to make the dose inaccurate.

If you go to your chain drugstore, even if they offer compounding medications they may not be doing them as accurately. So I’d always recommend working with a pharmacy that uses PCCA starters. Then making sure you ask for the medication to be prepared filler-free. A lot of times they can do that for you and make it gluten, dairy and soy free. There’s also 2 different types of fillers that can be used, Avicel and Methocel. And so the Methocel is extended release and some people with gut issues, which is mostly everyone with Hashimoto’s, may have trouble absorbing that medication.

I have seen people who were put on a compounded that was a suspend or release medication and they were not absorbing any of it. I would want to make sure you talk to your pharmacist about not including any kind of fillers that might impair the absorption of the medication.

Dr. Eric: What is the best way, in your opinion, to find a doctor who is willing to prescribe either Armour or compounded T4 and T3? Because most of them will just write a prescription for synthetic thyroid hormone medication such as Synthroid. What advice can you give with regards to finding a doctor who is more open minded to prescribe either natural thyroid hormone or the compounded thyroid hormone?

Dr. Izabella: Synthroid is the direct choice when you look at all the guidelines that most endocrinologists and physicians get. They’ll say that most people will do well on Synthroid and it’s the first drug you need to prescribe. There are some concerns, and back in the day Armour wasn’t standardized correctly. This hasn’t been an issue for many years now and the Armour and all of these other medications are going to be just as safe and potentially more effective for most people with Hashimoto’s.

I actually have a kind of pharmacist trick for this. In order to find a doctor in your area who prescribes this kind of medication then I suggest people work backwards and call their local compounding pharmacy, or call their local pharmacy, and I usually recommend working with independent pharmacies because the staff and people there actually want to take the time to get to know their customers, clients and patients vs. people who work in a community pharmacy, as they’re usually much more short staffed. If you’re working with the big chain boxes like CVS and Walgreens unfortunately people there don’t have enough time to interact with their patients.

So you call and ask them for a list of doctors in the area that prescribe these kinds of medications that you’re interested in getting. That will shorten your homework and research because when you just go through your insurance you’ll get a list of doctors and then you’d have to call each one and ask them if this doctor is open to prescribing these kinds of medications. Whereas, if you go through your pharmacy you’ll get a list of doctors that the pharmacists will know are good with exploring alternative thyroid medications and not just Synthroid.

For most doctors, if they haven’t prescribed something before then they’re not going to feel very comfortable with it because it’s a liability for them. And you probably don’t want to be the first patient they try on something either. So it’s good to go to a doctor who has a lot of experience with those kinds of medications.

Dr. Eric: You make an excellent point, because most people choose a doctor based on their insurance plan, and even if they don’t have health insurance they’ll just go to a doctor who is convenient. But starting with the pharmacist is probably a good idea. Even if you called some of the offices of the doctors, the doctor won’t actually speak with you. The receptionist will probably know what the doctor prescribes, but sometimes they won’t know.

So you might have to actually make an appointment to find out that the doctor’s only going to recommend Synthroid or another type of synthetic thyroid hormone. But that’s a good point to actually contact the pharmacist first and ask them for their list of doctors who will be willing to send you back to the pharmacist, and so that’s great advice.

Dr. Izabella: Just a little trick, right?

Dr. Eric: Yes, and thanks for that. I know you mentioned Armour with the fillers, but how about comparing Armour with Nature-Throid. Isn’t Nature-Throid a little more hypoallergenic than Armor?

Dr. Izabella: Yes, and so Nature-Throid is going to be a little bit cleaner and have fewer fillers compared to Armour. Then WP Thyroid which is made by the same company as Nature-Throid is going to be even cleaner and so that will have even fewer fillers.

So some people may react poorly to one of these medications, and I always want to make sure they’re reacting to the medication and not the fillers. So if they don‘t do well on Armour then they may want to consider doing something like Nature-Throid or the WP Thyroid medication, and that may absorb better for them. But if you’re someone who has a reaction to a filler in a medication, that may prevent you from properly absorbing the medication.

Dr. Eric: Okay that makes sense. WP Thyroid…is that the same as Westhroid?

Dr. Izabella: Yes, they kind of did this weird thing where they rebranded and what not, but yes, it’s through RLC Lab and that’s the new name they’ve had for the last 2 years or so. One thing about pharmacists is we always like our old names and so it’s taken awhile for me to call it that. But that’s a medication you can get that has fewer fillers and they call it WP Thyroid. They used to call it Westhroid Pure but there was some confusion with the other Westhroid and so it’s just WP Thyroid now.

Dr. Eric: Okay. For some reason I thought the ingredients were pretty much identical with Nature-Throid and Westhroid or WP Thyroid but it’s a little cleaner according to what you’re saying. So the WP Thyroid is cleaner than the Nature-Throid?

Dr. Izabella: Yes, and so it’s got even fewer fillers, and the fewer the better is my opinion on medications.

Dr. Eric: Great, and thanks for that as well. I commonly recommend the product Thytrophin PMG to my patients with Hashimoto’s and have done so for many years. I found it interesting that you mention it in your book. I wondered if this is also something you commonly use in your practice to help neutralize the effects of the thyroid antibodies?

Dr. Izabella: Yes, I found it very helpful. I’ve seen people reduce their thyroid antibodies by taking that supplement. It’s interesting because the science behind it is kind of weird. You try to look at the description from the company and basically what it says is that it neutralizes the antibodies and it helps to regenerate thyroid tissue and then it gives basically a blueprint for what a healthy thyroid gland is supposed to look like.

I kind of thought it was a very interesting mechanism of action but that’s all I was able to find on it. I tried it myself and have had clients who have tried it and most people have reported very positive results from reducing thyroid antibodies and feeling better. What has been your experience with it?

Dr. Eric: As I said, I’ve used it for a number of years and it does a pretty good job of neutralizing the effects of the antibodies. Of course it’s not removing the trigger, which is important to mention too. And just taking the Thytrophin PMG, if that’s all you do then it might minimize the effects of the immune system attacking the thyroid gland, but you still need to change your lifestyle and diet and try to find the trigger and remove it. But I’m still using it in my practice and recommend it to many of my patients.

Dr. Izabella: Good. I like to think of it as a decoy, right?

Dr. Eric: Yes.

Dr. Izabella: To distract the immune system from your actual thyroid gland while you work on all these other things. But it’s not something, like you said, that should be used on its own. Unfortunately, if there was a magic pill that’s not necessarily it.

Dr. Eric: I agree, and it’s good that you describe it as a decoy because from what I understand that’s what it does. The immune system actually attacks the Thytrophin PMG and so it’s just taking a lot of burden off the actual thyroid gland, thus allowing the thyroid tissue to regenerate as you were talking about. Once again, we do need to focus on removing the trigger, and so thanks for mentioning that as far as a decoy goes.

Obviously Hashimoto’s thyroiditis is an immune system condition even though some people perceive it as being a thyroid condition. In your experience, on average, and I know it varies from person to person, but how long on average does it usually take to rebalance the immune system once the cause of the condition has been addressed?

Dr. Izabella: It depends on the root cause. So for example, if someone had Celiac disease and that was their root cause, sometimes they get off gluten and dairy and within 3 months they don’t have any thyroid antibodies anymore and they start feeling amazing within a few days. I think that’s one of the best case scenarios where we identify the trigger and remove it right away.

With other things it can be progressive, and so let’s say if you have an H. Pylori infection that you treat. You might see a trend in reducing thyroid antibodies over the course of a few months but might not see the full effects for a year. But I’d say for every intervention, and I even recommend people to test their thyroid antibodies on a monthly basis when they’re actively doing different interventions trying to reduce them, you should see a trend of them going down in that first month.

Dr. Eric: I agree and ideally you want to see them consistently go down. Now sometimes I do see them fluctuate, but ultimately the goal is to get them where they’re going down and, of course, are eventually normal. Every now and then there will be someone who tests negative for antibodies the first time and then when you test them again they’re positive…so that’s another thing to bring up which you’ve probably have seen as well.

My point is that you can’t just go by one single antibody test if someone has an elevated TSH they get the thyroglobulin and thyroid peroxidase antibodies and both are negative. I’m sure you’ve seen where these might present as negative but then later on are positive. Have you seen that with some patients?

Dr. Izabella: Yes, absolutely and the thought is basically the autoimmune destruction of the thyroid may still be happening without any thyroid antibodies, and so that’s kind of one part of it. Then if your immune cells are out of balance and let’s say you don’t have enough white blood cells on board because overall your immune system is suppressed then you won’t be showing as many thyroid antibodies. As you get healthier and get a healthier level of white blood cells you might actually see a higher level of the thyroid antibodies as well, which some people might think is a negative but at the same time…you want to look at the whole picture.

How is the person feeling? If a person comes to me and they don’t have any thyroid antibodies and are feeling horrible, then of course we want to look at getting them to feel better and so we’re not going to say “well, your numbers look fine so I can’t do anything else for you”. And the reverse is also true, as if they’re feeling amazing and even if we see an increase in thyroid antibodies, of course we want to monitor that but we want to make sure that overall the first goal is to get the person to feel good, to get rid of their symptoms and then working on correcting all of the imbalances.

Dr. Eric: That’s an excellent point, as you have to look at the whole picture and not just the antibodies. As you said, if someone has antibodies that are decreasing but they’re still not feeling good, or for any reason they’re feeling worse, then obviously you want to address that. You’re not just treating the blood test results but you’re helping the person, and so that’s an excellent point there.

Let’s talk a little bit about selenium now. Can you talk about selenium and how it can potentially decrease thyroid autoantibodies in some cases? Perhaps you can discuss whether the average person can get enough selenium through food, or whether they need to take selenium supplements.

Dr. Izabella: Selenium is one of those things that I recommend for just about everybody with thyroid disorders. There are multiple studies that have shown that selenium can reduce thyroid antibodies in people with Hashimoto’s, and studies have also shown a positive effect on Grave’s Disease. Additionally, selenium has shown a positive effect on pregnancy and in preventing post-partum thyroiditis after pregnancy.

The different studies seem to show there’s a magic dose of it and so that’s going to be around 200 micrograms per day. A dose of 100 micrograms doesn’t work as well, and selenium is also one of those Goldilocks supplements that if you get too much of it, it can be toxic. So I will generally recommend anywhere between 200 and 400 micrograms per day of the selenium as a selenomethionine supplement.

The studies have shown that you’ll see a reduction of thyroid antibodies by about half at the 3 month mark. So if someone had 1,000 TPO antibodies, by taking the selenium they should see the antibodies drop to about 500. Selenium deficiency has been deemed as an environmental trigger for Hashimoto’s. What’s interesting is people with Celiac disease, people with Crohn’s Disease, people with any kind of irritable bowel issues are going to have a harder time absorbing selenium from their foods. As we know, the gut and thyroid are very much connected and this is a big thing that I always recommend for just about everybody in making sure they take a selenium supplement if they develop a thyroid condition.

Most multi-vitamins are not going to contain enough selenium in them and different things can impair its absorption. I can probably talk about multi-vitamins another time, but basically you put everything in one pill and all these different nutrients interact with each other for absorption and then you don’t end up absorbing anything when you take a multi-vitamin in a lot of cases. Some things do get absorbed but selenium absorption may not happen appropriately from the multi-vitamin.

I usually recommend taking the selenium supplement on an empty stomach in the morning. You do want to space your thyroid medications by about 30 minutes if you take those. What I’ve seen with clients is a lot of times they’ll say they feel a lot less anxious and their mood is going to be improved once they start taking a selenium supplement. If they’re monitoring their thyroid antibodies they’re going to see a reduction in their thyroid antibodies with that.

Another interesting thing to note that I just learned a couple of years ago is that gluten free diets, which are of course another big recommendation for people with Hashimoto’s, may make a person deficient in selenium as well. Some of the richest sources of selenium may include grains, as well as Brazil nuts. I know a lot of people have said they’ll take Brazil nuts to get their daily selenium dosage, but the only issue with that is that the content of the selenium in the Brazil nut is going to depend on where the Brazil nut was grown. If it was grown in a selenium rich soil it’s going to have more selenium, and if it’s grown in a soil that doesn’t have enough selenium then it’s not going to have an adequate dose of selenium. So people can actually under or over dose themselves with Brazil nuts given that we really don’t know how much selenium is in them.

A lot of times I’ll say to try to get most of your nutrients from food, but with selenium, because it’s such an important nutrient for thyroid function and because it has a neuro therapeutic index I’ll say skip the Brazil nuts and take a selenium supplement.

Dr. Eric: To summarize you said the average dosage would be between 200 and 400 micrograms. Is that correct? And then selenomethionine is typically what you recommend?

Dr. Izabella: Yes, that’s usually going to be my recommendation. Most people will do very well with that and the only exception is if someone is both iodine and selenium deficient, which is not very common, but selenium deficiency might exacerbate an iodine deficiency and so that would be the only thing.

So if you’re someone who reacted poorly to a selenium supplement and probably out of 1,000 people I’ve seen maybe one person like that, then there is a potential you may be iodine deficient.

Dr. Eric: I also found it interesting that you recommend taking it on an empty stomach because usually I recommend taking it with food. So I need to test it on an empty stomach with my patients and see if there’s a difference with the effectiveness. So you said to take it in the morning without food, such as a half hour after thyroid medication if they’re taking thyroid medication?

Dr. Izabella: Yes. I used to recommend it with thyroid medication and I had a couple of people, and I don’t know if their selenium had some calcium in it, the supplement they were taking had calcium and then that person reported that their TSH numbers got a little off balance. Now I recommend spacing it out about 30 minutes from the thyroid medications just to be sure. Thyroid medications are very finicky with absorption.

Dr. Eric: I agree with spacing it out and not taking with the thyroid medication. I haven’t given it to my patients on an empty stomach and so it’s something I’m going to test and see.

Dr. Izabella: Okay.

Dr. Eric: So just to clarify, if someone is on thyroid hormone medication you have them wait a half hour, they take selenium and then do you have them wait another half hour until they have breakfast?

Dr. Izabella: Basically, first thing when you wake up you’d take your thyroid medication and then you’d wait about 30 minutes to take your selenium and then wait another 30 minutes. I used to also recommend just waiting 30 minutes for thyroid medication but I found that not most people, but a lot of people actually need that hour before starting to eat because, like we said, thyroid medication can be finicky with their absorption.

Dr. Eric: Let’s talk about goitrogenic foods. Do you believe that people with Hashimoto’s should completely avoid goitrogens such as soy, and other goitrogens such as cruciferous vegetables?

Dr. Izabella: That’s such a great question and it’s one of those myths I like to bust. The word goitrogen is an old kind of word and it’s used to describe basically things that can enlarge the thyroid gland, but it can be done by a lot of different mechanisms.

Unfortunately, they’ve put these wonderful Brassica vegetables into this category like broccoli and cauliflower. A lot of people with thyroid disease think they can absolutely not have any broccoli which isn’t true. Basically, there’s a compound in these vegetables that could potentially interfere with iodine absorption into the thyroid gland. Well, if people are already taking thyroid medications or they have Hashimoto’s, iodine deficiency is sometimes the root cause, but in most cases it’s not. So usually eating these vegetables is not going to be an issue for most people.

I’ve just done a survey of about 2000 people with the kinds of foods they react to and what kind of reactions they were having with their foods. There was a huge percentage of people who reacted to gluten and dairy and soy and those kinds of foods, but as far as broccoli and cauliflower and foods like that, very few people reported that they actually reacted to those foods.

What I would suggest is that if someone isn’t on thyroid medication and is subclinical hypothyroid and maybe has an iodine deficiency, they may find that these vegetables slow things down for them a little bit more. So in that case you would just have to see them to break down the goitrogenic compound. But other than that, most people with Hashimoto’s can eat plenty of veggies. And so eat plenty of broccoli and cauliflower, raw or steamed or whatnot, it will be helpful with detoxification.

The only exception, of course, is soy. Soy works as a goitrogen because of a different mechanism, and so it interacts with thyroid peroxidase. They did studies in children who were fed a soy formula instead of breast milk and found these children were more likely to develop thyroid antibodies later on in life. So soy has been connected to Hashimoto’s and potentially inducing Hashimoto’s. So that’s one thing I definitely recommend avoiding.

In contrast, things like dairy or gluten, where people will often feel it in their stomach or gut when they eat this food. You may not have that kind of reaction to soy, but a day or two later after you eat it you might feel a little edgy or feel really tired. That’s because of its way of acting on the thyroid gland. So for most people with Hashimoto’s I recommend staying away from soy.

Dr. Eric: Yes, I agree. A few years ago I actually wrote some articles talking about goitrogens and I was telling people to minimize their consumption of goitrogenic foods. But that was not due to any research I did, but was based on information I learned from nutritional conferences I attended, and people who I perceived as being experts in thyroid health telling their patients not to eat goitrogens.

But then the more research I did and have done over the years I just realized that pretty much all of the studies have been on animals with regards to cruciferous vegetables, and usually involve large doses. Every now and then you’ll get a person who says when eating broccoli their thyroid swells. And like you said, if someone notices a difference they might want to ease up, but these are very healthy foods. So to deprive people of broccoli, kale and cauliflower… I think most people can definitely eat these foods without a problem.

And with soy, besides the goitrogenic properties, most soy is genetically modified. But even if you’re consuming non GMO fermented soy you still have to deal with the goitrogenic properties, and it also has some anti nutrients which also is a factor. So I agree with you about trying to not eat, or to limit the consumption of soy. Thanks for sharing that.

You’ve mentioned iodine a few times briefly so I want to talk a little more about iodine as far as some of the risks and potential benefits of iodine intake, and whether you think people with Hashimoto’s should completely avoid iodine, or if taking a small amount of iodine is okay.

Dr. Izabella: Wow we’re covering all the myths and controversies today. With iodine I know there are a lot of advocates out there who will say that high dose iodine can be very, very helpful for every thyroid disorder. I’m not going to disagree with that. I think everybody has to do what’s right for them, and iodine can help people with thyroid disorders.

The issue with Hashimoto’s, however, is that your thyroid gland, which is supposed to process iodine, is actually impaired. So when you give a person with Hashimoto’s who has an inflamed thyroid gland more work to do by giving it more iodine that can cause further inflammation.

In surveying my clients and readers about this…I’ll give you an example. About 80% of people said that going gluten free made them feel better and nobody said it made them feel worse. With high dose iodine I had about 25% of people saying it made them feel better and then 25% of people said it made them feel worse. So it’s kind of dangerous, I think, to be recommending it when you don’t really know and are just playing a guessing game, because for some people it may help them feel better and it may help especially if they’re iodine deficient and so you give them a high dose and it may actually make them feel better.

But then you have the other half of the people, which happen to be a lot of clients I’ve seen and I always try to recommend something safe first and safety is always my big thing. Let’s make sure everything is safe. And I’ve had clients who on their own or working with other practitioners they took very high doses of iodine and some had their thyroid antibodies skyrocket, going from a 200 or 300 range to the multiple thousand range. One woman’s TSH jumped to 98 and her T4 was at like zero, believe it or not, and she was bedridden because of the high dose of iodine.

I get super nervous about it, about these high doses of iodine, and studies have shown that it can accelerate thyroid tissue damage. On the other hand, the dosages you would get in a multi-vitamin is something like 150 micrograms. These dosages will actually be safe for most people with Hashimoto’s and will be helpful and they haven‘t shown any increase in thyroid antibodies when you just take a very tiny low dose of 150 micrograms per day, which is the recommended daily allowance.

Other studies have shown that people who actually go on an iodine restriction with Hashimoto’s may be able to improve their thyroid function as well. Where I am with that is for most people I’ll recommend working on these. I usually try to work on the things I know are very safe and very effective like the gluten free diet. Then if we’re still working with some of these issues then we may recommend a multi-vitamin. If someone has been on this super high dose iodine then I may recommend that person to just try to repair the damage and get off iodine for a short term period.

I wish I had a straightforward answer to say this is what we do every single time, but it’s not always so easy, and as you’re well aware there are a lot of different nutrients that act in synergy with one another. I always want to make sure everyone has their selenium on board, they’ve got their B vitamins and vitamin C on board and all these other things before we move on to the iodine. And iodine wouldn’t be a first level recommendation, it would be something like…okay we’re still struggling and we did this gluten free diet and we tried to address any infections and we’re still struggling…what else can we do?

But that is my stance in a nutshell for Hashimoto’s.

Dr. Eric: That’s great. I’m probably more pro iodine than you, but I’m also cautious with iodine, and I agree with you that some healthcare professionals will recommend high doses of iodine to all of their patients, or some people will take on their own a 50 milligram tablet of Iodoral daily without any testing. Some people will do fine, but some people don’t do well, and there’s really no way to predict who will do well and who won’t, and so I am cautious. And when I do recommend iodine I recommend testing, and even if someone is deficient I’ll recommend smaller doses and not have someone start out with very high doses. I usually don’t ever have people reach that high of a dose as I just mentioned such as 50 milligrams. So thanks for sharing that with us.

Alright, the last question I wanted to ask has to do with some of the common infections you see with your patients.

Dr. Izabella: For me, when I think about Hashimoto’s in general it’s in two parts, and one part is that your body is in a weakened state because maybe you’re nutrient deficient and/or maybe you’re eating foods you’re reacting to. Or maybe you’re under a lot of stress, or maybe you’ve been exposed to toxins, and that’s one thing that a lot of the lifestyle factors can address by getting you the right nutrients, getting you on the right diet, by taking supplements or doing some detoxifying.

The other part is the chronic infections. There’s a theory of autoimmunity called Molecular Mimicry where basically what is happening in very simple terms is that the immune system begins to recognize our thyroid glands as a foreign invader because there’s something else in our body that has invaded our body that looks similar to the thyroid gland. So different bacteria, viruses, potentially parasites might have protein structures that are similar to the thyroid gland, and so as the immune system… I like to think of it as walking around with a little IPhone and it takes a little picture of the protein sequence and then when it sees a similar protein sequence it will start attacking.

So there are a few different infections that have been identified as having a similar sequence to Hashimoto’s. H. Pylori and Yersinia are similar to the thyroid gland and have been identified. The most common infections that I’ll see are going to be H. Pylori, Epstein Barr Virus, and then parasitic infections in the gut. And so blastocystis hominis is a very common one too.

What we’ll find a lot of times is when you identify and treat that infection the person will feel better and in some cases they will see a reduction in thyroid antibodies and in some cases you’ll see the person going into remission. Those are the most common infections and I recommend doing stool testing. There is a company called BioHealth Labs that does the H. Pylori test and they also test for blastocystis hominis and you can have your doctor run a Epstein Barr virus panel. Most people have had Epstein Barr virus infections but they can become reactivated in people with Hashimoto’s and sometimes can keep the autoimmune response happening when they’re infected with that.

But research has connected so many different infections, and many are looking for that one infection, but it’s not always that one infection. I think it’s a combination of genes and maybe not having the right kind of natural flora, and the infection will determine what kind of disease you get.

Dr. Eric: With the stool testing, especially for parasites, do you typically have patients collect a stool sample on multiple days, such as collecting 3 or 4 different stool samples to increase the accuracy?

Dr. Izabella: Yes, that’s a really important question because a lot of times people will say I had a stool test and it was negative and they may have just had one stool test. The important thing to note is that the parasites may not shed in every stool or in every bowel movement, so the more stool samples you do the better your chances are at catching the parasites. So I actually recommend doing at least 4 stool samples on 4 consecutive days. You can also half that by doing it over 8 days where you put a little bit of a stool sample into each vial where you put 2 days worth of stool into one vial and that way you have a higher likelihood of potentially picking up the gut parasite.

I know this sounds nasty and gross and I didn’t want to believe it myself because we think we live in the Western world and we don’t have these kinds of things but it’s very common in people to have gut parasites and gut infections. They can then lead to all kinds of problems such as irritable bowel syndrome and having multiple food sensitivities, which then increases the antigenic load in Hashimoto’s.

Dr. Eric: Okay. One last question relating to the infections: do you take more of a natural approach, or do you prefer antibiotics, or does it depend on what type of infection?

Dr. Izabella: I’d say it depends on the person and it depends on the infection too. So whenever I write about it or I talk to clients about it I always want them to work with their own physicians and healthcare practitioners and I’ll give them a list of recommended therapies. So you may take a medication and then follow it with herbs, or you may take just the medication or just the herbs. I just give people some information on what some of the more effective ones that I know of and let them take this information to their doctor and make the decision on their own, because some people feel much more comfortable with antibiotics and others don’t feel comfortable with them at all. And there are certain infections that may not be susceptible to herbs, or it may take a really long time to eradicate them the herbal way of 2 to 3 months vs. 2 to 3 days on a medication.

So it’s different drugs for different bugs as I like to think of it.

Dr. Eric: I like that. Different drugs for different bugs. Thanks Dr. Izabella for answering these questions and I’m sure everyone found this information to be useful.

What I’d like you to do now is take a few minutes and talk about your excellent book, Root Cause. I’m sure many people reading this blog post have already read it, but I’m sure there are some who haven’t read it. So if you can talk a little bit about your book.

Dr. Izabella: Sure, and I think it has the longest title ever. It’s called Hashimoto’s Thyroiditis: Lifestyle Interventions for Finding and Treating the Root Cause. It’s available on Amazon. If you look for Hashimoto’s Root Cause or Izabella Wentz you’ll find it.

Basically it’s a patient guide to help people find out what the root causes and triggers may be and it gives people information on lifestyle changes they can start implementing on their own. So supplements they can take and different nutritional things they can do on their own, as well as more information so they can take it to working with doctors like yourself.

I think it’s really important for people to be empowered and be their own health advocates and be on board with what’s happening within their own bodies. And working with a physician is excellent but you don’t want the change to come from you because you can tell a person what to do and you have all this wonderful knowledge and experience with patients over so many years, but it’s really up to the patient to do it right in many cases.

Dr. Eric: Yes.

Dr. Izabella: To change their diets, to take that supplement and take that test. So the Patient Guide is all about how to figure out what’s going on with your body and the things you can do on your own to get yourself better.

I have a website too and its www.ThyroidPharmacist.com and I have lots of great information on there. I try to write a new blog post every week. I’m a big research nerd and so I’m always researching different types of infections and different root causes. As we both know, it’s not always the same thing for every person that triggers their Hashimoto’s but at the same time there are a lot of universal things that we can recommend that will help most people feel much better.

Dr. Eric: Great, and for anyone listening who hasn’t read her book I would definitely get it. I’m not saying that just because I’m interviewing you, but it is one of the best books I’ve ever read on Hashimoto’s. It’s one of those must reads for anyone with this condition.

Dr. Izabella: Thank you so much for that. I forgot to mention I also have a free book chapter if people go to www.ThyroidPharmacist.com/gift they can get the Nutrient Depletions and Digestions chapter and get a gluten free quick start diet as well as some recipes. When I first tried to go gluten free I did it all wrong. I was eating all this junk food and setting my blood sugar on fire.

Thank you so much for having me and I hope everybody found this information helpful.

Dr. Eric: Great and thank you again Dr. Izabella for sharing this information. Again, visit ThyroidPharmacist.com/gift for the free chapter in her book and ThyroidPharmacist.com for the weekly blog post. Then go to Amazon if you want to read the book which I highly recommend.

Again, thanks again for doing this interview. I thought it was great and I’m sure everyone has benefited from this information.

Dr. Izabella: Thanks so much Dr. Eric.

Dr. Eric: Thank you.

When someone gets a dental implant, it is commonly made out of titanium.  And titanium is also used in other procedures, as some hip replacements use titanium alloys.  While many people with these implants seem to do fine, some people have asked whether titanium can be a trigger for Graves’ Disease, Hashimoto’s Thyroiditis, or another autoimmune condition.

Before I answer this, you might wonder why titanium is commonly used in the first place.  One reason why it is commonly used is due to its high resistance to corrosion (1), which obviously is very important.  Another reason is because most people seem to have a low sensitivity to titanium when compared to other metals.  In fact, one study showed that all casting alloys seem to have a potential for eliciting adverse reactions in individual hypersensitive patients, although it listed titanium as being a possible exception (2).  However, as I’m about to discuss, some people do in fact react to titanium, and of course this can be a big problem for someone who has a dental implant, or titanium as part of a hip or knee replacement.

Why Is Titanium Problematic In Some People?

Although most people don’t have a problem with titanium implants, a small percentage of people are sensitive.  A clinical study involving 1,500 people who received dental implants showed that nine of these patients demonstrated a titanium allergy (3).  The good news is that only 0.6% of these patients experienced problems with the dental implants.  On the other hand, if titanium can lead to certain chronic health conditions, then even a small percentage o f negative reactions might be too high.  Another study involved fifty-six patients who developed clinical symptoms after receiving titanium-based implants, and 21 of these tested positive for a titanium allergy, with another 16 showing ambiguous results (4).  Sometimes someone will experience symptoms caused by these implants but they won’t make the connection, and many times their doctors also won’t be able to figure this out..

For example, a few years ago it was revealed that the actor Dick Van Dyke had experienced severe headaches which affected his sleep and caused chronic fatigue.  Over a seven year period he saw numerous healthcare professionals, received a CAT scan, MRI, and a spinal tap, along with other tests, but everything came back negative.  It wasn’t until his dental implants were removed that he finally received relief from his symptoms.

Once again, most people do fine with titanium implants.  But these patient experiences I mentioned show that in some cases, titanium can lead to severe symptoms.  In some cases the symptoms can be debilitating.  And many times people live with these symptoms for years before it is figured out that the problem is due to titanium.

Can Titanium Trigger Autoimmunity?

There is no concrete evidence that having titanium implants can trigger an autoimmune response.  However, this doesn’t mean that it’s not possible, as other metals such as mercury and nickel have been associated with thyroid autoimmunity (5) (6).  As a result,  if someone with Graves’ Disease or Hashimoto’s Thyroiditis was diagnosed with their condition after getting an implant which consisted of titanium, then this is a factor that should be considered.  Of course it can be difficult to make such a connection, as someone can be in the “silent” autoimmune stage for years, which means they might have elevated antibodies for many years, yet no positive tests or symptoms.  As a result, even if someone with an autoimmune thyroid condition began presenting with symptoms shortly after getting a titanium implant, this doesn’t necessarily mean the implant was responsible for the development of their condition.  With that being said, if you have a titanium implant and then developed an autoimmune thyroid condition, then it might be worth doing some testing to see if you have a sensitivity to titanium.

What Other Options Are There?

Before someone gets a dental implant, or a hip or knee replacement which involves titanium, it probably would be a good idea to get a metal allergy assessment along with some allergy testing.  Skin testing is an option, as the sensitivity of patch tests has been shown to be about 75% for a type IV metal allergy, although so far no study related to dental implant allergies has used this method (7).  A lymphocyte transformation test is another option, although false-positive results are possible (7).  There is also a Memory lymphocyte immuno-stimulation assay (MELISA) test (8), which can determine if someone has an allergy to a metal such as titanium.  In my opinion it should be routine to get such testing before getting a metal implant.

Another option is to use something else other than titanium.  Zirconia is a ceramic and is an option to consider.  It has been used to replace hip joints, and can also be an option to consider with dental implants.  However, even though one is less likely to be sensitive to zirconia, a sensitivity is still possible.  But if I were getting a dental implant I probably would choose a zirconia implant over a titanium implant.

In summary, although many people do fine with titanium implants, there are some people who have a titanium allergy.  And in some cases titanium can cause severe symptoms.  Although there is no research which shows that titanium can trigger an autoimmune thyroid condition such as Graves’ Disease or Hashimoto’s Thyroiditis, if someone received a titanium implant and then developed an autoimmune thyroid condition, it might be a good idea to do some testing to see if they have a sensitivity to titanium.  For those who are sensitive, zirconia can be an alternative option to consider.