hashimoto’s€™s.pdfthyroid gland, leading to alternating states of tissue breakdown and...
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www.flourishmd.com 320-424-0771
Hashimoto’s
Not just about the thyroid
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Thyroid Basics
● Thyroid is a regulatory organ - hormones regulate many things in the body
● Thyroid hormones affect most tissues● Too little thyroid hormone→ sluggishness of the metabolism and
processes. Hypothyroid○ Treat with thyroid medications
● Too much thyroid hormone → hypermetabolism. Hyperthyroid○ Kill the thyroid gland - Radioactive Iodine. Then treat resulting hypothyroid.
● Both often caused by an autoimmune response/destruction.● Both cause symptoms and diseases
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Hashimoto’s
● Autoimmune destruction of the thyroid (>90%) ● This leads to hypothyroidism (7 years)● This is the typical “low thyroid” that almost everyone has● Generally treated with thyroid medication● Autoimmune destruction continues● Highly associated with celiac disease (same gene sequence - HLA DQ)
○ Also the same as CIRS
● Most are women aged 20-60○ Becoming younger and younger at diagnosis
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Stages of Autoimmunity
● Stage 1: Silent autoimmunity○ Elevated TPO and/or thyroglobulin antibody (anti-thyroid antibodies) with no symptoms
or loss of tissue
● Stage 2: Autoimmune Reactivity○ Elevated TPO and/or thyroglobulin antibodies with symptoms and normal TSH
● Stage 3: Autoimmune disease○ Elevated antibodies with symptoms, measurable tissue destruction, and elevated TSH
Important to pick it up and address in early stages.
Check your kids yearly if you have Autoimmune thyroid disease
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Important notes
● There is no perfect replacement○ It has to be individualized
● Replacement isn’t the final treatment○ Very necessary part of the process - but the autoimmune has to be addressed
● It is actually treating the autoimmune process that is key● Need to check antibodies - not just TSH
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Antibodies
● Antibodies are created to kill pathogens and foreign bodies● Antibodies tell us what the body has recognized as foreign● Autoimmune means immune killing of self● Autoimmune thyroiditis - Hashimoto’s - immune destruction of thyroid
○ Often has other processes at the same time - brain is the primary
● Anti-thyroperoxidase (anti-TPO, TPO Ab) - 95% Hashi - rare in controls○ Best marker!
● Thyroglobulin Ab (TgAb)○ Positive in 60-80% Hashimoto patients
● Thyrotropin receptor Ab - activating, blocking or neutral
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Antibodies
● Anti-TPO - ○ 90% Hashimoto’s will have this - primary marker○ 75% Grave’s Disease○ 10-20% nodular goiter and cancer○ 10-15% of normal can have this
● Activating thyrotropin Ab - Grave’s/hyperthyroid● Antithyroid AB’s - increase subfertility, miscarriage, pre-term births● See Ab’s prior to clinical disease - best time to take action
○ Antibody levels are not associated with the severity of disease○ But they will go up and down from baseline
● Ab’s themselves don’t destroy tissue - They bind to bad T-cells - NK cells → destroy the thyroid (so destruction is about T cell - not Ab level)
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Hashimoto’s
● Not just a thyroid disease!● It is a multi-system disease with numerous vicious cycles and must be
managed as a multi-system disorder● You cannot expect resolution of all symptoms with thyroid medication
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Fluctuations TSH● Consider checking every 3 months if there are symptoms of instability● Check every 6 months overall● Check TSH but also antibodies● Get baseline level of Ab’s.
○ Then watch for changes (more stable than TSH)
● TSH can fluctuate with relapsing and remitting AI reactions against the thyroid gland, leading to alternating states of tissue breakdown and changing in circulating thyroid levels
● TSH can be low (<1) - episodes of hyper○ In active phases of destruction of the thyroid gland○ Releases excess T3/T4 when destroyed ○ Flare of tissue destruction causes hyperthyroid s/s - anxiety, insomnia, etc..
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Hashimoto’s
● There is no cure● You can go into remissions - but realize it can flare at times● Remission/reactivations● All AI diseases are incurable - but goal long term remission● We need to control it once genes turned on ● Monitor symptoms - understand labs - what to do● Big picture
○ Triggers, treatments
● Important for you to know when it seems to be triggering as soon as possible
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Clinical Considerations with Hashimoto’s
● Is the autoimmune reactivity stable?○ Fluctuating between hyperactivity and hypoactivity
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Clinical symptoms thyroid overreactivity
● Tremor - hold hands straight out - put paper on them○ Slight shake
● Brisk reflexes● High heart rate - > 100
Due to:
● Acute thyroiditis flare (destruction leads to thyroid hormone escape)● Uncontrolled hashimoto’s● Excess thyroid replacement
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2 Key Pathophysiological and Alternating Responses
● Fluctuating release of thyroid hormones from tissue breakdown● Fluctuating conversion rates (T4→ T3)● Thyroid hormone replacement fluctuations
○ How it’s metabolized○ How it’s converted○ Microbiome○ Binding
● Fluctuating thyroid receptor responses○ Inflammation at the receptor site
All lead to fluctuating hyper and hypo activity
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Fluctuating inflammatory and Autoimmune responses
● Inflammation● Immune dysregulation● Immune suppression● Autoimmunity
These feed each other, create vicious cycles
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Unstable Hashimoto’s
● Hard to find the perfect replacement● Increased metabolic activity● Hard to control● This is not a good sign● There are active environmental and AI triggers that need to be
addressed
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Clinical Considerations with Hashimoto’s
● How aggressive is the autoimmune thyroid response?○ How often are we increasing dosage
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Etiology of Hashimoto’s
● Combination of factors● Environment:
○ Smoking, alcohol, drugs○ Selenium, Vit D○ Iodine○ Stress, infections
● Genes:○ TSHR, TG ,HLA, CTLA4, and many more
● Essential factors:○ Female sex○ Parity
● This has escalated due to food chain, microbiome changes, toxins and more
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Potential dietary triggers after the gene is turned on
● Gluten● Sodium intake● Iodine● Lectins● Lack of dietary diversity● Glyphosate-rich foods● Pro-inflammatory diet● Grains● Casein● Albumin● Dietary protein cross reactivity
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Potential lifestyle triggers after the gene is turned on
● Insomnia● Sedentary lifestyle● Overtraining● Smoking● Alcohol● Drug use● Lack of rest● Unhealthy relationships● Stress
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Potential chemical triggers after the gene is turned on
● Bisphenol-A (plastics!!!) - huge trigger!!● Pesticides● Air pollution● Fire retardants● Benzene● PCBS● PBDE● Perchlorate● Mercury
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Potential pathogen triggers after the gene is turned on
● H Pylori● Toxoplasma Gondii● Yersinia enterocolitica● Candida● Hepatitis C● Epstein-Barr Virus● Cytomegalovirus● Herpesvirus-6● Parvovirus B-19● Borrelia Burgdoreferi
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Complex web/knot
● There is no 1 protocol● Everyone is different with various triggers, starting places● The web is dynamic and changes
○ The starting point may be different with different flares
● We need to untangle the web looking at all the factors/triggers● We need to address the damage done along the way● Not caused by a single nutrient deficiency
○ Cannot supplement out of this!!
● Need to check lifestyle, environment and pathogens● Pick top targets - and then peel away layers
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Clinical Priorities
● Is the thyroid disease stable or fluctuating between hyper and hypo?● Do you have appropriate thyroid replacement?
○ Do not want high TSH
● What obvious triggers can you identify?○ Lifestyle○ Food proteins○ Dysglycemia○ Antigens○ Chemicals/pollutants
● What nutritional strategies can you use to reduce thyroiditis?● What mechanisms are impacting immune tolerance?
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Webs
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Multiple “webs” for each system affected
Each system that is affected by thyroid can be impacted in multiple ways and interconnect
We will look at each to determine what co-existing issues that may need to be addressed
Take notes on those systems/webs/issues within that seem to affect you
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Immune-thyroid web
● All Hashimoto patients have this issue● Thyroid is key for immune function● Can’t untangle the web if in a hypothyroid state (high TSH)● Need replacement first!● Thyroid hormones calm the immune system, the autoimmune response,
and inflammation● Thyroid hormones modulate every cell in the immune system● Expect a honeymoon phase● Hypothyroid → worsens oxidative stress, worsens leaky gut● Check regularly! Take hormones
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Web of Hashi and Immune System
● Need to remove triggers then focus on the web● Can’t just focus on the gut - need to look at the whole web● Suppressed SigA - more vulnerable to food allergies, pathogens, toxins● Autoimmune - significant decrease in antioxidant production
○ Superfoods○ Exercise○ Sleep○ Give Antioxidants
● Blood brain barrier is important!
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Clinical considerations For Hashi-immune web
● Are there any patterns of aggressive thyroiditis (thyroid swelling)?○ Hard to swallow, hoarseness, swelling over gland→ if positive - active!
● Are there any patterns of active infections?○ Check CBC, panels, infections. Can affect intestinal permeability, decrease antioxidants
● Are there any patterns of immune suppression?○ Total WBC <4 (Can get T and B cell profile). Cyrex Array 12
● Are there clinical findings of impaired antioxidant status?○ Workout - don’t recover well○ Chemical sensitivity (no reserve)○ Chronic pain and swelling
● Are there any patterns of immune barrier breakdown? (Array 2, 20)○ BBB - brain fog, Gut - reacting to food, Lung - respiratory issues, cough with a deep
breath
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Clinical considerations For Hashi-immune web
● Are there any patterns of autoimmunity in any other tissue?○ Lab screen - cyrex 5
● Are there any clinical findings of immune compromise by chemicals?○ Measure if needed○ Timelines○ Non-metals affect thyroid (BPA/plastics, pesticides, flame retardants)○ Array 11
● Are there any findings of impaired immune tolerance? ○ How a person responds to a stressor○ Intolerance to smells, jewelry, products, MCS, skin outbreaks
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Hashimoto’s and the Brain
● Many develop early neurodegeneration and brain inflammation○ Source chronic fatigue and depression
● This needs to be addressed even when in remission○ Significant brain inflammation○ Autoimmune to the brain
● There is now separate AI reactions in the brain to be addressed○ TPO Ab can bind in the brain - cerebellum. Increased inflammation and then
degeneration.○ Myelin protein Abs common in Hashi○ High cytokine in the brain
● Hashi is not just thyroid - also the brain!
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Cerebellar degeneration
● Depression, brain fog● Check rhomberg, ataxia (truncal)
○ If ataxia or other signs - brain is in trouble
● Cerebellum - muscles, vestibular proprioception, initiating cognitive tasks
● Check antibodies to the brain
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Cerebellar Degeneration
● TPO binds to the cerebellar tissue - can destroy the tissue● Gluten also does● Car sickness - is it getting worse?● Hashimoto’s almost always affects the thyroid and cerebellum
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Hashimoto’s Encephalopathy
● Significant issues with brain damage due to AI reaction● Not common but important to recognize● Responds to corticosteroids!
○ May add IvIG
● Relapsing-Remitting or Chronic Progressive● Higher anti-TPO● Exclusion of other diseases (lab, MRI)
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Clinical Considerations for the Hashi-Brain Web
● Are there any clinical findings of cerebellar degeneration?● Are there any clinical findings of autoimmune demyelination of the
central nervous system?● Are there any clinical findings of autoimmune demyelination of the
peripheral nervous system?● Are there any clinical findings of peripheral nerve entrapments from
tissue swelling? (Carpal tunnel)● Are there any clinical findings of neurovascular entrapments from tissue
swelling? (Thoracic outlet syndrome)● Are there any clinical findings of neuroinflammation or microglial
priming?
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Clinical Considerations
● Are there any clinical findings of blood-brain barrier permeability?○ Leaky brain
● Are there any clinical findings of impaired plasticity?○ Can’t learn new or coordinated motor skills, struggle with cognitive skills, memory
● Are there any clinical findings of disrupted synaptic activity?○ Mood disorders, depression, anxiety (Neurotransmitter pathways)
● Are there any clinical findings of Hashimoto’s encephalopathy?
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Hashimoto’s and the Microbiome/GI System
● Microbiome and thyroid interact bidirectionally○ Both affect the other
● Gut microbiome is different in Hashimoto patients○ Less diversity○ Often have bacterial overgrowth
● Oral tolerance is directly related to diversity of the microbiome● High rates gallbladder issues (sludge/stones) → malnutrition → can’t
absorb fat soluble vitamins● Bile acids help modulate microbiome.
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Clinical Considerations for Hashi-GI Web
● Are there any clinical findings of impaired intestinal motility (constipation)○ Chronic constipation, Hx SIBO○ Need to use magnesium or laxatives for having BM’s○ Fiber supplements make GI symptoms worse
● Are there any clinical findings of intestinal permeability?○ Category 2 on metabolic form○ GI: Increased reactions to food, Chronic GI symptoms (diarrhea, pain, bloating), IBD○ Non GI: Autoimmunity, Chronic pain, chronic depression, CFS, Multiple food
sensitivities
● Are there any clinical findings of malabsorption syndromes?○ Discuss later
● Are there any clinical findings of gallbladder dysfunction?○ Category 8. How would a very greasy or fatty meal make you feel?
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Clinical Considerations for Hashi-GI Web
● Are there any clinical findings of digestive enzyme impairment?○ Unable to digest high protein meals → HCL need○ Unable to digest high fiber or starchy meals → pancreatic enzyme need○ Unable to digest fatty meals or tolerate fried foods → Pancreatic lipase and GB
dysfunction
● Are there any clinical findings of dysbiosis or microbiota imbalances?● Are there any clinical findings of reduced microbiome diversity?● Are there any clinical findings of intestinal infection?
○ Red flags: Acute change in symptoms, Eosinophil - >3%, Gi panel
● Are there any signs of intestinal autoimmunity? Cyrex 5○ Nothing seems to fix it - has tried many things
● Are there any clinical findings of SIBO? Category 7
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Hashi and Blood Sugar Issues
● Most overlooked issue with Hashimoto’s● It is a main trigger!● Hypoglycemia and/or insulin resistance
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Dysglycemia
● If you can manage this - will calm the AI response○ Can improve up to 50% with this
● Hyperglycemia and hypoglycemia → oxidative stress, inflammatory markers○ Cerebral cell death○ BBB permeability
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Clinical considerations for Hashi-Glycemic Web
● Are there any clinical findings of hypoglycemia? Category 10● Are there any clinical findings of insulin resistance? Category 11● Are there any clinical findings of mixed patterns of both?
○ Energy after meals, fatigue after meals, both
● Are there patterns of dysglycemia induced by lifestyle, diet or other factors?○ Meal and snack type - skipping meals
● Are there any patterns of pancreatic autoimmunity (Type 1, LADA)? Array 5○ Fatigue after meals, weight change, increased thirst, urination, appetite. Labs +
● Are there any patterns of adrenal autoimmunity (21-hydroxylase Ab)● Are there any patterns of advanced glycation end products (A1C)?● Are there any clinical patterns of post-prandial dysglycemia?
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Hashimoto’s and Hepatic Function
● Thyroid hormone metabolism entirely depends on a healthy liver ● A biologically healthy liver is crucial for the well being of thyroid
hormone● If we hurt the thyroid → hurt the liver
○ Antithyroid drug therapy -> hepatitis, cholestasis, damage of liver
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Clinical considerations for Hashi-Hepatic Web
● Are there any clinical findings of chemical burden?○ Toxin testing (metals and non-metals, Toxic Core, Cyrex 11 (Ab)
● Are there any clinical findings of impaired biotransformation?○ Category 9
● Are there lab elevations of ALT, AST?● Are there lab elevations of cholesterol and lipoproteins (LDL, HDL,
VLDL)?● Are there elevations of bilirubin or creatinine on blood tests?● Are there any clinical findings of chemical-induced inflammation?
○ Symptoms inflammation/pain/swelling, elevated CRP and ferritin
● Are there any clinical findings of liver disease?
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Hashi and the female hormone system
● Autoimmune thyroid disease occurs in 18-40% of PCOS women● Infertility in Hashi - 47%
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Clinical considerations for Hashi-Female Endo Web
● Are there any clinical patterns of flare-ups associated with the menstrual cycle?○ PMS, pelvic pain (hormone spikes can trigger an AI response)
● Are there any patterns of thyroid symptoms after taking oral contraceptives?○ BCP increase TBG - decreases free thyroid available
● Are there any patterns of thyroid/autoimmune flare-ups with hormones?● Are there any patterns of dysmenorrhea or amenorrhea?
○ Fixing glucose can help this alot
● Are there any patterns of hormonal fluctuations with perimenopause?
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What to do?
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So what do we do?
● Level 1 interventions○ Diet○ Nutraceuticals○ Lifestyle○ Hormone replacement
● Level 2○ Personalized autoimmune plan based on your web and triggers○ This will be dynamic, changing, and fluid○ It will build upon itself○ Re-evaluate often
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Level 1 recommendations
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Iodine
● Hashimoto’s is not caused by an Iodine deficiency!● Normal consumption of food is enough iodine● Iodine can actually cause flares of Hashi/AI reactivity● There is absolutely no research to support giving Iodine● 2011 - “Excessive iodine intake is a well-established environmental factor
for triggering thyroid autoimmunity” - Current Genomics● “Iodinated thyroglobulin is responsible for triggering the autoimmune
process….exposed to prolonged iodine supplementation” - 2007● Excess iodine promotes thyroid cell death● Increase in all thyroid issues with increasing iodine intake
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Iodine
● Iodine increased in China - increased TPO Ab● “Iodine may change the natural course of autoimmune thyroiditis,
resulting in a more rapid progression towards hypothyroidism” - Journal Endocrinology
● Slovenia - increased I in kitchen salt from 10mcg->25mcg○ Hashi more than doubled○ Turned on the genes of susceptible people
● Study - 78.3% hypothyroid patients with HT - returned to normal thyroid function with only iodine restriction within 3 months○ Less than 100/ug/day○ Table salt has more than this in a tsp.
●
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Low-Iodine Diet - try 3-4 weeks (esp if stuck)● No iodine in salt (use Sea salt)● Seasoning mixed with with iodized salt● Onion salt, garlic salt, or seasoned salt made with iodized salt● Seaweed, most seafood (except fresh water fish)● Any food with iodates, iodides, algin, alginates, carrageen, agar● Commercial bread and bakery products with calcium iodate, potassium iodate● Milk and milk products● Egg yolks● Check your minerals or multivitamins for Iodine - stop● Food, pills, capsules with Red Dye #3● Restaurant and processed foods● Soy products - edamame, tofu and soy burgers (Boca)
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Goitrogens
● Foods - cassava, lima beans, linseed, sweet potato● Cruciferous vegetables such as cabbage, kale, cauliflower, broccoli,
turnips, rapeseed● Tremendous benefits for Hashi patients!!!● Testing in vitro (test tube) - goitrogen● Testing in human - shows benefit● No disruption T3 or T4 output● Benefits due to combating oxidative stress
○ Helps glutathione production (master detoxer) - protects thyroid
● Chemical goitrogens (pollutants) are harmful
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Gluten
● GF diets shown to decrease titers, AI response, T3/T4 doses, and increases Vit D
● Celiac - High T cell response and devastation to gut wall and inflammation
● Gluten sensitivity - also problematic● If you have celiac - GF diet can be profound● Gluten sensitivity - GF diet is very helpful● Wheat germ agglutinin directly cross reacts with TPO - so may be
another reason to be GF (Array 3X)
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Lectins
● Can have cross reactivity with TPO● This causes a TPO Autoimmune reaction● This can lead to thyrocyte destruction● We can check this with Cyrex Array 10● Cyrex Array 3X - Wheat Germ Agglutin - tells us also● Not all react to lectins
○ Can do a trial off○ Check labs
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Autoimmune Protocol
● Improved vitality, physical and general health at 10 weeks● CRP decreased● WBC went to normal● Can be helpful if you are stuck● Most will do GF/DF → AIP (with nightshades) → AIP without nightshades
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Specific Dietary Protein Cross-Reactivity
● Cross reactivity can occur between dietary proteins and human tissue due to molecular mimicry○ Have similar amino acid sequences
● If you have Ab’s to tissues - food can mimic this○ Only happens if you have auto-antibodies
● AIP diet first● Cyrex 10 if not better and remove possible cross reactive foods
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Microbiome Diversity
● Studies show less diversity in HT patients● Bacterial overgrowth also common● Dietary fiber diversity = microbiome diversity● Don’t eat the same foods over and over!!● With some of the food restrictions - it is common to eat the same foods
○ Don’t do this!!
● Veggie mash-up○ But many vegetables, herbs - Wash - Food process - final product of each○ Combine into different mixes - freeze in glass jars○ 2 Tbsp daily○ Kale (3 types), broccoli, parsley, cilantro, dandelion greens, cabbage, beet tops, celery,
mint, ginger, carrots, yellow beets, radishes…..
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Immune Tolerance - microbiome diversity
● If you are limited - need to focus on immune tolerance (program to come)○ Dr. Kharrazian’s 3D immune tolerance program
● SCFA (short chain fatty acids)○ Butyrate, proprionate, and acetate - fuel to the microbiome and T reg cells
● Fibers - help diversify bacteria○ Guar gum, pectins, flaxseed bran, cellulose gum, psyllium
● Critical for AI issues - microbiome diversity
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Sodium Intake
● An immune response occurs from excess sodium○ Increased inflammation○ Decreased T regulatory cells needed to dampen inflammation○ Increases cytotoxic T cells
● Try not to eat too much salt (and definitely not table salt)● Use potassium with a salty meal (blocks the bad effects)
○ 1000mg with the meal
●
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Blood glucose
● Need to manage this● Hypoglycemia - feels better after eating● Insulin Resistance - feels tired after eating● Mixed - can be either/varies● Hypoglycemia: No missed meals, avoid sugar and limit carbs, small
portions○ Don’t do fruit smoothies, no hangry episodes
● Consider ketogenic and IF if Insulin R issues
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Lifestyle
● Stress○ Affects turning genes on and also reactivation
● Sleep○ T4, T3 decreased and rT3 increased significantly with sleep deprivation○ OSA - increases risk AI disease
● Exercise○ Keeps metabolic balance, influences AI status○
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Hormone Therapy● Consider many options - don’t get stuck in one● Focus patient symptom relief and labs - not just labs● Consider T4 vs combination based on patients
○ Synthetic vs. non-synthetic - either may work just fine○ If tissue breakdown is too high - T3 can be very stimulating and not tolerated
● Brand name synthetics:○ T4: Synthroid, levothroid, levoxyl, unithroid, Tirosint○ T3: Cytomel○ T3 and T4: Thyrolar
● Brand name Bioidenticals (fixed doses)○ Armour, Westhroid, Nature-throid, NP thyroid
● Generic T4: Levothyroxine, L-thyroxine● Generic T3: Liothyronine Generic T3/T4: Liotrix Bioidentical:
Dessicated
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Treatment of hypothyroid with hormones
● Decreases oxidants and increases antioxidants● CRP and inflammation improved● Decreased antibody levels● Need to check often in unstable Hashimoto’s (every 3 months)● Others need to check every 6 months
○ Don’t want to be hypothyroid!○
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How to pick treatment?
● T4 monotherapy or T4/T3?○ Patient dependent○ T4: Covered by insurance, not bioidentical, Tirosint gel (no fillers), more tolerable in
aggressive disease○ T3/T4: Typically not covered, can support impaired conversion, can support those with
greater need T3
● Go on signs and symptoms● rT3 high - may be better with combination if tolerated● Don’t expect hormones to correct weight, or make you go into remission● The goal is to normalize TSH (not be hypothyroid)
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Synthetic Vs. Bioidentical
● Synthetic: ○ Covered by insurance○ Used for those who cannot tolerate T3○ less reactivity to those that have autoimmunity against T3,T4, ○ Cytomel available for T3 (easier to dose seperately)○ Liotrix/thyrolar - combination
● Bio-identical:○ Not covered usually○ Cannot be used by those sensitive to T3○ More reactivity to those with AI for T3, T4
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Thyroid absorption concerns
● Celiac not treated - malabsorption and many GI issues that impact● General appearance of malabsorption:
○ Dry unhealthy hair and scalp○ Pale skin, dry or flaky skin○ Loss muscle mass
● Clinical red flags on labs for malabsorption○ Low cholesterol (<150) → significant malnutrition○ Anemia → Iron, B12, or internal bleeding○ Low albumin → Protein malnutrition○ Vit D deficiency → Fat soluble-vitamin and or/D malabsorption○ Low platelets → Fat soluble vitamin and/or K malabsorption
● Vitamin C with thyroid - can improve absorption!! (helps with GI issues)
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Reactions to fillers?
● Many fillers in tablets/capsules to hold it together● Modified wheat starch (glutenfreemeds)● Lactose monohydrate, dyes, confectioner’s sugar, microcrystalline
cellulose● BHA, Talc, Croscarmellose sodium, calcium phosphate, silicon dioxide● Mannitol, Mg stearate, acacia, sucrose, povidone, Sodium lauryl sulfate● Some will react to these or the gelatin of the capsule (Cyrex)
○ Those with significant food and chemical sensitivities○ Forget meds awhile and feel better??
● Gel has no fillers - Tirosint (T4, gelatin, water, glycerin)● Tirosint also has liquid - if sensitive to gelatin
○ Better absorption overall
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Autoimmune reactivity to thyroid hormones?
● If the AI reactions are severe - may create reactivity to T3, T4● This can make it hard to tolerate at all● If this occurs - synthetics are often easier to tolerate
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Correct Dosing
● Important in management of thyroid● Both excess and insufficient thyroid hormone may produce adverse
effects in various target tissues● Very important to manage high TSH (hypothyroid)● Also important to manage a hyperactive response (too much overall or
too much T3)
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How often to evaluate labs?
Patient dependent
● 1. Is the thyroid autoimmune reactivity stable?○ Or fluctuating between hyper and hypoactivity
● 2. How aggressive is the autoimmune response○ Is there a constant need to increase dosage
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Triggers and Nutriceuticals
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Pathogens
● We don’t generally start with pathogen finding and treatment unless there are clinical indications such as abnormal lab work or a clear history that pathogens are an issue
● Could spend $1,000s ● Could chase your tail and not focus on main immune issue● H.Pylori - may want to screen- esp. With symptoms - stool● Hep C - fatigue, fever, muscle aches, L sided abdominal pain● Candida - serum Ab’s are best testing/OAT● Parasites - can be helpful/dormant/or active
○ If inflammatory markers on stool - may be active and treat!
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Supplements
● Vitamin D - check levels (ideal 50-100)○ Vitamin D helps decrease inflammation, helps immune tolerance, metabolic balance,
repair..○ Many have low D and hard to raise (genes, inflammation, malabsorption gut)○ Dose 10,000 - 50,000IU per day
● Selenium - essential○ Helps the immune system, increases glutathione, improved inflammation, improved
markers● Magnesium
○ Needed for function, mitochondrial function and more! ○ Often low if taking diuretics
● Myo-inositol○ Regulates oxidation for thyroid hormone generation○ 600 mg twice daily (with selenium 83 mcg twice daily)
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Supplements
● Glutathione ○ Master detoxer, decreases inflammation, decreases autoimmunity
● These can be individualized for symptoms and the web
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Level 2 - Webs and triggers
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Environmental Pathogens
● Viruses can directly infect the thyroid → painful thyroiditis○ Pain and swelling○ Can get alot of thyroid release and hyperthyroid symptoms
● Viruses can turn on the immune system → Ab’s and inflammation → flares auto-Ab’s → painless thyroiditis
● Pathogen reactions:○ Thyroid gland swelling
■ Difficulty swallowing■ Neck mass sensation■ Hoarseness■ Painful or painless
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Pathogens associated with Hashimoto’s● Cosmetic/Therapeutic: Botox (high link to AI thyroid - mimics TPO AB)● GI Pathogens:
○ H. Pylori - most common infection. GERD/ulcers/asymptomatic. Can spread families.○ Toxoplasma gondii - can be benign - but if s/s - address. Neg Ab/PCR - in the gut only○ Yersinia enterocolitica○ Candida
● Viral pathogens:○ Hepatitis C - very common○ EBV - Can be cause or flare○ CMV - can get a thyroid flare with active EBV/CMV○ HHV6 - Everyone has had. Re-activation with PCR, fever, roseola, seizures → HT○ Parvovirus B19
● Spirochete: Borrelia Burgdorferi
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Environmental pollutants
● Rising in number● Autoimmune thyroid and thyroid cancer continue to rise● Pathway 1: Chemicals that act as Goitrogens
○ Goiter caused by increased TSH or GH (hcg)○ Interrupt thyroid hormone production → increased TSH → goiter○ Many chemicals - PCBs, phthalates, DDT and more. ○ Iodine, lithium, antifungals, bromine and flourine
● Pathway 2: Chemicals that disrupt thyroid signaling pathways○ BPA!!!!!!!! BPA free is BPS - even worse. Avoid all plastic!! Even a lid on coffee
■ Cutting BPA almost as serious as cutting gluten!○ Also phthalates, perchlorate, pesiticides
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Toxins
● Pathway 3: Chemicals that promote AI thyroiditis○ 28% increase HT with glyphosates○ Glyphosate binds and changes the wheat - HLA-DQ with HT and celiac○ Many grains have increased pesticides and glyphosate
● AIP diet - may help because of pulling grains and thus decreasing glyphosate
● BPA - TPO positivity, destroys thyroid cells, increased thyroid cancer● Toxic metals - lead, cadmium
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Toxins
● We all have chemicals in our body and exposures● Pull the web slowly
○ Chelation too early can be harmful○ Often we address this later - unless the s/s started after acute exposure
● Work on toxins that you can● Toxin course● Pull all plastics!!● Look at clinical considerations
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Clinical considerations - toxins
● Ongoing exposure that can be avoided○ BPA, fire retardants, carpets, etc..
● Biotransform and metabolize chemicals?○ Thyroid needed for phase II - support phase I and II○ Check Phase II: High homocysteine/MTHFR, sulfation, etc..
● Do you have proper AO reserves to protect against free radicals?○ Exercise response? Chemical exposure response?
● Permeability issues?● Increased load - can test this● Chemical-immune reactivity? Can test for AB to chemicals
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Clinical considerations - pathogens
● Active infection? Lab work. May be a priority if active● Are there patterns of silent infection?● Can it be eradicated by medicine?● Are there strategies to improve immune function to eradicate the
pathogen?● If not sure - decide together if these are initial targets or later.
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Overview
● Look at the big picture first● Draw out your web - specific to your symptoms and findings● Decide where to start and order to address issues
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5 initial considerations
● Is the thyroid autoimmune reactivity stable?○ Varying from hypo to hyper?
● How aggressive is the AI thyroid response?○ Increasing dose steadily - yearly or more
● Does the patient have cerebellum cross-reactivity?● Does the patient have AI reactivity in any other tissue?● Are there any medication interactions with the thyroid gland?
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Physical Exam
● Hair thinning○ Insulin and inflammation
● Thinning of lateral third eyebrow● Facial swelling● Hand swelling/carpal tunnel● Signs of poor circulation
○ Pale nail beds, weak nails, fungal toenails
● Cold hands and feet (can check temps)● Capillary refill● Thyroid swelling/goiter/nodules●
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Next - Assess the web - Metabolic Assessment Form
● Category 1 - Dysbiosis● Category 2 - Intestinal permeability● Category 3 - Loss of immune tolerance● Category 4 - HCL need● Category 5 - Gastric ulcer symptoms● Category 6 - Pancreatic Enzyme Need● Category 7 - SIBO● Category 8 - Gallbladder sludge/stone● Category 9 - Impaired hepatic biotransformation● Category 10 - Hypoglycemia● Category 11 - Insulin Resistance
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Metabolic Assessment
● Category 12 - Underactive Adrenal Function● Category 13 - Overactive Adrenal Function● Category 14 - Electrolyte Imbalance● Category 15 - Low Thyroid Function● Category 16 - Hyperactive Thyroid Function● Category 17 - Prostate (males)● Category 18 - Andropause symptoms (male)● Category 19 - Perimenopause (female)● Category 20 - Menopause (female)
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Overall Care
● Dynamic and changing ● We will try things which may or may not work● Take a new approach● Dig into triggers and pathways as we go● Must understand the big picture and what to tackle first● Must continue to be vigilant and monitor● Understand this is not just about thyroid medication● There will be relapses and remissions
○ Goal is you recognize them early
● Goal - longest remission possible with minimal symptoms● Must be out of hypothyroid state first - then triggers and web
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Summary
● Thyroid gland recommendations● Lab and special testing ● Lifestyle recommendations● Dietary recommendations● Supplement recommendations
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Apex Energetics
● Dr. Kharrazian● Made in the US, with US products● Verified dairy and gluten free● Temperature controlled●
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Thyroid Wellness
● Thyroxal○ MVT for Hashimoto’s - without Iodine!○ A,D,B5,Mg, Selenium and more○ 45 days (90 tabs) - $20
● Thyro-CNV○ Helps with the conversion T4-->T3 (5 deiodinase enzyme)○ Good for those on T4 only or T3 is in the lower range○ 45 days (90 tabs) - $20
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Glutathione (master antioxidant)
● OxiCell - Cream over the thyroid (pain or swelling) - $24○ Massage in for a minute or two○ With or without essential oils
● Trizomal Glutathione - $37○ NAC and Glutathione○ Acetyl form glutathione is better absorption○ Liquid - able to titrate easily○ 10 ml three times daily to start → down to 1-2 times daily
● AC-Glutathione - $31 (month)○ Capsule for travel, work, when can’t have liquid
● Glutathione recycler - $20 (month)○ Helps to increase glutathione in the cell
● Use oxicell, trizomal and recycler if significant AI flares
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Gluten
● GlutenFlam○ Many have issues - so important to decrease reaction○ Digestive enzymes to break down the gluten peptide (specific)
■ Peptides are damaging - once broken down - it is not○ Botanicals to decrease intestinal inflammation○ 1-2 every few hours after exposure until feeling better○ $22
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Intestinal Permeability
● RepairVite (continue once healthy) $26○ L-glutamine, DGL, Aloe, and others to soothe and heal the GI tract
● RepairVite● RepairVite GT - adds ginger● RepairVite SE - for those with many intolerances - $23
○ SIBO, extreme sensitivity
● RepairVite Program available - food program with the product
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Blood Sugar Issues - hypoglycemia
● Eat more frequently● Eat more protein and fiber vs. carb meals and snacks● Proglyco SP - $22 month
○ MVT/mineral 1-2 with each meal - amino acids - glandulars and other to help BS
● Adaptocrine - $20 (45-90 days)○ Synergistic herbs for adaption, cortisol and other BS support
● AdrenaStim - for low BP/dizziness - $24○ Licorice cream. Helps retain sodium - helps BP
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Blood Sugar Issues - Insulin resistance
● Fibromin - $15○ 1-2 with meals - slows the glucose uptake to decrease sugar spike
● Glysen - $26○ 1-2 with meals up to 3-4 with a meal○ How many does it take to not get tired after a meal?○ If not helpful - add glycoberine
● Glycoberine● Glycoberine MX
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Biotransformation
● Support the pathways - 2-3 weeks initially● Everyone should do this 1-2 x a year for 3 weeks● ClearVite
○ Phase I,II, minerals
● -CLA - collagen for the protein● -PSF - vegetarian version - no collagen. Pea protein
○ So not good with lectin issues
● -GL - no protein at all
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Immune Support
● X-Viromin○ TH1 Support - T cells, NK cells○ Astralagus, echinacea, mushrooms, pomegranate
● X-FLM○ TH2 Support - B cells○ Green tea extract, Grapeseed extract, Resveratrol
● Autoimmune patient - with a virus - do both● Some have trouble with 1 or the other - check history
○ Try one and then the other○ There are small bottles to try 1st
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Other:
● GI Synergy○ Pathogens GI
● Turmero Active ○ Turmeric
● Resvero Active○ Resveratrol
● Both - 10 ml 1-3 times a day initially ● Someone with a lot of inflammation and oxidants
○ Use both plus X-FLM
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Immune Modulation
● Enterovite - SCFA○ Helps microbiome, energy, T reg cells○ 4-5 capsules 1-2x/day
● Enzymix Pro○ Digestive Enzyme
● Liquid A and D if higher doses needed● Strengtia
○ Probiotic with most common needed for the gut
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Cyrex Panels
● 2 - Intestinal Permeability $195● 3x - Wheat and gluten $269● 4 - Gluten Cross Reactive $225● 5 - Multiple autoimmunity $575● 6 - Diabete AI $175● 7 - Neuro AI $275● 7x - Neuro expanded $430● 8 - Joint AI $195● 10 - Food $469● 10: 10-90 Food $299
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Cyrex Panels
● 11 - Chemical $295● 12 - Pathogen $379● 14 - Mucosal $339● 20 - BBB $225● 22 - IBS/SIBO $259
With an order: Get the following at this price
10 - $399, 10-90 - $269, 20 - $175
2,3,and 4 - $595
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Keto and Fasting
● Needs to be entered into cautiously for those with hypoglycemia● Ketones dampen anti-gliadin cells and autoimmune reactions● Autophagy - clears out the bad
○ IF helps this
● 3 day fasts - rid of brain debris and are the best once worked up to
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