I regularly read through recent literature on autoimmune thyroid disease/Hashimoto's. I post about each of these studies on instagram as I review them and put it all together on this blog twice per year. 

You can use the categories located to the right of this post and click 'Hashimoto's Research Update' to see all of the updates.

TPO Antibodies and Quality of Life (https://pubmed.ncbi.nlm.nih.gov/21186954/)  (2011)

This study included 426 females who planned to undergo thyroid surgery. They only included participants whose TSH, FT3 and FT4 were in the normal range. TPO antibodies were tested prior to surgery and they examined the thyroid tissue that was removed. These women also took symptom and health questionnaires prior to surgery. 

The researchers found that the level of TPO antibodies correlated with the grade of thyroid inflammation. This makes a lot of common sense, higher antibodies = more thyroid destruction. The following symptoms were found to be higher in the patients with elevated TPO antibodies: chronic fatigue, dry hair, chronic irritability, chronic nervousness, dysphagia, and easily fatigued. Remember, the study participants all have normal thyroid hormone levels. The researchers also found that higher TPO levels were associated with an overall decreased quality of life. 

A patient recently told me that her endocrinologist lamented that Hashimoto’s is so ‘overblown’. This paper was published in 2011. It’s time we start listening to patients AND keeping up with the research. There is nothing overblown about Hashimoto’s and just treating thyroid hormones (TSH, FT3, FT4) isn’t enough for Hashimoto’s patients. We can do better. 

Epstein-Barr virus association with Hashimotos (https://pubmed.ncbi.nlm.nih.gov/32215255/) (2020)

Epstein Barr virus, one of the viruses that cause mononucleosis or ‘mono’, is considered a possible trigger of Hashimoto’s disease. This study investigated the prevalence of different types of antibodies to Epstein Barr virus (EBV) in people with Hashimoto’s thyroiditis (HT) and healthy controls. Approximately 95% of the adult population is infected during their life so not surprisingly, all participants tested positive for the antibody that measures if someone has been infected. What’s interesting is that the amount of antibodies present was significantly higher in the HT patients than in healthy controls. In addition, one of the antibodies, the early antigen IgG which is considered a marker of reactivation of the virus, was positive in HT patients at a significantly higher rate than controls. 

Review of Nutrients Needs In Hashimoto’s (https://doi.org/10.1967/s002449910507) (2017)

This review article published in 2017 provides an update from the literature regarding several key factors impacting Hashimoto’s. I will summarize their findings for each below. 

Iodine: Hashimoto’s is more common in areas that have plenty of iodine in the food supply/soil. Even small increases in iodine intake increase the risk of Hashimoto’s. The authors recommend discouraging excess iodine intake but caution that iodine levels of 250mcg daily are still required for pregnancy. Note from Dr. Barrett: this is a ‘goldilocks’ situation- you still need adequate iodine, just not too much. For non-pregnant patients I recommend limiting total iodine intake daily to 150mcg. 

Selenium: The thyroid tissue contains the highest concentration of the trace mineral selenium in our bodies. This mineral acts as an antioxidant and has anti-inflammatory properties. The exact mechanism of benefit to the thyroid has not been determined but we do know that it seems to modify the immune and inflammatory response. Three meta analyses have confirmed that selenium reduced TPO and TG antibodies. Selenomethionine is superior to sodium selenite because selenomethionine is absorbed more easily. The authors concluded that supplementing with selenomethionine is beneficial for Hashimoto’s patients. 

Vitamin D: This one is pretty straightforward. Vitamin D supplementation improves Hashimoto’s disease. The authors explain that the low cost and low side effect profile of 2,000- 4,000IU of vitamin D daily make it another good candidate to improve Hashimoto’s disease. 

Gluten: The authors argue that according to a recent meta analysis all patients with Hashimoto’s should be screened for celiac disease because of the high association between these two autoimmune conditions. “ In summary, whereas it is not yet clear whether a gluten- free diet can prevent autoimmune diseases, it is worth mentioning that HT [Hashimoto’s Thyroiditis] patients with or without CD [Celiac Disease] benefit from a diet low in gluten as far as the progression and the potential disease complications are concerned”. Note from Dr. Barrett: I think it’s warranted to try the gluten free diet in Hashimoto’s after screening for celiac disease.  

Association of antithyroid peroxidase antibody with fibromyalgia in rheumatoid arthritis (https://doi.org/10.1007/s00296-015-3278-1) (2015)

Hashimoto’s is an autoimmune condition that destroys the thyroid tissue and may lead to hypothyroidism. These two conditions are often lumped together but it’s possible to have Hashimoto’s and not develop hypothyroidism. This study investigated the presence of autoimmune thyroid disease in patients already diagnosed with rheumatoid arthritis (RA). Their aim was to determine if there is an association with chronic widespread pain (CWP) and/or fibromyalgia and autoimmune thyroid disease. Their findings are quite interesting. There is a strong association with the presence of one of the thyroid antibodies and CWP and fibromyalgia but not the other! Only TPO antibodies were associated with the increase in chronic pain in this population. Another interesting finding is that the association of TPO antibodies with fibromyalgia was independent of hypothyroidism. This is important because hypothyroidism can cause widespread pain so the assumption could be made that the association with this antibody and pain could be due to the low thyroid function. That isn’t the case. There is something about the presence of the TPO antibody that is the association with pain. I find these results important because patients are often told once their hypothyroidism is treated, their autoimmune thyroid symptoms should be resolved. This study supports the fact that many patients are still symptomatic even when their thyroid hormones have normalized. The authors conclude that testing for TPO antibody should be standard of care in RA patients to help determine risk of CWP and fibromyalgia. 

The association of other autoimmune diseases in patients with autoimmune thyroiditis (https://doi.org/10.1016/j.autrev.2016.09.009 ) (2016)

The association of other autoimmune diseases in patients with autoimmune thyroiditis: Review of the literature and report of a large series of patients.

This literature review found an increased prevalence of several autoimmune disorders when someone has autoimmune thyroid disease. The most common associations were Autoimmune thyroid disease + chronic autoimmune gastritis + vitiligo and Autoimmune thyroid disease + chronic autoimmune gastritis + polymyalgia rheumatica.

Other conditions that were more common alongside autoimmune thyroid disease include: rheumatoid arthritis, celiac disease, diabetes, sjogren disease, multiple sclerosis, systemic lupus erythematosus, sarcoidosis, alopecia, psoriatic arthritis, systemic sclerosis, and HCV-related cryoglobulinemia

Chronic autoimmune gastritis (CAG)  was the most commonly associated autoimmune disease with autoimmune thyroid disease. CAG is largely asymptomatic and can remain undiagnosed for a long time. Sometimes laboratory results can clue us in such as low iron and or low B12. Some people can feel generalized digestive upset, reflux and/or feeling full early.  CAG is diagnosed with antibody testing (parietal cell and intrinsic factor antibodies) and endoscopy. 


Reference:
1. Ott, Johannes & Promberger, Regina & Kober, Friedrich & Neuhold, Nikolaus & Tea, Maria & Johannes, Huber & Hermann, Michael. (2011). Hashimoto's Thyroiditis Affects Symptom Load and Quality of Life Unrelated to Hypothyroidism: A Prospective Case-Control Study in Women Undergoing Thyroidectomy for Benign Goiter. Thyroid : official journal of the American Thyroid Association. 21. 161-7. 10.1089/thy.2010.0191

2. Assaad SN, Meheissen MA, Elsayed ET, Alnakhal SN, Salem TM. Study of Epstein-Barr virus serological profile in Egyptian patients with Hashimoto's thyroiditis: A case-control study [published correction appears in J Clin Transl Endocrinol. 2020 Dec 17;23:100242]. J Clin Transl Endocrinol. 2020;20:100222. Published 2020 Mar 12. doi:10.1016/j.jcte.2020.100222
 
3. Liontiris, M. I., & Mazokopakis, E. E. (2017). A concise review of Hashimoto thyroiditis (HT) and the importance of iodine, selenium, vitamin D and gluten on the autoimmunity and dietary management of HT patients.Points that need more investigation. Hellenic journal of nuclear medicine, 20(1), 51–56. https://doi.org/10.1967/s002449910507 

4. Ahmad, J., Blumen, H. & Tagoe, C.E. Association of antithyroid peroxidase antibody with fibromyalgia in rheumatoid arthritis. Rheumatol Int 35, 1415–1421 (2015). https://doi.org/10.1007/s00296-015-3278-1
​
5.  Poupak Fallahi, Silvia Martina Ferrari, Ilaria Ruffilli, Giusy Elia, Marco Biricotti, Roberto Vita, Salvatore Benvenga, Alessandro Antonelli.The association of other autoimmune diseases in patients with autoimmune thyroiditis: Review of the literature and report of a large series of patients. Autoimmunity Reviews. Volume 15, Issue 12 (2016) Pages 1125-1128. ISSN 1568-9972,
https://doi.org/10.1016/j.autrev.2016.09.009 ​

I will start off by saying, read this book. James Clear makes an excellent argument that the quality of our lives depends on the quality of our habits. Once he has convinced you that habit change is life changing, he outlines many practical and small (atomic) ways to shift your habits. I am going to summarize two points from the book that really stuck with me.
 
Behavior changes starts with an identity change. 

Clear explains that one reason why we fail to stick with habits is that our self image gets in the way. We tell ourselves that we are trying to become a person who exercises daily instead of making the identity shift into believing that you are a person who exercises daily. This is the best way to be intrinsically motivated, if you identify as a fit person who enjoys exercise then the habit that sustains that identity becomes easier. One thing Clear wrote that really stuck with me on this topic is “every action you take is a vote for the type of person you want to become”. It sounds hyperbolic but when you really think about it, it rings true. 

Forget goals, focus on systems.
​
Clear emphasizes that systems are what keep our habits running and eventually lead us to our goals. There are a few issues with a goals first mentality. One issue is that it’s harder to live in the moment and enjoy your day to day life if you are just striving for a goal. Another issue is what happens when you hit your goal? Most of us don’t savor that feeling, we just move the milestone. Clear asks us to fall in love with the process, to savor the systems that keep us slowly moving towards the people we want to be. This way, as long as your systems are running you feel content and satisfaction. I’ve been trying this out for the last 6 weeks since I finished the book and I really like it. I’ve put systems in place (daily exercise, reading and meditation) without goals per se aside from putting in the time. Just knowing that my systems are running feels great! The quote from this section that I keep coming back to is “You do not rise to the level of your goals. You fall to the level of your systems.”
 
The book is filled with more concepts, these are just two that really stuck with me. This book has something for everyone. If you have struggled to make a habit change last I highly recommend reading Atomic Habits. ​

As we enter our third year of the pandemic, the last thing we want to hear more about is healthcare. We’ve been inundated -- it’s all anyone can talk about. Personally, I would love to talk about travel, art shows, concerts and book clubs, all the things I miss!

Unfortunately, we still need to talk about healthcare because many Americans are missing critical healthcare screenings. At first, we just put them off not realizing how long the pandemic would last. Now, I think we are just collectively burned out regarding anything healthcare related. Even before the pandemic, my patients struggled to check all the boxes for preventative healthcare. I’ve put together a list below of routine healthcare screenings that I recommend. 

Annual physical exam 
Your primary care physician should perform a physical exam each year. This overall screening helps identify any concerns. This will include a screening for blood pressure.  Bloodwork is often ordered during this visit. 

There are many other screenings that are based on age including mammograms, colonoscopies, prostate exams and gynecological exams. Your primary care physician can help you determine when it’s appropriate to have these screenings done. 

Bloodwork 
What lab work to run annually is probably the most ‘controversial’ on my list because everyone has a different opinion. For example, some providers run vitamin D each year and others insist that it’s not worth it. Each provider is going to have their own opinion about what’s warranted each year.

Here’s mine: 

• For someone who is generally healthy: Vitamin D, lipid panel, CMP, CBC, TSH, A1c. It’s a long list for a healthy person but catching something early or seeing a trend change over time is critical in preventing more serious illness. 
• For someone with metabolic concerns or strong family history of metabolic disease: Vitamin D, lipid panel, CMP, CBC, TSH, A1c, insulin and maybe also CRP

For more details on some of the lab markers above check out my blog on ‘Knowing Your Numbers.’
 
Dental
Oral health is critical to our overall health. Too many of us skip regular dental exams. Cleanings are typically recommended every 6 months with x-rays every year. Talk to your dentist about what’s right for you. 

Eye Exams
These are particularly important if you have blood sugar dysregulation or family history of glaucoma. Many Americans need glasses and don’t realize it. So if it’s been a few years make an appointment with your eye doctor so they can weigh in about just how often you should be screened. 

Skin Exams
I recommend annual skin exams at your dermatologists office. If you have many moles or very fair skin you may need to be screened more often. Your dermatologist can help you determine the appropriate frequency of visits. 


It’s a lot, I know, but you’re worth it! There are a few strategies you can employ to help you remember to get these appointments checked off your to-do list.

One option is to pick a ‘health month.’ For example, if January is your health month you would schedule your eye exam, physical, skin check, etc. in January each year.

Another option is to assign each check up to a month. Maybe your annual physical is in January every year. Then you have your eyes checked each February and so on. 

Early screenings and regular check ups save lives. Please make a plan and talk to your doctor about which screenings are appropriate for you.

American’s are underslept. I knew this before I read Why We Sleep by Matthew Walker, Phd but I didn’t fully grasp the health implications. Dr. Walker opened my eyes to the staggering statistics regarding sleep in our country and how insufficient sleep increases our risk for a whole host of health concerns. 

An excerpt from Dr. Walker’s book reads “Scientists have discovered a revolutionary new treatment that makes you live longer. It enhances your memory and makes you more creative. It makes you look more attractive. It keeps you slim and lowers food cravings. It protects you from cancer and dementia. It wards off colds and the flu. It lowers your risk of heart attacks, stroke, not to mention diabetes. You’ll even feel happier, less depressed and less anxious. Are you interested?” The evidence to back up these claims has been well documented. You just need adequate sleep. 

Unfortunately, 1 in 3 US adults fail to achieve the absolute minimum of 7 hours of sleep per night. 

Insufficient sleep impacts all the major physiological systems of the body, this includes our cardiovascular, immune, reproductive, and metabolic systems. Lack of sleep increases our risk for cancer, cardiovascular disease, diabetes, and dementia. Insufficient sleep also shortens our lifespan.  

I screen every patient for sleep quality and length. In my experience, many patients dismiss lack of sleep as a possible root cause of disease, they want to talk about "more important" things such as changing their diet. I am here to tell you, sleep is just as important (likely more so!) than what you eat. I am often debunking common misconceptions about sleep. Some think they can just ‘make it up’ on the weekends (spoiler, you can’t!). Others feel they function "great" on less than 7 hours of sleep. We even have a new term ‘revenge bedtime procrastination' because so many of us are staying up late looking for a little downtime in our busy schedules and missing out on critical sleep time. 

Sleep is the fundamental need for our bodies that all other aspects of our health are built on. If you read this far and you still think that you can skimp on sleep and remain unscathed I urge you to read or listen to Dr. Walker’s book. It was eye opening. 

I think one reason patients can be convinced that their lack of sleep isn’t impacting them is that their baseline of health has shifted and they don’t realize it. Dr. Walker wrote “With chronic sleep restriction over months or years, an individual will actually acclimate to their impaired performance, lower alertness and reduced energy levels. That low-level exhaustion becomes their accepted norm, or baseline. Individuals fail to recognize how their perennial state of sleep deficiency has come to compromise their mental aptitude and physical vitality, including the slow accumulation of ill health.” In other words you don’t realize how good you could feel with adequate sleep. 

With the advent of wearable technology, we have a whole new way of gathering data about ourselves. It’s been interesting for me to look at my sleep data overlaid with my stress levels (I picked my tracker particularly for the HRV data). I can absolutely see a correlation with nights that I sleep poorly and elevated levels of stress. I am a sucker for data but you don’t need a sleep tracker to optimize your sleep. Dr. Stamer wrote a great article with some tips for getting a good nights sleep. You can read that article here. 


Having read a small summary about how sleep deprivation can be a root cause of your illness I hope it empowers you to take a closer look at your sleep and make sleep a priority. 





References:

1. Matthew Walker, PhD (2017) Why We Sleep Unlocking the Power of Sleep and Dreams
2. CDC article “1 in 3 adults don’t get enough sleep” Accessed 11/13/2021 https://www.cdc.gov/media/releases/2016/p0215-enough-sleep.html 

Warm baths are actually good for your health.

That’s right, a simple soak in warm to hot water actually has proven health benefits. These benefits include improving blood circulation, relaxing muscles, improving sleep quality, and reducing stress. 

When I prescribe baths for my patients I recommend adding 2 cups of Epsom salts to the tub.  Epsom salts are a particular type of salt mined from a spring in England. Epsom salt breaks down to magnesium and sulfate in water. Historically, epsom salts have been used for a laundry list of ailments from sore muscles to enhanced detoxification. Epsom salt baths are another traditional therapy that we don’t have the science to back up (yet!).

Anecdotally, adding Epsom salt to baths appears to increase the therapeutic benefit of a bath. I’ve heard all sorts of theories about how Epsom salt improves our health. There is one myth I want to dispel. Some folks are under the impression that the Epsom salt in a bath can somehow pull toxins from our tissues into the bath water. Not only is there no evidence to support this, it’s biologically improbable. What I suspect is happening is that we are absorbing some of the magnesium and sulfate in the water. This theory is also unproven but a small report in 2014 did show a modest increase in sulfate and magnesium in the blood after an Epsom salt bath. Magnesium is necessary for over 300 biochemical reactions in our body. We don’t know exactly how the magnesium moves from the water across our skin and into our tissues but that’s the main theory behind the additional benefit of adding Epsom salt to the bath water. 

When I recommend Epsom salt baths I instruct patients to add 2 cups of salt to the bathtub, allow the salt to dissolve (4 minutes or so) and then soak for 20-30 minutes. I encourage patients to take an Epsom salt bath 2-3x per week in the evening. 

I recommend Epsom salt baths to patients regularly for a variety of reasons:

• Forces folks to slow down and relax even if it’s just 20 minutes
• The warm bath will likely improve their sleep quality that night
• It may increase their tissue levels of magnesium
• Soothes sore muscles and joints
• Likely improves gentle detoxification via increased magnesium 

Some reasons to be cautious or skip Epsom salt baths:

• Low blood pressure, high blood pressure, POTS, or orthostatic hypotension: warm baths relax your blood vessels and increase your heart rate both of which can cause changes to your blood pressure. If you have any of these conditions be cautious getting out of the tub and make sure someone is nearby to help you in case you feel faint. I also recommend just a warm bath instead of a hot bath in these cases. 
• Sulfate allergy: the sulfate in the water could cause hives

In summary, Epsom salts are a low cost and safe addition to a therapeutic warm bath. 



References: 

1. Hoekstra, S. P., Bishop, N. C., Faulkner, S. H., Bailey, S. J., & Leicht, C. A. (2018). Acute and chronic effects of hot water immersion on inflammation and metabolism in sedentary, overweight adults. Journal of applied physiology (Bethesda, Md. : 1985), 125(6), 2008–2018
2. http://www.epsomsaltcouncil.org/wp-content/uploads/2015/10/report_on_absorption_of_magnesium_sulfate.pdf
3. https://www.epsomsaltcouncil.org/faq/
4. https://health.clevelandclinic.org/reasons-to-take-a-bath/​

This is a follow up to my recent blog post on alcohol titled, "Are You Drinking Too Much?" That article prompted some interesting conversations with patients. Many folks use alcohol in the evenings as a way to ‘unwind’ after a long day. With so many of us working from home, pouring an alcoholic beverage can be that ritual that signals the work day is over. Ritual is important and having a ritual of crafting a beverage for yourself at the end of the day is lovely. I found myself helping patients concoct an alcohol-free version of a drink that helps them relax without the negative impact of alcohol. I am going to share some ideas with you below - happy (alcohol-free) drinking!

My relaxing beverage changes with the seasons. Something warm is soothing in the colder winter months but I love a sparkling and refreshing mocktail in the summertime. 

My go-to in the winter time is warm tea. There are so many fantastic relaxing herbs to choose from. I will list a few of my favorites that I like to drink alone or blended together:

• Tulsi 
• Ashwagandha
• Chamomile
• Lemon balm
• Passionflower

Don’t forget you can mix tea bags together. I often add a bag of hibiscus tea to improve the flavor of whatever herbal tea I’m drinking. Also consider buying combination blends. 

If you want to increase the relaxation power of your tea consider adding some L-theanine powder and/or magnesium powder. 

L-theanine is an extract from green tea that increases alpha waves. This means that L-theanine helps you feel relaxed without causing drowsiness. You could try using a decaffeinated green tea or you can open a capsule of L-theanine and dump the powder into your beverage. I recommend using 100-200mg of L-theanine. 

Magnesium is a mineral that has a calming effect. I personally use ‘Natural Calm Powder’ aka magnesium citrate powder regularly in an evening beverage to help me relax after a long day. You can pick up an unflavored magnesium powder so it’s easy to add to a warm beverage or a ‘mocktail.’ Note: magnesium may cause loose stools in large quantities so be careful with your dosing and start with 100-300mg. 

If tea isn’t for you, try Golden Milk, a lovely blend of warm milk, honey and spices. 

Use relaxing herbs to boost your mocktail. In the warmer months I enjoy putting together a ‘mocktail.’ I keep tinctures of chamomile, lemon balm, passionflower, valerian, and kava kava* on hand. My favorite way to make a refreshing mocktail is to mix some sparkling water (flavored or unflavored) with some tart juice and add a few droppers of a tincture. A tincture is a concentrated herbal extract in alcohol. You will get about ½ tsp of alcohol using this recipe so please skip this if you struggle with alcohol addiction. I listed the tinctures above in order of ‘strength’ for their ability to help you relax. The tincture also adds a little bite and helps it taste like an actual cocktail. Consider using tart cherry juice in your mocktail. Tart cherry has been shown to boost melatonin levels.

Since we want to lean into the power of a ritual, use a fun glass! If there is something about holding a wine glass that really helps you shift into ‘home mode' then use a wine glass for your new beverage of choice. 

What helps you unwind at the end of the day?



*Caution with Kava kava root. Please do not combine with alcohol and don’t use this tincture daily. It can damage your liver (just like alcohol!) if you use it daily for longer than 3 months. 

We are heading into my favorite season, Fall! It’s the time of the year I like to spend hours at a time outdoors. Being in nature feels good for my body, mind and spirit and science backs up that feeling. I have heard nature referred to as ‘Vitamin N’ and I love it! A vitamin is defined as an organic substance that is essential to the nutrition of most animals. While time in nature isn’t really essential for nutrition, in my opinion it is essential for optimal human function. 

Spending time in nature has physical benefits including a reduced heart rate, muscle tension, and blood pressure as well as a reduction in stress hormones. That’s not all, researchers at Tokyo’s Nippon Medical School found an increase in the white blood cells that fight viruses and cancer in women who spent 6 hours in the woods over the course of a two-day period. The increase in white blood cells lasted at least 7 days after their nature exposure. 

Spending time in nature improves mood. We move from depressed, stressed and anxious to more calm and balanced. This is the main reason I turn to nature. In our overstimulating world nature offers a sense of calm that is incredibly grounding and so needed.  
 
‘Forest bathing’ or Shinrin-yoku was developed in Japan in the 1980’s and has become a cornerstone in Japanese medicine. The concept is simply to visit a natural area and walk in a relaxed way to enjoy health benefits. The proven benefits are long and include a bolstered immune system, improved recovery from surgery, improved sleep and reduced stress.

I am often prescribing vitamin N to my patients and it doesn’t have to be a large dose. The Shinrin-yoku research has found that the sweet spot is 2 hours per week which is roughly 20 minutes per day. 
 
A 2015 study published in the International Journal of Environmental Research and Public Health  found that even looking at pictures of green space for 5 minutes increased parasympathetic activity (calm) after a stressful event. It’s pretty incredible that even pictures of nature can reduce your stress. If you can’t get yourself outside more often, consider adding nature images to your home and workplace.

Ideas to increase your dose of vitamin nature:

• Take a less urban route when driving.
• Eat your lunch outside
• Go for a walk around the block
• Read in the grass
• Walk on a less urban street or make a point to walk near or in a park.
• Find windows in your home or office that overlook nature and make a point to look outside and appreciate what you see.
• In the wintertime if you are cold sensitive, spend time in a conservatory such as Como Park in St. Paul.
• Get physical outside, make a point to run outside vs on a treadmill
• Put a bird feeder outside a window that is easily visible and make a point to appreciate the animals that stop by.
• Add plants to your home and office.
• Garden! Consider a community garden if you don’t have a yard.
• Make sure you have natural light entering your home.

References

1. Li Q, Morimoto K, Kobayashi M, et al. A forest bathing trip increases human natural killer activity and expression of anti-cancer proteins in female subjects. J Biol Regul Homeost Agents. 2008;22(1):45-55
2.  Pearson DG, Craig T. The great outdoors? Exploring the mental health benefits of natural environments. Frontiers in Psychology. 2014;5:1178. doi:10.3389/fpsyg.2014.01178.
3. van den Berg MM, Maas J, Muller R, et al. Autonomic Nervous System Responses to Viewing Green and Built Settings: Differentiating Between Sympathetic and Parasympathetic Activity. Int J Environ Res Public Health. 2015;12(12):15860-15874. Published 2015 Dec 14. doi:10.3390/ijerph121215026

Are you drinking too much? I know I’ve asked myself this question more than once during the pandemic. Like most Americans, during the pandemic my drinking dramatically increased. It’s so easy to unwind at the end of a long day with a glass (or two!) of wine. Once you start this cycle it’s hard to break free. Before I jump into the data, I invite you to check in with yourself. Has your drinking increased during the pandemic? How does it feel in your body? How are you sleeping? Is your energy level where you want it to be? When you think about cutting back on your consumption do you feel resistance? If you are feeling resistance try to meet that with some compassionate curiosity and see what you find. 

If you want more on this topic and you don’t want to continue reading check out this link to watch a Curiosity Corner where Jesse Haas and I discussed the documentary, "The Truth About Alcohol."

Alcohol use is so pervasive in our culture that it’s considered normal and safe. Unfortunately, alcohol is not a benign substance. In fact, it’s a known carcinogen. The UK spent 3.5 years reviewing all of the literature on alcohol and health and in 2016 overhauled its alcohol guidelines. The new guidelines are 14 units per week. To put that into context; a glass of red wine can be between 2-3 units depending on the strength of the wine and the size of the glass. For beer, a pint is typically between 1.5-2 units. So if you are drinking one or more alcoholic beverages per day you may be exceeding these guidelines. The UK also recommends 14 units or less regardless of your gender.

The main reason the UK took such a hard stance on alcohol was the research proving that alcohol is a potent carcinogen. Folks that regularly consume alcohol increase their risk of developing a wide range of cancers. Cancer is concerning but honestly, the cancer risk isn’t what really convinced me to reduce my consumption. How damaging alcohol is on our sleep is what did it for me. I don’t know about you but I have been so tired throughout the pandemic. The increase in daily stress and workload is a lot for us to carry. So when I started listening to Dr. Matthew Walker’s book, Why We Sleep, and learned about the relationship between alcohol and poor sleep I took action. Even 1 alcoholic beverage consumed hours before bed inhibits your ability to achieve REM sleep. Walker jokes that if you want to consume alcohol and still sleep well you have to start drinking with your morning coffee (please don’t try that). He goes on to discuss the shocking impact alcohol has on memory. I have heard from so many patients about memory trouble in the past year. Of course, the stress we are under will negatively impact memory but I wonder if alcohol consumption is playing a part for some folks as well. 

You might be thinking, but a little red wine every day is good for me, right? Well, the only demographic that benefits from alcohol consumption are folks with ovaries who are 50+ years old and consume 2-3 glasses of wine per week. That’s it. So unless you fit in that demographic, the red wine you are drinking is likely not helping your heart. Alcohol contributes to leaky gut, depletes nutrients, and it weakens our immune system. 

I know, I know I really shouldn’t be coming for your alcohol. It’s been a hard year. You feel that you need that wine or beer at night. I hear you. It’s been a very hard year. Most of us are exhausted and completely drained. It’s time to be honest, the alcohol is not helping. 

What if you start with one day per week that you skip the alcohol and slowly increase to more days during the week? Can you find something truly nurturing to replace it with? An epsom salt bath? Hot tea? A stroll after dinner? A chat with a friend? Some people are better with abstention vs moderation. If that’s you then try a month without alcohol and see how your health changes. I know it's difficult but I think it's worth exploring the impact alcohol is having on your health and wellbeing. 

I regularly read through recent literature on autoimmune thyroid disease/Hashimoto's. I post about each of these studies on instagram as I review them and put it all together on this blog twice per year. 

You can use the categories located to the right of this post and click 'Hashimoto's Research Update' to see all of the updates. ​

Vitamin D Treatment in Patients with Hashimoto's Thyroiditis May Decrease the Development of Hypothyroidism (2016)

What if you have elevated thyroid antibodies but your TSH isn’t elevated yet, ie it’s Hashimoto’s Thyroiditis (HT) but not yet progressed to hypothyroidism? Conventionally patients are often told to just watch and wait. Wait until it turns into hypothyroidism, then you can take medication. 

This study published in 2016 demonstrated that supplementing with vitamin D actually reduced thyroid antibodies and prevented the progression of HT into hypothyroidism. So there is something you can do instead of just watch and wait. 


One limitation of this study is that it was performed in Turkey, a country with notoriously low vitamin D levels. The average vitamin D level in patients with HT entering the study was 9 and the control group average was 12! During the study all of the groups raised their vitamin D blood levels to around 50. So it’s important to test your vitamin D levels. If you are already around 50/60 you likely wouldn’t benefit from additional vitamin D supplementation. 


The Composition of Gut Microbiota in Patients Bearing Hashimoto's Thyroiditis with Euthyroidism and Hypothyroidism (2020) 

This study compared the gut microbiome between three groups; normal controls, people with Hashimoto’s but normal thyroid function (HT), and people with Hashimoto’s and hypothyroidism (HTH). This study consisted of 97 people all from a particular region in China. The researchers found that the richness of diversity in the gut microbiome was significantly lower in HT patients than in the control group. The patients with HTH had the least microbial abundance. Our gut microbiome plays a vital role in our immune system so it makes sense that shifts in the microbiome could be playing a role in autoimmune diseases. Something else to consider is that thyroid hormones also influence the function of our GI, especially motility. It’s possible the change in diversity from HT to HTH could be partly due to the influence of low thyroid hormone on GI function. 

This research further confirms why it’s so important to nurture a healthy gut microbiome. 


Psychological Wellbeing in Hashimoto’s (2017) 

The main finding of this study is that health related quality of life is impaired in euthyroid Hashimoto’s patients. Let’s break this down a bit. Euthyroid Hashimoto’s Thyroiditis (HT) is when a patient has thyroid antibodies and/or Hashimoto’s specific abnormalities on thyroid ultrasound but a normal TSH. This study evaluated the quality of life for HT’s patients and found that HT’s patients had lower quality of life regarding physical functioning, general health and mental health. Specifically this study found that patients with euthyroid HT had increased levels of both anxiety and depression. Interestingly, this study included a group of euthyroid HT patients that were taking levothyroxine and a group not taking any medication. There were no differences between these two groups in terms of depression, anxiety or quality of life scores. So medication did not improve these symptoms. 

My patients are consistently told by endocrinologists if they are on medication and their TSH is normal then their symptoms are not from Hashimoto’s. Not true. Evidence is mounting that there are deeper mechanisms here. 

Another nugget from this paper that I have to directly quote, it’s so good! “TSH levels were slightly higher in HT group than control group although all the participants were in euthyroid state in our study. Higher TSH levels were also found in previous studies comparing euthyroid HT and control subjects. These findings might suggest that slightly higher TSH even in the normal range might be related with impairment in psychological well-being in patients with euthyroid HT.” One more time for the folks in the back! HT patients have been fighting to be heard around this issue for such a long time. It’s time to reevaluate the ‘normal’ range for TSH especially in HT patients.  


Effect of Low Carbohydrate Diet in Autoimmune Thyroiditis (2016) 

The title is misleading because they changed a lot more about the diet than just carbohydrate content. The authors removed several common food intolerances (dairy, eggs and gluten) in addition to implementing a low carbohydrate diet. 

Here’s the breakdown: 180 total participants 84 males and 96 females aged 30-45 years. All subjects tested negative for celiac disease (in truth the specific language they use is “all subjects did not present celiac disease” so I am uncertain if they actually tested them or not).

The experimental diet was followed for 3 weeks and included aiming for macro’s of carbs 12-15%, proteins 50-60%, and lipids 25-30%. Foods excluded: goitrogenic foods (unlisted specifically what these were), eggs, legumes, dairy, bread, pasta, fruits and rice. Control group followed a low calorie diet without restrictions on types of food to consume. 

The author referenced goitrogenic foods repeatedly as part of the dietary exclusion but in the materials and methods section these foods were not specifically listed. In the introduction the author discusses goitrogenic foods and states “These substances (known as goitrogens) are found especially in products of the cruciferous (Brassicaceae) family (rape seed or canola, cabbage, turnip, watercress, arugula, radish, horseradish) and in milk produced by cattle nourished with these vegetables. Other goitrogens include soy, spinach, millet, tapioca, and lettuce. Even certain food additives, ie, nitrates used for fish and meat preservation, prevent iodine uptake by the thyroid gland.” So it’s unclear which foods were actually excluded in the experimental group. What is clear is this is not a simple low carb diet analysis. 

The author also put a heavy emphasis on goitrogens and Hashimoto’s. I haven’t seen goitrogen’s make much of a difference clinically with Hashimoto’s patients. Check out this article written by Dr. Alan Christianson for a much deeper dive into goitrogens and Hashimoto’s.  

Bottom line: don’t switch your diet just yet, we need more research on nutrition and Hashimoto’s. This study used too many dietary variables and was very short in duration. 

Oxidative Stress and Hashimoto’s (2014) 

This study is straightforward. The investigators compared biomarkers in people with euthyroid autoimmune thyroiditis (read: Hashimoto’s disease but normal levels of TSH, FT3, and FT4) and people without any thyroid disease. It was a small study with only 70 participants. I appreciate that they looked at a diverse set of biomarkers to assess oxidative stress including oxidized LDL. They controlled for variables that could impact oxidative status such as age, BMI, and fasting glucose. It is not surprising that folks with Hashimoto’s had a decrease in antioxidants and an increase in oxidants vs controls. We have a delicate balance of free radicals (oxidative stress) and antioxidants keeping our bodies healthy. If the scales tip and we are under higher levels of oxidative stress a whole host of disease can occur. Excessive levels of oxidative stress is considered one of the factors underlying the autoimmune response. 

Bottomline: Folks with Hashimoto’s have lower levels of antioxidants and higher oxidative stress. It’s important to consume a diet rich in antioxidants. 





​References: 

1. Ucan B, Sahin M, Sayki Arslan M, Colak Bozkurt N, Kizilgul M, Güngünes A, Cakal E, Ozbek M. Vitamin D Treatment in Patients with Hashimoto's Thyroiditis may Decrease the Development of Hypothyroidism. Int J Vitam Nutr Res. 2016 Feb;86(1-2):9-17. doi: 10.1024/0300-9831/a000269. Epub 2017 Jul 12. PMID: 28697689.
2. Liu S, An Y, Cao B, Sun R, Ke J, Zhao D. The Composition of Gut Microbiota in Patients Bearing Hashimoto's Thyroiditis with Euthyroidism and Hypothyroidism. Int J Endocrinol. 2020 Nov 10;2020:5036959. doi: 10.1155/2020/5036959. PMID: 33224194; PMCID: PMC7673947.
3. Muhittin Yalcin M, Eroglu Altoniova A, Cavnar B, Bolayir B, Akturk M, Arslan E, Ozkan C, Cakir N, Balos Toruner F. Is thyroid autoimmunity itself associated with psychological well-being in euthyroid Hashimoto’s thyroiditis? Endocrine Journal. 2017, 64(4), 425-429
4. Esposito T, Lobaccaro JM, Esposito MG, Monda V, Messina A, Paolisso G, Varriale B, Monda M, Messina G. Effects of low-carbohydrate diet therapy in overweight subjects with autoimmune thyroiditis: possible synergism with ChREBP. Drug Des Devel Ther. 2016 Sep 14;10:2939-2946. doi: 10.2147/DDDT.S106440. PMID: 27695291; PMCID: PMC5028075.
5. Baser, H., Can, U., Baser, S. et al. Assessment of oxidative status and its association with thyroid autoantibodies in patients with euthyroid autoimmune thyroiditis. Endocrine 48, 916–923 (2015). https://doi.org/10.1007/s12020-014-0399-3