​I am starting up a new blog series to highlight research updates for Hashimoto’s Thyroiditis (HT). My intention is to review recent literature every 6 months. I am starting by pulling together a variety of research articles until I feel ‘caught up’ (will I ever feel caught up?!) and will then focus solely on new research. My plan  is to publish an update every January and July. 

For this first installment I have pulled together a variety of research articles. 

Gluten and Hashimoto’s (2019)

Krysiak R, Szkróbka W, Okopień B. The Effect of Gluten-Free Diet on Thyroid Autoimmunity in Drug-Naïve Women with Hashimoto's Thyroiditis: A Pilot Study. Exp Clin Endocrinol Diabetes. 2019;127(7):417-422. doi:10.1055/a-0653-7108

I read this article in 2019 when it came out and was excited to see that research is starting to support what we have known clinically for years. Many patients with Hashimoto’s Thyroiditis (HT) benefit from a gluten free diet. The sample size was small and it wasn’t randomized, patients were allowed to choose the gluten free group or the control group. That said, even with the small sample size there was an improvement in both TPO and TG antibodies in the gluten free group as well as a slight increase in thyroid hormone output. 

The authors hypothesize that the improvement in autoimmunity may be due in part to an increase in vitamin D that was seen in the gluten free group. The participants did not increase their vitamin D intake and it’s unknown why a gluten free diet would have improved their vitamin D status. 

This study is very interesting and I hope it’s the first of many exploring the important connection between a gluten free diet and HT. 


Vitamin D and Hashimoto’s (2016 + 2018)

Sahin, M., Corapcioglu, D. The effect of vitamin D on thyroid autoimmunity in non-lactating women with postpartum thyroiditis. Eur J Clin Nutr 70, 864 (2016). https://doi.org/10.1038/ejcn.2016.56

Xu J, Zhu XY, Sun H, et al. Low vitamin D levels are associated with cognitive impairment in patients with Hashimoto thyroiditis. BMC Endocr Disord. 2018;18(1):87. Published 2018 Nov 26. doi:10.1186/s12902-018-0314-7

We know from observational studies that low vitamin D status seems to contribute to thyroid autoimmunity. What sets this research apart is that they looked at women post partum to see what impact vitamin D supplementation has on antibodies. ⁠If you are familiar with Hashimoto's you probably know post partum is a common time for the condition to flare. ⁠
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The investigators found that the women with post partum thyroiditis (PPT) had lower levels of vitamin D than post partum women without thyroiditis. Giving vitamin D (either 2,000IU or 4,000IU depending on the patient's vitamin D blood level) to the PPT women significantly lowered their antibodies without any side effects. Between 20-40% of women with PPT go on to develop permanent hypothyroidism and lowering antibodies is an important step to prevent that outcome.

The second study looks at the relationship between vitamin D, Hashimoto's Thyroiditis (HT), and  cognitive impairment. 
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We already know that low vitamin D is correlated with cognitive impairment in the general population and that there is a high prevalence of low vitamin D in patients with HT. It wasn't surprising that they found low vitamin D is associated with cognitive impairment in patients with HT. ⁠

The authors  also found that vitamin D levels were inversely related to TPO antibody levels.

Bottom line study #1 and #2:  If you have Hashimoto's I highly recommend talking to your provider about your vitamin D level. ⁠
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Depression and Hashimoto’s (2011 + 2014)

Giynas Ayhan M, Uguz F, Askin R, Gonen MS. The prevalence of depression and anxiety disorders in patients with euthyroid Hashimoto's thyroiditis: a comparative study. Gen Hosp Psychiatry. 2014;36(1):95-98. doi:10.1016/j.genhosppsych.2013.10.002

Hardoy MC, Cadeddu M, Serra A, et al. A pattern of cerebral perfusion anomalies between major depressive disorder and Hashimoto thyroiditis. BMC Psychiatry. 2011;11:148. Published 2011 Sep 13. doi:10.1186/1471-244X-11-148

The first study looked at the prevalence of depression and anxiety in euthyroid Hashimoto’s thyroiditis. Euthyroid Hashimotos’ is when a patient has Hashimoto’s but their thyroid hormones are not abnormal (yet!). They looked at patients who have a normal FT3, FT4 and TSH but also have thyroid antibodies and an abnormal thyroid ultrasound. There are already several studies that show a higher prevalence of psychiatric disorders in patients with Hashimoto’s but this study is unique in that they only included HT patients who had ‘normal’ thyroid function based on thyroid hormone testing. Surprise! They found there was a higher prevalence of anxiety and depression in these patients than in the general population or control. There are many theories as to why HT patients have a higher incidence of psychiatric disorders and many center around imbalanced levels of TSH, FT3 and FT4. There is likely more to the story. This study might be the first to find a relationship between OCD and HT. The prevalence of OCD in the HT group was 15.7% and the prevalence in the general population is around 0.8% to 3.2%. 

Bottom line study #1 - If you have anxiety or depression and your thyroid has been screened with just a TSH make sure to talk to your provider about a comprehensive screen that includes antibody or ultrasound testing  especially if you have a family history of thyroid disorders. 

The authors summarized the second study very well so I am going to quote the authors directly “The debate on the pathogenesis of depression in thyroid autoimmunity involves two hypothesis, it is suggested that the neuronal tissue is hypersensitive to hormonal deficiencies and are more vulnerable to possible subclinical hormonal deficiencies not detectable with routine laboratory tests. In the second hypothesis, a possible pathogenic factor linked to inflammation is postulated, consequent to cytokine activation or extraglandular lesions similar to vasculitis induced effects.” 
In other words it could be that our brains are hypersensitive to fluctuations in thyroid hormone so even when the levels are ‘normal’ our brains might suffer and/or there is likely a role of inflammation in altering blood flow. 

Bottom line study #2: Depression and brain blood flow changes happen with HT (both euthyroid and hypothyroid) and patients with depression, especially atypical depression, need comprehensive thyroid screening. 

For more frequent research updates check out my Instagram account.

​I have been writing about how self criticism and perfectionism have negative health consequences. If you missed those articles you can read them here (self criticism and autoimmunity; perfectionism and autoimmunity)

The antithesis to self criticism is self compassion. Self compassion is extending the same compassion to yourself that you would to a good friend. Kristin Neff, Ph.D, an associate professor in human development who studies self compassion, explains that self compassion is composed of three parts: mindfulness, common humanity and self kindness. Dr. Neff has created an online quiz to assess your level of self compassion.

It sounds like a nice notion, treating yourself with kindness, but it’s more than that. Practicing self compassion can actually improve your health. Positive emotions are the counterbalance to our threat activation system. If we are soothed, calm, or feel contentment, it stimulates our vagus nerve and our parasympathetic nervous system. Compassion meditations lower the stress hormone cortisol and inflammatory cytokine IL-6.

It can be challenging to accept kindness from strangers and even harder to accept it from ourselves. You know what I hear most often when I ask patients about accepting kindness or being kind to themselves? They think they don't deserve it. Take a minute to think back to the last time someone did something kind for you. Did you accept it with gratitude? Did you feel awkward? Maybe even a little guilty because you couldn’t or didn’t reciprocate? What about the last time you performed a random act of kindness? How did you feel? It feels really good to do something kind for someone else, but we struggle to extend that same kindness to ourselves and accept it from others. 

I want to be clear that self compassion is not a cop-out. We all make mistakes. We all have biases, prejudices and learned behaviors to work on. Healthy self reflection and improvement can be done from a place of love and caring. Self compassion teaches you to approach yourself with kindness, even when you need to grow and learn. Let’s be clear, we are all constantly growing and evolving. We all make mistakes and have a lot to learn about being human. If your friend or a young child made a mistake, how would you speak to them about it? Self compassion is extending that same grace to yourself instead of harsh self reproach.  

Healthy self-improvement may help boost your self-esteem. Instead of tearing yourself down, what if you built yourself up? Focus on your good qualities and recognize when you stop, reflect and grow. Self esteem may buffer against acute stressors and lead to more resiliency. 

Dr. Neff’s website is full of tools you can use to improve your self compassion. One of my favorites I recommend to my autoimmune patients is loving kindness meditation. Compassion medication can reduce stress induced immune changes. 

Working through your inner self critic and cultivating self compassion can be challenging. I recommend checking out Dr. Neff’s resources including her book Self Compassion: The Proven Power of Being Kind to Yourself  and consider working with a mental health professional especially if you are working through shame and trauma. 

I will leave you with a mantra from Dr. Neff’s book about building self compassion: 

“This is a moment of suffering.
Suffering is part of life.
May I be kind to myself in this moment.
May I give myself the compassion I need.”

References:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4311753/ 
Self compassion as a predictor of interleukin-6 response to psychosocial stress

www.ncbi.nlm.nih.gov/pubmed/18644432.
Higher self esteem reduced the inflammatory response to acute stressors.

 www.ncbi.nlm.nih.gov/pmc/articles/PMC2695992/.
Compassion meditation reduced stress induced immune changes

Self Compassion: The Proven Power of Being Kind to Yourself by Dr. Kristin Neff

​This is a follow up to Self Criticism and Autoimmunity. 

Perfectionists are often the harshest self critics. Brene Brown, Ph.D defines perfectionism as “a self-destructive and addictive belief system that fuels this primary thought: If I look perfect and do everything perfectly, I can avoid or minimize the painful feelings of blame, judgement, and shame.” 

Self criticism is used as a way to ensure you are ‘perfect’. The lie perfectionists tell themselves is that constant second guessing means you will not make a mistake. The trouble is you spend so much of your life second guessing yourself that you don’t get a chance to live in the moment. Instead, you are caught in a constant ‘fight-flight-or-freeze’ sympathetic loop. 

Why create a whole blog on perfectionism? I noticed a pattern in my practice that patients with autoimmune disease tend to be hard on themselves. I started looking into the research and I found this paper revealing that patients with autoimmune disease are more self deprecating than controls, which confirmed my suspicions. Years of overwork and stress to prove your worthiness leads to chronic activation of our sympathetic system. Our stress activation system is closely linked with our immune system. The full mechanisms of action for self criticism and immune activation are not fully worked out yet, but there is a connection. 

Just like Dr. Brown said, perfectionism is a misguided tool to reduce or minimize the painful feelings of blame, judgement and shame. Criticizing ourselves and striving for perfection unfortunately do not produce the desired outcome and can harm our health. 

Instead, try holding a hand over your heart and saying to yourself: ‘I am enough’.

Click to read Part 3 Self Compassion and Autoimmunity


References:

https://www.ncbi.nlm.nih.gov/pubmed/2148613
Women with autoimmune disease found to be more self deprecating than controls

The Gifts of Imperfection: Let Go of Who You Think You're Supposed to Be and Embrace Who You Are by Brene Brown, PhD.

We must take a holistic look at complicated ​chronic diseases. This includes exploring the connection between our mind and body. When we are critical of ourselves, it has negative consequences for our health and even impacts our immune system. According to Merriam-Webster self criticism is ‘the act of or capacity for criticizing one’s own faults or shortcomings’.  We have a complex system designed to monitor our environment for threats. When a threat is identified, we are flooded with stress hormones to help us survive. The trouble is, this system can’t differentiate between threats in our environment and threats inside our head. Criticizing ourselves activates our threat system in the same way anxiety does. Chronic stress happens when this system is constantly engaged. 

Chronic stress increases interleukin-6 (IL-6). IL-6 plays an important role in signaling during an active infection. IL-6 increases inflammation and antibody production.  Elevated IL-6 actually increases anxiety, alters the immune system and increases neuro-inflammation. 

We live in a culture that teaches us to be self critical. We grow up internalizing the ideal that we must push ourselves to achieve greatness. It’s easy to put high expectations on ourselves, which leads to self criticism when we can’t meet those expectations. Some use self criticism as a tool to push themselves harder and harder and even fear that without the inner critic they might become ‘lazy’.

I think one of the core issues is confusing self criticism for self improvement. To be human is to learn and grow. Healthy reflection coming from a place of love and compassion is an important part of the human experience. You don’t need to be critical of yourself to induce positive change. In fact, shaming and harsh self-reproach are counterproductive and lead to resistance. 

Consider this scenario with two different internal dialogues. Margaret set her alarm for 6pm instead of 6am and overslept. She rushed to get to work but arrived 30 minutes late and her boss noticed. 

Internal dialogue A: “How could you set your alarm wrong? You are so stupid. Now your boss is mad at you. You need to stay late tonight and do extra work to make up. Your boss is going to think you can’t be relied on. How could you let this happen?” This situation stays on Margaret’s mind the rest of the day and impairs her focus. 

Internal dialogue B: “It’s ok, accidents happen. I feel really guilty about coming in late, but being late does not mean I am a bad person. I am going to apologize to my boss and let her know I will stay an extra 30 minutes today to make up the work. Let’s take three deep breaths and let this go so I can focus on my work today.” Margaret was able to concentrate on her work. Her boss accepted the apology and was understanding. 

Did it hurt to read dialogue A a little bit? It was hard to write dialogue A! Unfortunately, for many people their inner dialogue is quite cruel. A good rule of thumb is to stop and think about whether you would talk to someone you love the way you are talking to yourself. Most people would never speak to another person the way they speak to themselves.

See Part 2 Perfectionism and Autoimmunity and Part 3 Self-Compassion and Autoimmunity for more information on combating self criticism. 

References:
https://link.springer.com/article/10.1007/BF02895112
Personality traits and the immune system

https://www.sciencedirect.com/science/article/abs/pii/S0006322318319292 
IL-6 Induced by Social Stress 

According to the American Thyroid Association more than 12% of the US population will experience thyroid dysfunction in their lifetime.  The thyroid is a gland that sits in our lower neck and releases thyroid hormones, which activate genes in virtually all cells of the body. These hormones increase functional activity, which can be simplified to say they regulate our metabolism. There are many types of thyroid dysfunction. This article will focus on hypothyroidism (under functioning thyroid gland), specifically the most common type of hypothyroidism: Hashimoto’s.
 
The technical name for Hashimoto’s is chronic autoimmune (lymphocytic) thyroiditis. Hashimoto’s is a condition in which the immune system attacks and destroys the thyroid gland. This leads to a gradual loss of thyroid function over time. Hashimoto’s is seven times more common in women than in men. Most often patients with Hashimoto’s experience the typical symptoms of hypothyroidism which can include: weight gain, fatigue, cold intolerance, constipation, hair loss, depression, heavy periods, muscle aches, poor concentration, dry skin and more. Some patients experience Hashitoxicosis, which happens when the immune system attack on the thyroid causes an excessive amount of thyroid hormone to be released for days or weeks. This excess hormone leads to hyperthyroid symptoms such as sweating, insomnia, palpitations, etc. This is often followed by a period of hypothyroid symptoms, which can leave the patient feeling like they are on a roller coaster!
 
What causes Hashimoto’s?
As with any autoimmune disease we don’t know all of the triggers that exist but here is a “short” list.

Postpartum: Pregnancy naturally causes a shift in the mother’s immune system to allow for the fetus to develop inside her body. This immune shift can trigger Hashimoto’s postpartum as the mother’s immune system tries to return to “normal”. It can be a transient or a permanent condition.

Iodine: Mild iodine deficiency is associated with a lower prevalence of Hashimoto’s disease and hypothyroidism while excessive iodine intake is associated with a higher prevalence.

Molecular mimicry: This is a critical piece to autoimmune disease. The basic concept is that your body mounts an immune response to something (pollen, food, virus, bacteria, etc.) and then those immune cells become confused and start attacking your tissues. With Hashimoto’s this happens frequently with gluten. I see many patients whose antibodies drop significantly upon going gluten-free. It also happens with certain GI bacteria especially Yersinia. Epstein Barr Virus has been implicated with triggering Hashimoto’s. On another gluten note, patients with Hashimoto’s are at an increased risk for celiac disease!

Intestinal permeability: This goes hand in hand with molecular mimicry. Intestinal permeability is often called “leaky gut”.  Our GI tract is technically outside of our body, you could eat a penny and it would pass right through your GI and out into the stool. Your body determines what is brought in through the GI tract in to your blood stream. When there is a breakdown in this process and larger particles are allowed in to the blood we call that intestinal permeability. When larger strings of amino acids (pieces of food that aren’t entirely broken down) make it through, the body attacks these as foreign invaders (as it should!). This attack can go awry and lead to attack on your own bodily tissues. Intestinal permeability is caused by stress, poor diet, overuse of NSAIDS, alcohol and more..

Genetics: There is a strong association with family history of thyroid disease and developing Hashimoto’s. Several genes have been implicated but, as is true for genetics as a whole, we don’t’ yet have a full understanding of exactly what genes are contributing.

Stress: It feels like we are always talking about stress! The health implications for excessive stress that isn’t managed with healthy outlets are far reaching. Even conventional medicine recognizes the impact stress has on developing Hashimoto’s and hypothesize it is due to the effects of cortisol on the immune system.  When addressing hypothyroidism/Hashimoto’s adrenal health is important to assess.

Radiation exposure: The thyroid is very susceptible to radiation so be sure to ask for a thyroid collar for any X-rays you receive.  Having excessive radiation exposure to your thyroid can increase the risk of thyroid disorders.
 
Typically conventional endocrinologists are not concerned with diagnosing Hashimoto’s. For an endocrinologist, the treatment is the same whether the patient has Hashimoto’s or plain hypothyroidism. In both cases the patient would be given synthetic T4 to replace the under functioning gland.
 
When treating a patient naturopathically the root cause of someone’s condition matters a great deal. With Hashimoto’s the underlying issue is an autoimmune disease that needs to be addressed. With simple hypothyroidism you want to look at co-factors for thyroid hormone production, adrenal health and other issues that could be playing a role. The treatment is very different between Hashimoto’s and simple hypothyroidism. Of note, when someone has an autoimmune disease they are more likely to develop another autoimmune disease so addressing the cause is critical!
 
Diagnosing Hashimoto’s is rather simple and can be done with blood work and/or a thyroid ultrasound. The ultrasound looks for thyroid damage characteristic of Hashimoto’s. Thorough blood work should include:
TSH
FT3
FT4
Anti-TPO antibodies
Anti-TG antibodies
 
Either antibody being elevated beyond normal is a clue that it might be Hashimoto’s. There is a percentage of the population that can have elevated antibodies without an elevation in their TSH or abnormalities of the T3 and T4. Conventionally this is a watch and wait situation. I recommend treating as if the patient has Hashimoto’s and working on diet and any possible underlying causes. In my experience it is possible for a patients antibodies to return to normal levels.

Approach to treatment:
 
Treatment is always tailored to the patient and includes dietary changes with an emphasis on a high antioxidant diet rich in vegetables. We also work to help balance the immune system by using herbs and supplements.  One part of working on this immune reaction is getting to the bottom of what caused it with helping to heal any intestinal permeability and balance the healthy flora in the GI tract.
 
Mind body medicine is important for Hashimoto’s. We must analyze stressors, stress response and any somatic manifestations of that stress. I often ask my thyroid patients, are you able to speak your truth?, with the thyroid located so close the voice box one has to wonder if somatic stress manifestation is one contributing factor to thyroid dysfunction.  
 
I do recommend that patients also use thyroid medication to help treat their Hashimoto’s. Patients who use thyroid hormone can see a reduction in their antibodies. Our goal with naturopathic treatment is to keep the medication dose stable and slow or stop the thyroid destruction. I am often asked if patients can expect to stop their medication eventually and that depends on the extent of the thyroid damage. Typically there will be some lifelong hormone replacement.
 
There is some concern that using natural desiccated thyroid (NDT) such as Armour thyroid, Nature-Throid or WP Thyroid can cause antibody levels to rise. This is mostly a theoretical concern that I have only seen once, maybe twice in practice. Many patients feel better using an NDT over synthetic thyroid hormone. How someone responds to thyroid medication is very individual and unfortunately it is often a trial and error process to find the right match.
 
If you are struggling with Hashimoto’s or simple hypothyroidism I recommend working with a naturopathic doctor to help identify the root cause of your autoimmune disease.
 
 
*The treatment discussion in this article is simplified and meant for educational purposes only. Please consult with a naturopathic doctor before implementing changes to your treatment plan.