Myo-inostiol and Selenium for Hashimoto's (2017)
You might already know that selenium can be very helpful for Hashimoto’s. It’s an antioxidant that supports the production of glutathione. Selenium is helpful in reducing anti TPO antibodies. This study compared patients using selenium alone and selenium with myo-inositol. 

Inositol is involved in cell signaling specifically around TSH, FSH and insulin. You may be familiar with inositol’s benefit for some patients with polycystic ovarian syndrome (PCOS) and it turns out, it’s helpful for patients with Hashimoto’s as well. 

This study found that using 600mg of inositol in combination with selenium was superior to selenium alone in reducing TSH levels and improving thyroid hormone concentration. TPOAb concentration decreased in both groups as expected. TgAb doesn’t tend to reduce with selenium supplementation alone and this study found that when adding myo-inositol there is a reduction in TgAb concentration! Patient’s also reported more symptom improvement when using a combination of selenium and myo-inositol. 

Bottom line: consider talking to your provider about using a combination of selenium and inositol to support your thyroid health.  


Nutraceuticals for Thyroid Health (2020)
This article is a review article which means the authors scoured the literature looking for all the information they could find on the topic. As the title indicates, most studies they looked at and discussed were done in animals. This article is full of great information about nutrients and their role in thyroid health. I am going to summarize some high points-
Vitamin D: Likely plays a protective role in preventing thyroiditis 

Zinc: Positively impacts thyroid function

Selenium: Improves immune regulation

Inositol: This was the topic of last month’s review article, these authors reviewed that study among others that concluded inositol is beneficial in autoimmune thyroid disease. 

Resveratrol: I’ve previously reviewed research exploring the mental health implications of Hashimoto’s disease and it appears that resveratrol might be useful. It improved BDNF and had antidepressant activity in hypothyroid mice. In addition, resveratrol appears to prevent the metabolic toxicity caused by fluoride exposure (drinking water) and restored the functional status of the thyroid. 

Soy: There is no easy answer here. Soy likely has different impacts on human health during various life stages (ie the effects on a baby fed soy formula are different from a perimenopausal person) making animal models unreliable for humans. It also appears that the potential goitrogenic effect of soy is made worse with low iodine in the diet. (My opinion- deciding soy is ‘bad’ for the thyroid and completely avoiding it is a little bit like throwing the baby out with the bathwater. If we took ever food/nutrients that may inhibit thyroid function out of the diet we would have very little left to eat.)

They also reviewed several synergistic reactions which really interests me. It’s not often we find THE ONE nutrient that the body needs to function better. We are complex creatures and nothing works in isolation. They found melatonin’s benefits were improved with zinc, selenium’s benefits were improved with inositol, and vitamin E’s benefit was improved with curcumin. 

There is much more to the article than what I summarized. It’s an open-access article available free online so check it out if you want more details :)


Cognitive functioning in Hashimoto's Patients (2018)
Something I hear at least weekly in practice is, “I am on levothyroxine/synthroid and my doctor says my thyroid is fine but I still have symptoms”. Well that is exactly the outcome from this study. They compared 139 patients with Hashimoto’s Thyroiditis (HT)  who were properly treated with medication and 111 people who do not have thyroid disease. The TSH, FT3 and FT4 were no different between the thyroid patients and controls. You know what was different between the two groups? Symptoms. Global cognitive function, anxiety and depression scores were all significantly worse in the adequately treated HT patients. This isn’t surprising to those of us that treat thyroid disease holistically. Just replacing thyroid hormone doesn’t get to the root of the problem. 

If you have Hashimoto’s and you’ve asked your conventional provider to check your antibodies (TPOAb and TGAb) you have likely been told that antibodies levels don’t matter. Well this study also helps disprove that long-held theory. The researchers found that TPOAb levels correlated with a lower quality of life in hypothyroid patients. 

Bottomline: Just replacing thyroid hormone often doesn’t improve symptoms in Hashimoto’s patients and checking antibody levels is an important part of your care. If your provider isn’t on board, might be time to look for a new one. 


Differences in food consumption between patients with Hashimoto’s thyroiditis and healthy individuals (2020)
I am pleased to see another study evaluating the relationship with food and Hashimoto’s Thyroiditis (HT) but unfortunately this study doesn’t give us very much clinically useful information. 

The most statistically significant results were that folks with HT consumed more animal fat and processed meat that controls. Controls consumed more red meat, grains, plant oils and non-alcoholic beverages. 

There was an association with elevated T3 levels in those who consumed more plant oil. The questionnaire used offered 3 options for fat intake: plant oil, olive oil and animal fat. So unfortunately, ‘plant oil’ covers a variety of oils and this nugget isn’t very helpful. 

This study isn’t clinically useful for a variety of reasons. This is a cross sectional, observational study that is not designed to give a causal connection between the consumption of food groups and HT development. It is also very challenging to accurately measure food intake via questionnaires. Anyone who has filled out or reviewed a diet diary understands this! The questionnaire used in the study was not designed to collect quantitative data on dietary intake, only frequency of intake. If someone eats 1 TBS of animal fat vs 5 TBS of animal fat 3x per week, that’s a big difference and isn’t taken into account in this study. 

Bottomline: Really nothing helpful here to incorporate into practice unfortunately. Again, still happy to see more research on diet and Hashimoto’s disease though!



References

1. ​Nordio M, Basciani S. Myo-inositol plus selenium supplementation restores euthyroid state in Hashimoto's patients with subclinical hypothyroidism. Eur Rev Med Pharmacol Sci. 2017 Jun;21(2 Suppl):51-59. PMID: 28724185.
2. Benvenga S, Ferrari SM, Elia G, Ragusa F, Patrizio A, Paparo SR, Camastra S, Bonofiglio D, Antonelli A, Fallahi P. Nutraceuticals in Thyroidology: A Review of in Vitro, and in Vivo Animal Studies. Nutrients. 2020 May 8;12(5):1337. doi: 10.3390/nu12051337. PMID: 32397091; PMCID: PMC7285044.
   
3. Djurovic M, Pereira AM, Smit JWA, Vasovic O, Damjanovic S, Jemuovic Z, Pavlovic D, Miljic D, Pekic S, Stojanovic M, Asanin M, Krljanac G, Petakov M. Cognitive functioning and quality of life in patients with Hashimoto thyroiditis on long-term levothyroxine replacement. Endocrine. 2018 Oct;62(1):136-143. doi: 10.1007/s12020-018-1649-6. Epub 2018 Jun 29. PMID: 29959689.
   
4. Kaličanin, Dean & Brčić, Luka & Ljubetić, Katija & Barić, Ana & Gračan, Sanda & Brekalo, Marko & Lovrić, Vesela & Kolcic, Ivana & Polasek, Ozren & Zemunik, Tatijana & Punda, Ante & Perica, Vesna. (2020). Differences in food consumption between patients with Hashimoto’s thyroiditis and healthy individuals. Scientific Reports. 10. 10670. 10.1038/s41598-020-67719-7. ​

​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. ⁠
⁠
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. 
⁠
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. ⁠
⁠
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.

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.