Chapter 3
Hypothyroidism Treatment and Optimization
He who has health has hope, and he who has hope has everything.
—ARABIC PROVERB
Hypothyroidism is the thyroid issue most linked to weight-loss challenges. And, for most thyroid patients, hypothyroidism—an underactive thyroid condition that requires thyroid hormone replacement for life—is also the end result of the disease process or treatments.
There are occasionally people with an active case of Graves’ disease who instead of losing weight—which is typical—will gain weight. But for the most part, as I sometimes say, “all roads lead to hypothyroidism.” For Hashimoto’s thyroiditis patients, the thyroid typically burns itself out over time, becoming less able to produce thyroid hormone, leaving most patients hypothyroid. With Graves’ disease and hyperthyroidism, most doctors in the United States administer radioactive iodine (RAI), which leaves patients without a functional thyroid. So these patients end up hypothyroid, even if they started out with an overactive gland. With thyroid nodules and goiter, surgery may be performed to remove all or part of the thyroid. The end result is often hypothyroidism. And almost all thyroid cancer patients have their thyroid gland removed entirely, leaving them completely hypothyroid and reliant on outside thyroid hormone replacement.
So whatever the thyroid disease or condition, and particularly if you are a thyroid patient who is struggling to lose weight, it’s likely that you are or will soon be hypothyroid, unable to produce sufficient thyroid hormone on your own, and taking thyroid hormone replacement medication. Getting proper treatment for your hypothyroidism may be the key to weight loss.
THYROID HORMONE REPLACEMENT MEDICATIONS
Conventional treatment of hypothyroidism typically involves replacing the missing thyroid hormone, using prescription thyroid hormone replacement drugs. The following summarizes the various drugs in this category:
Levothyroxine
The most commonly prescribed thyroid hormone replacement drug is levothyroxine. Levothyroxine is the generic name for the synthetic form of thyroxine (T4). It is sometimes referred to as “l-thyroxine” or “L-T4.” Some endocrinologists also incorrectly call it “thyroxine,” which is actually the name of the hormone produced in the body.
Levothyroxine is considered by conventional doctors to be the standard treatment for hypothyroidism, and many doctors will only prescribe levothyroxine for thyroid hormone replacement. The rationale is that people only need the synthetic T4, and the body will convert the T4 in the medication into T3 (triiodothyronine)—the thyroid hormone active at the cellular level. Some people with hypothyroidism find that levothyroxine therapy is sufficient treatment for their hypothyroidism.
Many doctors do not recommend generic levothyroxine. They tend to prefer brand names because there are several manufacturers of generic levothyroxine, and with each refill you may end up getting medication from a different manufacturer. These medications can vary in some cases from 95 to 105 percent of the stated potency, causing symptoms and testing irregularities. (And, for thyroid cancer survivors, erratic dosing can jeopardize therapy to prevent cancer recurrence.).
The primary difference between brand names is that each brand has different fillers, binders, and dyes, and some patients may have allergies to those ingredients. The 50 (mcg) pills from the brand-name levothyroxine manufacturers typically are free of dyes and are more likely to be hypoallergenic.
Levothyroxine came on the market in the late 1950s, without approval from the Food and Drug Administration (FDA). It was grandfathered in under approval for natural thyroid (Armour Thyroid) that had been available since the early 1900s. In 1997, the FDA required levothyroxine to go through the new drug application process and receive formal approval, given concerns over stability, potency, and reliability. The drugs were to be approved by 2000, but among the drugs on the market at the time, only Unithroid received approval within the FDA deadline. Levoxyl, Levothroid, and Synthroid were eventually approved.
There are several main brand names of levothyroxine on the market: These include
• Synthroid, the market leader, made by Abbott Laboratories. Synthroid is also one of the top-selling drugs in America.
• Levoxyl, the second highest-selling brand of levothyroxine.
• Levothroid, made by Forest Pharmaceuticals.
• The brand known as Unithroid, which was manufactured by Jerome Stevens, is now distributed as a generic by Lannett. This levothyroxine is considered to be of good quality.
• A newer, gelcap (instead of tablet) form of levothyroxine called Tirosint is also available. Tirosint has a liquid form of levothyroxine in its gelcaps, and a key benefit is that it is free of dyes, gluten, alcohol, lactose, and sugar.
As noted, a number of other manufacturers also make and distribute generic levothyroxine.
Synthroid, as a heavily marketed drug for more than three decades, enjoys a high degree of brand loyalty from physicians. Over the years, Synthroid’s manufacturer has been a major financial supporter of medical meetings and physician education, and has taken many opportunities to get Synthroid’s name in front of both new and established physicians. As a result, the name Synthroid is sometimes used by doctors to describe the whole category of thyroid hormone replacement drugs in general (in the same way that the brand name Kleenex has, for example, become synonymous with tissues or Xerox with photocopying).
Liothyronine
Liothyronine is the synthetic form of triiodothyronine (T3), the thyroid hormone active at the cellular level. Liothyronine is available in one manufactured drug, Cytomel, and as generic triiodothyronine.
Research has shown that some patients feel better with the addition of T3 in some form, and so practitioners prescribe a form of liothyronine along with a levothyroxine medication, or natural thyroid medication.
Francesca, who is perimenopausal with a thyroid problem, started going to a new nurse practitioner who put her on Cytomel.
My only side effect was a minor headache for two days, which went away with aspirin. The third day I realized I was awake. I woke up in the morning and was alert for the first time in years. It didn’t take me a hour to drag myself out of bed. I was only taking 5 mcg of Cytomel, and had an immediate result. My body temperature has risen to 98.1 degrees, and I am noticing little things changing in my body and health.
Liothyronine is also available from compounding pharmacies, which can make it available in regular or time-release capsules.
Dr. Richard Shames has found that T3 can be a helpful addition to a patient’s thyroid therapy.
When it comes to T3, some patients do well on T3, but it seems that some patients do better on time-release T3. It seems that the compounded, time-release form prevents that spike of T3 that you get with the manufactured T3 pills. For some patients, the time-release T3 provides the necessary gradient that helps to drive the T3 across the cell membrane barrier.
Sometimes thyroid cancer patients preparing for a scan are given T3 for several weeks, to help aid with hypothyroidism symptoms that result from the withdrawal from other thyroid medication that is needed for the scan’s accuracy.
Increasingly, integrative physicians are also using slow-release compounded T3-only treatment as a treatment for reverse T3 dominance.
Liotrix (Thyrolar)
Thyrolar is the brand name for liotrix, a combination of synthetic T4 (levothyroxine) and synthetic T3 (liothyronine) that is made by Forest Pharmaceuticals. This drug is not very regularly prescribed, but it is preferred by some physicians who wish to provide both T4 and T3 but prefer a synthetic drug versus natural (desiccated) thyroid.
The primary benefit of Thyrolar was that, as a single pill, it simplified the taking of a T4/T3 synthetic combination, and because it is a manufactured drug, some doctors are more comfortable prescribing it than prescribing T3 as a separate treatment.
Thyrolar is rarely prescribed anymore, however, because long-term shortages of the drug have made it difficult to ensure a steady supply. The drug is also expensive and requires refrigeration in order to maintain potency. Many patients who took Thyrolar in the past have switched to synthetic T4 and T3 as individual pills.
Natural, Desiccated Thyroid (Armour, Nature-Throid)
Natural desiccated thyroid is the original form of thyroid hormone replacement that first came into use early in the 1900s. From the early 1900s to the 1950s, this was the only thyroid replacement drug available—namely, Armour Thyroid. The drug fell out of favor with some endocrinologists, as Synthroid’s extensive marketing promoted synthetic thyroid drugs as a better, more modern option for thyroid treatment in the second half of the twentieth century. Marketing efforts aside, since the 1990s, the natural thyroid drugs have been enjoying a resurgence in popularity with some patients and practitioners.
Natural desiccated thyroid is derived from the thyroid gland of pigs and contains natural forms of the thyroid hormones T4 and T3, as well as other, lesser known thyroid hormones such as T2 and T1, the hormone calcitonin, and nutrients typically found in a natural thyroid gland. Some patients report improvement in symptoms using natural thyroid versus the synthetic medications. Decades ago, bovine (cow) thyroid was used, but prescription natural thyroid sold in the United States is currently porcine (from pigs).
The popularity of natural thyroid has grown with doctors, in particular osteopaths, naturopaths, integrative physicians, and holistic MDs, some of whom prefer to start their hypothyroid patients on a desiccated thyroid drug because they believe that since the drug contains a full spectrum of thyroid hormones as well as nutritional cofactors, it more closely mimics the action of human thyroid hormone, and their patients generally respond better.
The top-selling brand of natural thyroid is Armour Thyroid, made by Forest Pharmaceuticals.
RLC Laboratories also makes natural desiccated thyroid products Nature-Throid and Westhroid, which are hypoallergenic. The two RLC-manufactured natural desiccated thyroid drugs are identical except for the different names. Another brand of natural desiccated thyroid, from the manufacturer Erfa, is available in Canada, and some patients are importing this drug into the United States by prescription. A generic natural desiccated thyroid is available in the U.S. market, made by Acella.
Most endocrinologists and conventional practitioners tend to oppose use of natural thyroid on principle, primarily based on outdated concerns about potency, or because they are unfamiliar with the current manufacturing processes for desiccated thyroid or how to properly dose these medications.
Raw materials shortages, government-mandated manufacturing shutdowns, and other challenges to production have caused availability of natural desiccated thyroid drugs at times. It is also likely that the FDA will call for these drugs to go through a formal drug approval process—they have so far been able to bypass the formal approvals process because they were on the market and in safe use for decades before the FDA was created.
Compounded Thyroid Medications
Special pharmacies known as compounding pharmacies can create individualized combinations of thyroid medications at customized doses. Compounded thyroid medication, available only by prescription, can include:
• Combinations of synthetic T4 and T3 in regular or slow-release formulas
• Natural desiccated thyroid
• T4 only, in slow-release form
• T3 only, in slow-release form
WHAT THYROID MEDICATION SHOULD YOU TAKE?
You may wonder which thyroid medication you should take for hypothyroidism. The answer is not clear-cut.
In some cases, you may not have a choice. Your physician may make it standard practice to start everyone on a particular medication—often a levothyroxine drug such as Synthroid—although there are some holistic and integrative practitioners who start most of their patients on a natural desiccated thyroid drug. Your choice of medication or brand may also be dictated by cost, and you’ll start out with a medication that is covered by your insurance or HMO.
Over time, and with careful monitoring of your thyroid levels and symptoms, you’ll discover whether you might benefit from a different brand or a different medication.
There are some practitioners and patients who believe that one size fits all and suggest that everyone will and should feel perfectly fine on a particular thyroid drug. You’ll hear this about Synthroid, but there are some equally strong voices arguing that natural desiccated thyroid is vastly superior to any synthetic combination drugs.
I disagree with them all.
The best thyroid medication is the one that safely works best for you. It’s tempting to want to declare a particular drug the “winner”—but I’ve talked to too many thyroid patients in the past fifteen years to believe that any one treatment works for everyone. Patients want to keep in mind several important factors:
1. With any thyroid drug, one brand’s fillers, dyes, and binders may affect you differently than another’s, so you may want to try a different brand of medication.
2. Some patients seem to need additional T3; others are extremely sensitive to it and do well on T4-only treatment.
3. Some patients who are unable to relieve symptoms on synthetic treatments do better on natural desiccated thyroid.
4. Some patients who are unable to relieve symptoms on natural desiccated thyroid do better on synthetic treatments.
Some practitioners like to start with a T4 drug, add T3 if needed, and switch to a natural thyroid drug as a third option. Others may prefer to start with natural thyroid.
Hormone expert and holistic gynecologist Dr. Sara Gottfried explains her approach.
My tendency when I see someone from the start who is newly diagnosed as hypothyroid is to start them on a natural desiccated thyroid preparation, either Armour or Nature-Throid. I even use it with patients who have autoimmune thyroiditis, despite the old dogma not to use it with those patients. I find that clinically it’s very effective. I frequently see patients who are already on Synthroid or Levoxyl, but the TSH not where it should be, and free T3 is low. With those patients, I’ll often add T3—either Cytomel or a slow-release T3.
OPTIMIZING THYROID TREATMENT
If you are still suffering from thyroid symptoms and finding it difficult or impossible to lose weight, or if you’re gaining weight even though you’re on a healthy diet and exercise program, there’s a good chance that your thyroid treatment is not optimized. Many integrative practitioners believe that the optimal TSH level for the majority of thyroid patients is between 1 and 2. Free T4 levels should be in the top half of the normal range, and free T3 in the top half—or in some cases the top 25 percent—of normal. Reverse T3 should not be substantially elevated. And many doctors, including thyroid and weight-loss expert Kent Holtorf, MD, like to see the ratio of free T3 to reverse T3 at 0.2 or above, with reverse T3 ideally below 150.
A number of situations can contribute to less-than-optimal thyroid treatment:
• Insufficient T4
• Insufficient T3
• Problems with conversion of T4 to T3
• Problems with the cells’ ability to absorb the T3
Any of these problems can interfere with optimal thyroid function and disrupt metabolism. Here are some questions you can consider that address the various concerns relating to optimal thyroid function.
Are You at the Optimal TSH for You?
The first step, no matter what thyroid medication you are taking, is to make sure that you are on the right dose for you.
As noted earlier, while the normal reference range for TSH still typically shows up on lab reports as 0.5 to 5.0, many practitioners believe that levels above 2.5 to 3.0 are indicative of hypothyroidism. A study reported in the Journal of Clinical Endocrinology and Metabolism found that the mean TSH level for people who don’t have a thyroid condition is actually 1.5.
So if your TSH is on the higher end of normal for you, it’s no wonder that you may find it hard to lose weight. If you are on thyroid medication, check your most recent blood test results; if your TSH is above 2.0, consult with your physician about whether a slight increase in medication dosage would be better for your health.
Allie, age fifty, started having a weight problem around the time she hit forty. She also had a laundry list of symptoms, including dry skin, hot flashes, memory loss, and low sex drive. Her doctor decided it was menopause and depression. Allie kept insisting on a thyroid test. She was finally tested and diagnosed as hypothyroid at age forty-eight. Her symptoms continued, and she insisted on more blood work. Her TSH level was 5.2, which according to Allie’s doctor was normal.
I insisted that, knowing my body, it was too high for me. He was quite adamant that my problem was not my thyroid, but that I needed to admit that it was depression and that I had all the symptoms. When I told him that all of my symptoms were from a low thyroid problem and that the latest count just wasn’t compatible with my body, and that I wasn’t depressed, his answer was, “I’ll bet 95 percent of the people in the psychiatric ward say the same thing.”
Allie finally saw another physician, who said she was being undertreated and upped her dosage of thyroid hormone replacement. She’s feeling dramatically better.
Do You Need a Seasonal Adjustment in Dosage?
One little-known issue for thyroid patients is the seasonal variation in thyroid function. A number of studies show that TSH naturally rises during colder months and drops to low-normal or even hyperthyroid levels in the warmest months. Some doctors adjust for this by prescribing slightly increased dosages during colder months and reducing dosage during warm periods. Most doctors and patients are not aware of this seasonal fluctuation, however, leaving patients suffering with worsening hypothyroidism symptoms during colder months, or going through warmer months suffering with hyperthyroidism symptoms due to slight overdosage. This seasonal fluctuation becomes more pronounced in older people and in particularly cold climates. Twice-yearly tests, at minimum during winter and summer months, can help assess fluctuations and guide any seasonal dosage modifications needed.
Are You on the Right Brand of Levothyroxine for You?
The reality is, most people start out taking a levothyroxine drug. But some people simply do not feel well on one brand of levothyroxine, and changing brands seems to help. Keep in mind that Synthroid is known to dissolve extremely slowly and may not get fully absorbed in someone with quick digestion. Synthroid also contains lactose and acacia as fillers, and these substances can make the medication less effective or problematic for people who have lactose intolerance or seasonal allergies to tree and grass pollen. The other leading brand name of levothyroxine, Levoxyl, does not contain these ingredients. Levoxyl is a very fast-dissolving formula—in fact, it should be taken with a big glass of water—and may be better suited for some thyroid patients. The new liquid capsule form of levothyroxine, Tirosint, has no fillers, dyes, binders, lactose, acacia, soy or gluten, and may be a better choice for some patients who are especially sensitive to any of these ingredients.
With several FDA-approved brands (Levoxyl, Synthroid, and Tirosint, among others) available, you may wish to discuss a change with your physician. Do stick with a brand name, however, and not a generic, to ensure consistency. (Unless you have a relationship with your pharmacist, who will ensure that you get the same manufacturer of generic each time. Otherwise, every time you refill a generic prescription, you are at risk of getting a different manufacturer’s levothyroxine, and they can vary in potency from one maker to the next.)
Do You Need T3?
Some people do not feel their best and find it difficult to lose weight without the addition of a second thyroid hormone known as T3. T3 is the active thyroid hormone. Usually, the body converts T4 to T3, but nutritional deficiencies, toxins, and a variety of other physiological factors may prevent the body from accomplishing that conversion process properly, leaving you deficient in this most important thyroid hormone. In one research study, experts found that among a group of one hundred obese patients, more than 90 percent of those studied had T3 levels that were below the mean. So it’s clear that low T3 or inability to convert T4 to T3 may contribute to weight gain or difficulty losing weight.
In late 2009, a Danish study, reported on in the prestigious European Journal of Endocrinology, studied the effects of a levothyroxine-only therapy versus levothyroxine plus T3 (in this case, a dosage of 20 mcg of T3 daily was used). Tests for quality of life and depression were performed at the start, and after twelve-week treatment periods where the study subjects were given levothyroxine plus T3, or levothyroxine plus placebo, and then switched for the next twelve-week period. Participants were “blind” in that they were not aware whether they were taking active T3 or placebo.
The quality of life and psychological factors evaluated included, among other factors: general health, social functioning, mental health, vitality, sensitivity, depression, and anxiety. The study showed that among the patients, most of whom were women, 49 percent of the patients preferred the combination treatment, and only 15 percent preferred levothyroxine-only treatment.
Researchers have been going back and forth for more than a decade about the value of T3, but based on their own practical experience with patients, and on the growing body of research evidence, integrative hormone experts are increasingly adding supplemental T3 as a solution to help optimize thyroid treatment for some patients. They add T3 in one of several ways:
• Adding T3 to levothyroxine treatment, via the addition of the prescription synthetic T3 drug Cytomel or generic synthetic T3
• Adding synthetic T3 via compounded sustained-release T3 in addition to levothyroxine
• Adding a dosage of a natural desiccated thyroid, such as the prescription drugs Armour Thyroid or Nature-Throid, to a levothyroxine treatment, or switching patients to a natural desiccated thyroid drug entirely
• Prescribing the combination synthetic drug Thyrolar, which includes both T4 and T3 (increasingly less common, as Thyrolar has gone through such extensive shortages, back orders, and manufacturing issues that it seems to be unavailable most of the time)
The key point? Check with your physician about whether supplemental T3 might be helpful for you.
It’s important to keep in mind, however, that because T3 is the active hormone, it can have an overstimulatory effect on heart rate and pulse in some people, especially those with a history of heart disease, the elderly, and those with heart irregularities such as mitral valve prolapse. T3-savvy physicians evaluate the safety of T3 as compared to the potential benefits on a case-by-case basis.
Even in those patients who do not have any heart- or age-related issues that may make T3 problematic, some patients are simply more sensitive to T3. The heart is very sensitive to thyroid hormone in general, and for some people, even low doses of Cytomel or generic T3 can cause a rise in pulse, or heart palpitations.
For those patients, physicians often recommend a time-release form of T3 called sustained-release or slow-release T3, available by prescription from compounding pharmacies.
Many physicians, in fact, believe that the slow-release T3 is actually the optimal form for supplemental T3, as it more closely resembles the body’s own conversion to and release of T3, and because the slow-release form is less likely to cause any side effects.
A 2008 Canadian study found that treating primary autoimmune hypothyroid patients who had persistent symptoms and signs of hypothyroidism with a combination of levothyroxine plus slow-release T3 (the dose in this study was approximately 13 mcg) resulted in a significant rise in the serum T3 level and a decrease in persistent hypothyroidism symptoms, without a change to the TSH.
Do keep in mind, however, that many conventional endocrinologists do not recognize the need for T3. Lou explains her situation:
After I had my thyroid removed due to nodules and went on Synthroid, I ballooned to over 200 pounds from 145 pounds over six months. My endocrinologist said I had “fork-in-mouth” disease and sent me to a psychiatrist for depression. The psychiatrist said he didn’t think I was depressed, I just needed T3, and called the doctor and told him so. The endocrinologist was married to Synthroid and said no. In the meantime I continued to gain weight on a 900-calorie diet.
Eventually she found a new doctor, who added T3 to her treatment, and she was able to lose weight and shift to a healthier diet.
Kent Holtorf, MD, is finding that either a T4/T3 combination or, increasingly, a T3-only treatment is optimal for his thyroid patients who are struggling to lose weight. Says Dr. Holtorf:
I find that T4 alone rarely works optimally for anyone. I’ve had a handful of patients who don’t tolerate T3, but T4/T3 is so much better for most patients. I find, however, that the more symptomatic they are, the more T3 they often need.
Do You Need Natural Desiccated Thyroid?
Some practitioners believe that certain patients simply do best on natural desiccated thyroid. This drug—known as porcine thyroid, or sometimes as “natural thyroid” or “pig thyroid”—is manufactured from the dried thyroid gland of pigs. The drugs in this category include Armour Thyroid, Nature-throid, and Erfa Thyroid, and are prescription thyroid drugs that have been in use for more than a century. Integrative hormone experts believe that these drugs, which provide T4, T3, T2, T1, and other thyroid hormones and nutritional elements, more closely resemble human thyroid hormone than the synthetic drugs, and report that their patients feel better on them. Some patients find that they feel best on natural thyroid drugs, or on synthetic drugs plus some natural thyroid.
Keep in mind that the conventional view of natural thyroid drugs—and in particular, the view of many endocrinologists—is that these drugs are out of date and not “consistent,” and many simply will not prescribe them. If you want this type of medication, you may have to find a holistic or alternative physician.
Margie describes her experience with natural thyroid:
At the age of forty-nine, I was diagnosed with hypothyroidism by my family practitioner. I had been gaining weight for about a year at that time, after having been thin to normal weight all through my adult life. She put me on Levoxyl. I continued to gain weight, along with all the other symptoms continuing unabated. I had horrible fatigue, no sex drive, mental fog, hair loss, brittle fingernails, irritability, fibroids and heavy bleeding (for which I ultimately had a hysterectomy), night sweats, sleep disturbances, and high blood pressure—you get the picture. My insurance company switched me to the generic levothyroxine, and I put on another quick seven pounds. We messed with the dose. Nothing happened. I consulted an endocrinologist, who switched me to Synthroid and changed my dose again. The symptoms and weight gain continued. She also told me that my weight gain was “the totally normal twelve to twenty-two pounds”! Over the course of six years, I was beginning to feel like I might have to spend the rest of my life dragging myself around feeling awful, and awful to be around. I decided I had to try Armour. I begged my endocrinologist to put me on a trial of Armour, as I sat crying in her office. She did, and immediately my life changed. Within days, the weight started coming off. My hair stopped falling out. My fingernails stopped breaking. I started to wake up in the morning rather than forcing myself out of bed, totally exhausted. I was less irritable, more productive at work, less overwhelmed. I did not change my diet, although I was less hungry for sugar and processed food, and did not require as much coffee to get me going in the morning, as I was sleeping through the night and the night sweats went away. I did not exercise more until I dropped the first fifteen pounds. In fact, I was not exercising at all! All in all, I lost thirty pounds. My only regret is that I didn’t do this much, much sooner. It has taught me many lessons about being proactive with health professionals and my own health care needs, lessons that I will use the rest of my life.
At first, Alex struggled to get diagnosed:
My TSH was never above 4.9 and I have Hashimoto’s antibodies. With this TSH, however, my doctor never treated me, however, telling me my thyroid tests were perfect. Over time, after my TSH went up, I finally was treated, but meanwhile, I had gone from a slim person with small bones to this really quite fat person for my bone structure. Even at 112 mcg of Synthroid, I was getting worse every day. I left my GP and my endocrinologist and went to a doctor who put me on desiccated thyroid. My weight gain stopped within two weeks. So far, on the natural thyroid, I have lost thirty-one pounds. I actually didn’t diet. What happened was that my switch from my brain changed back to telling me, I had eaten enough. When I was not treated and on Synthroid, this turnoff switch in my brain was gone and my brain never told me I was full. I was eating quite a lot and I think it was because I was so tired all the time, but more than that, my disease made me into a binge eater. Now I am a new person. It is magic to not be eating so much, not because I have to try and diet, but because my brain is getting what it needs to stop the binging. My taste in food has altered totally too, and I don’t crave carbs day and night; I crave good food now.
Should You Take Your Thyroid Medication More than Once a Day?
If you are taking a levothyroxine drug, there is no benefit to splitting or staggering your dose and taking it multiple times a day because the drug such a long half-life in your body.
For drugs that contain T3, including Cytomel, Thyrolar, Armour and the other desiccated thyroid drugs, and compounded drugs that contain T3, you may in fact want to stagger your dosage throughout the day, to help maintain a steady level and offer the best possible relief of symptoms. T3 is faster-acting and has a shorter half-life in the body, and some people report better results when they take their thyroid medications two or three times a day. Some patients take a dose in the morning and at bedtime; others take a morning, lunchtime, and bedtime dose. Time-release compounded drugs eliminate the need for split dosages by gradually releasing T3 throughout the day.
Note: You should always discuss any change in the way you take your medication with your physician.
Are You Being Deliberately Underdosed?
Some practitioners make it a practice to underdose thyroid medication. This means that they will give you just enough thyroid medication to get your TSH level into the top end of whichever normal range they follow—even though many practitioners and patients recognize that the majority of patients feel best at a level more like the general population’s average TSH of 1.0 to 2.0.
The main reason for this policy of underdosing is the fear of osteoporosis, which was discussed earlier in the chapter. Practitioners are mistakenly concerned that maintaining a woman’s TSH level at a level of, say, 1.0 to 2.0, rather than above 4.0, is a risk factor for osteoporosis. Meanwhile, if you’re being treated but your TSH is still in the high-normal range—and I consider that to be 3.0 and above—then you may not feel well.
If you have a doctor who has this philosophy, you may be able to get the doctor to work with you on increasing dosage by agreeing to have periodic bone densitometry testing. This will assure your doctor that the medication is not having an adverse effect.
Are You Taking Your Medication Properly?
There are a number of guidelines on how to properly take thyroid hormone to ensure that you are absorbing the drug and receiving the maximum possible benefit.
• Don’t take your thyroid hormone replacement drug within four hours of taking calcium supplements or calcium-fortified juice. This includes antacids such as Tums or Mylanta in liquid or tablet form, which also contain calcium. Calcium can delay or reduce the absorption of your thyroid hormone.
• Don’t take thyroid hormone replacement drugs within four hours of taking any supplements that contain iron, including prenatal vitamins, which are usually high in iron.
• Don’t take your thyroid medication until at least an hour after you have had coffee. Coffee can block absorption of your thyroid pill.
• Try to take your thyroid hormone around the same time each day. For best results, maximum absorption, and minimum interference from food, fiber, and supplements, doctors recommend taking it in the morning on an empty stomach, about an hour before eating.
• If you need to take your thyroid hormone with food, be consistent and always take it with food.
• If you start or stop a high-fiber diet while you are on thyroid hormone, have your thyroid function retested around six to eight weeks after your dietary change. High-fiber diets can change the speed of thyroid drug absorption, and you may require a dosage adjustment. You should also be consistent about your daily fiber intake. Don’t have 10 grams one day, 30 grams the next day, and so on, or you’re risking erratic absorption.
• If you start or stop an antidepressant medication, or a medication that contains estrogen, have your thyroid function retested around six to eight weeks later to see if you need a adjustment to your medication, as these drugs can affect thyroid absorption or effectiveness.
• If you are taking the Levoxyl brand of levothyroxine, take the drug with a lot of water and swallow the pill quickly. The pill dissolves rapidly, and if it dissolves in your mouth before swallowing it, you risk not absorbing all of the active ingredients.
Are Other Medications Interfering with or Interacting with Your Thyroid Medication?
Use of tricyclic antidepressants such as doxepin (Adapin), amitriptyline (Elavil), desipramine (Norpramin), and imipramine (Tofranil) at the same time as thyroid hormones may increase the effects of both drugs and may accelerate the effects of the antidepressant. Be sure your doctor knows you are on one before prescribing the other.
Also, researchers have found that taking thyroid hormone replacement while taking the popular antidepressant sertraline (Zoloft) can cause a decrease in the effectiveness of the thyroid hormone replacement. This same effect has also been seen in patients receiving other selective serotonin reuptake inhibitors (SSRIs) such as paroxetine (Paxil) and fluoxetine (Prozac).
If you are taking an antidepressant and your doctor prescribes thyroid medication (or vice versa), be sure get your thyroid retested six to eight weeks after starting your new medication to evaluate any possible interactions.
A number of other drugs interact with thyroid hormone or affect thyroid function:
• Insulin. Thyroid hormone can reduce the effectiveness of insulin and the similar drugs for diabetes. Be sure your doctor knows you are on one before prescribing the other.
• Cholestyramine (Questran) or colestipol (Colestid). These cholesterol-lowering drugs bind thyroid hormones. A minimum of four to five hours should elapse between taking these drugs and thyroid hormones.
• Anticoagulants (blood thinners). Anticoagulant drugs such as warfarin (Coumadin) or heparin can sometimes become stronger in the system when thyroid hormone is added to the mix. Mention it to your doctor if you are on one or the other.
• Corticosteroids, adrenocorticosteroids. Steroid drugs like prednisone can suppress TSH and can block conversion of T4 to T3 in some people.
• Amiodarone (Cordarone). This heart drug can cause hypothyroidism or hyperthyroidism and interfere with T4 metabolism. People taking amiodarone should be monitored periodically for thyroid changes.
• Ketamine. Some patients using ketamine, a drug used as an anesthetic (and illegally as a recreational hallucinogen known as “K” or “Special K”), experience elevated blood pressure and a racing heartbeat when taking levothyroxine sodium and ketamine at the same time.
• Maprotiline. This antidepressant can increase a risk of cardiac arrhythmias when taken with thyroid hormone products.
• Theophylline. This drug for asthma and respiratory diseases may not clear out of the body as quickly when someone is hypothyroid, but usually clears normally when the thyroid is in the normal range.
• Lithium. Lithium, used to treat bipolar disease and some forms of depression, is known to actually create hypothyroidism by blocking secretion of T4 and T3. People taking lithium should be monitored periodically for thyroid changes.
• Phenytoin (Dilantin). This anticonvulsant may accelerate levothyroxine metabolism, and tests may show decreased total T4 levels.
• Carbamazepine (Tegretol). This anticonvulsant pain medicine may accelerate levothyroxine metabolism, and tests may show decreased total T4 levels.
• Rifampin. This antituberculosis agent may accelerate levothyroxine metabolism, and tests may show decreased total T4 levels.
Are You Forgetting to Take Your Medication?
Surprisingly, one of the key reasons patients don’t feel well on thyroid treatment is that they are failing to take their medications regularly, as prescribed. When you are taking thyroid hormone replacement, it’s critical that you take it every day as prescribed. Even a day or two’s failure to take thyroid medications can throw off your treatment regimen and have a dramatic effect on your overall health. Here are some tips on how to remember to take your thyroid medication.
• Write it in your datebook. Write it in a special color that is hard to miss.
• Schedule a reminder. If you use a computer, cell phone, or personal digital assistant (PDA) such as a BlackBerry or iPhone, consider putting a reminder in your scheduling program. Some programs allow you to set a regular daily “appointment” at a particular time. Some even have an alarm function you can set to remind you.
• Use a screen saver. You may be able to put a message on your computer’s screen saver.
• Keep your pill container right on top of your alarm clock. This can help you remember to take your medicine first thing in the morning. (But be careful to keep your medications away from children.)
• Link taking your medicine with key daily events. One example might be brushing your teeth in the morning.
• Put a note wherever you’ll notice it every day. Try on the refrigerator, on your coffeemaker, on your toothbrush, or on your bathroom mirror.
• Take your medicine the same time every day. This will help it become a habit.
• Hire a calling service to give you a daily wake-up call to remind you to take your pill. If you have a home voice mail answering system, you may be able to program a daily reminder call at the same time each day. You can even sign up online for free services such as those at Wakerupper.com, which will make free reminder calls to you.
• Use a pill sorter. This device, also known as a dosette, has compartments for different days, or even different times of the day.
• Get a special device to remind you to take your pill. You can get medication computers, vibrating watches, automatic dispensers, beepers, and other alarms that can help keep you on schedule for taking your medication.
• Enlist the aid of a family member or friend. Sometimes just a few weeks of friendly reminders can help you get into the habit of taking your medicine at the right time every day.
RELATED IMBALANCES
For thyroid patients, several other imbalances should be tested for.
Ferritin
Ferritin is a protein that stores and releases iron, and it has a relationship to hormone balance, energy, and hair. Dr. Sara Gottfried explains:
My opinion is that we need ferritin to be between 50 and 80 ng/mL (nanograms per milliliter) to feel our best and for hormones to operate properly. I find that to be especially true for menstruating women. If I find a low ferritin, my preference is for a patient to get it from food. If someone is not vegan, I’d recommend grass-fed beef, organic lamb. Leafy greens are also good, especially kale, chard, and watercress. For iron supplements, sometimes I will use glandulars like Integrative Therapeutics Iron Complex. Because people can have trouble absorbing iron, I also sometimes recommend Floradix liquid, which is a ferrous gluconate form that is better absorbed, but more expensive.
According to Jacob Teitelbaum, MD:
If ferritin comes back under 50 (normal is anything over 12), taking iron is helpful. If it is over 50, you likely don’t need iron unless you have hair loss, in which case supplement with iron until your ferritin is over 100.
Adrenals
For some thyroid patients, an important factor that must be addressed simultaneously in order to treat hypothyroidism is an adrenal dysfunction, or a condition known as adrenal fatigue. Thyroid and hormone expert Dr. Richard Shames explains the different levels of adrenal fatigue:
A failing adrenal gland goes through a hyper phase before it becomes totally exhausted. In the 1950s, the famous researcher Hans Selye divided the physiology of fight-or-flight into three phases. In the first phase, adaptation, a person intermittently secretes slightly higher levels of the fight-or-flight hormones in response to a slightly higher level of stress. The second phase, called alarm, begins when the stress is constant enough, or great enough, to cause sustained excessive levels of certain adrenal hormones. This can be the very earliest glimmer of what later can become stress-induced illness. The third phase is called exhaustion, wherein the body’s ability to cope with the stress is now depleted. At this point, adrenal hormones plummet from excessively high to excessively low. It is this latter phase of adrenal exhaustion that sometimes accompanies, or is confused with, low thyroid. Where do low thyroid and adrenal stress intersect? If you find yourself in the alarm phase of adrenal stress (high levels of ACTH and high levels of cortisol), one result might be altered conversion of T4 into T3, or thyronine. Thus, your adrenal situation might profoundly affect the availability of biologically active thyroid hormone.
In addition to the continuation of thyroid symptoms after treatment and feeling “tired but wired,” some common signs of adrenal fatigue include:
• Excessive fatigue
• Unrefreshing sleep (you get sufficient hours of sleep, but wake fatigued)
• Feeling overwhelmed by or unable to cope with stress
• Feeling especially run down or exhausted after stressful physical or emotional experiences
• Exhaustion or slow recovery after exercise
• Poor resistance to respiratory infections
• Difficulty recuperating from illness
• Slow to recover from injury
• Difficulty recuperating from jet lag or time changes
• Generally feeling run-down or overwhelmed
• Cravings for salty foods
• Excess mood responses after eating carbohydrates
• Feeling exhausted in the morning, or at highest energy in the evening
• Difficulty concentrating; brain fog
• Low sex drive
• Dark circles under the eyes
• Particularly low blood pressure
• Momentary light-headedness after standing up
• Extreme sensitivity to cold
• Chronic food or environmental allergies
• Cystic breasts
• A history of mononucleosis or Epstein-Barr virus reactivation
• A history of chronic fatigue syndrome
According to Richard Shames, MD:
If low-thyroid people with these symptoms are put on thyroid hormone alone, they sometimes respond negatively. These people may have coexistent, but hidden, low adrenal. If they take thyroid hormone by itself, the resultant increased metabolism may accelerate the low adrenal problem. The addition of thyroid hormone in this situation unmasks the low adrenal situation.
Many integrative physicians use the twenty-four-hour saliva cortisol test to evaluate adrenal function, looking at the levels of cortisol at four or six points during the daily cycle. Other hormones measured to evaluate adrenal function include pregnenolone and dehydroepiandrosterone (DHEA). Pregnenolone, which is synthesized from cholesterol, is a precursor for three hormones: the adrenal hormone cortisol and reproductive hormones DHEA and progesterone. Because it is the precursor for all the other reproductive hormones, pregnenolone is sometimes called a “parent hormone.” Pregnenolone has roles in helping to elevate mood and energy, relieve joint pain, and improve concentration, and it is thought to help with brain function. DHEA is a steroid hormone produced by the adrenal glands as well as by the brain and the skin. DHEA levels peak around age twenty-five to thirty and steadily decline after that, so that by age eighty, the DHEA level is typically only about 15 percent of the peak level. DHEA is derived from pregnenolone and broken down into estrogen and testosterone. DHEA helps with memory, the immune system, reduction of fatigue, strength, and building muscle.
Dr. Adrienne Clamp incorporates adrenal analysis into her overall hormone balancing approach. According to Dr. Clamp:
The role of suboptimal adrenal function is not very well addressed or recognized. It can wreak havoc and undermine health and wellness if not addressed. When thyroid function appears to be normal and still someone suffers with all the symptoms of hypothyroidism, often adrenal hypofunction is to blame. Diagnosis can be suggested by the history of recent or prolonged stress, or recurrent bouts of serious illness. It is best confirmed by measurement of saliva cortisol levels throughout the day and evening. Measurement of the other hormones made by the adrenal gland such as DHEA sulfate and aldosterone is also helpful.
Treatment of the adrenal gland dysfunction depends on the pattern. I usually turn to herbal adaptogens first, as well as recommending work on stress reduction by means such as meditation, relaxation, learning different coping mechanisms and psychological counseling, among others. Sometimes hormone replacement is needed and, in extreme cases of hypofunction, even low doses of cortisol, though this is typically recommended only after trying the other approaches.
If evidence of adrenal imbalance or fatigue is found, some practitioners recommend adaptogenic supplements, such as ashwagandha. If adrenal fatigue is evident, a variety of herbal and vitamin approaches may be tried. In some cases, a combination glandular adrenal/herbal support formula is recommended. One that I have found helpful for me is Enzymatic Therapy’s Fatigued to Fantastic: Adrenal Stress End, formulated by Jacob Teitelbaum, MD, or Adreset, by Metagenics. In some cases where adrenal insufficiency may be more severe, some practitioners prescribe low doses of hydrocortisone, a bioidentical form of the hormone cortisol.
Keep in mind that traditional endocrinologists do not typically recognize the existence of low-level adrenal dysfunction. Much as it took several decades for endocrinology to recognize the concept of prediabetes or insulin resistance, the endocrinology community is slow to recognize that imbalance or mild insufficiency of adrenal hormone represents a diagnosable, treatable hormonal imbalance in some patients.
NUTRITION AND SUPPLEMENTS FOR THYROID FUNCTION
You’ll also want to make sure that you are getting proper nutritional supplements to help support your thyroid. The following are the basics that many physicians recommend.
Multivitamins
A high-potency multivitamin is essential for thyroid patients. Look for one that has high amounts of vitamins B, C, and E and a good range of minerals. One that I particularly like is Dr. Jacob Teitelbaum’s formulation, known as Daily Energy Revitalization (see Resources). The vitamin comes as a flavorful powdered drink and this replaces more than 30 vitamins and supplement pills each day. The formulation includes only a trace amount of calcium, so it’s suitable for thyroid patients to take with their thyroid medication. The formula includes a low dose of iodine that Dr. Teitelbaum feels is a healthy maintenance level to help support the thyroid. You may want to slightly reduce your daily dosage if you are iodine sensitive. Says Dr. Teitelbaum: “I also added vitamin K, strontium, lipoic acid, and increased vitamin D levels to make it even more optimized for people with thyroid problems and the general public.”
A good option if you want an iodine- and iron-free antioxidant multivitamin is the Advanced Nutritional System line of vitamins from Rainbow Light. They have a SafeGuard Iron-Free, Complete Nutritional System Iron-Free, and Just Once Iron-Free SafeGuard multivitamins.
Specifically, you want to make sure you are getting:
• Vitamin A. A deficiency in vitamin A may limit the ability to produce thyroid hormone.
• Vitamin B2 (riboflavin). A shortage of vitamin B2 can depress endocrine function, especially the thyroid and adrenals.
• Vitamin B3 (niacin). Vitamin B3 helps keep cells working by aiding in respiration and delivery of energy to cells.
• Vitamin B6 (pyridoxine). Vitamin B6 helps the body convert iodine to thyroid hormone.
• Vitamin B12 (cyanocobalamin, methylcobalamin). Hypothyroidism makes us less able to absorb sufficient B12 from diets. Some experts believe we should be getting 1,000 to 5,000 micrograms (mcg) a day, even via injection when possible. Sublingual B12 is a more effective form of delivery than other B12 supplements.
• Vitamin E. Vitamin E is an essential antioxidant, and also can help with immune function.
Vitamin C
Many experts recommend that you add 2 to 3 grams—that is, 2,000 to 3,000 mg—of vitamin C each day. You can use capsules, tablets, or powdered forms of vitamin C.
Some research has also shown better absorption of thyroid medication when it’s taken along with vitamin C.
One particular favorite of mine is Emergen-C drink mix. It’s very low in calories and sugar but very flavorful (I particularly like the raspberry, cranberry, and tangerine flavors). Each envelope makes one drink, and the drink has a bit of fizz to it, so it functions like a soda. But it’s packed with 1,000 mg (1 gram) of vitamin C, as well as B6, B12, potassium, and a variety of other useful nutrients.
Vitamin D
Vitamin D is a vitamin, but it also functions as a hormone. It is necessary in order for the pituitary gland to produce thyroid hormone, and it may play a role in T3 binding to its receptor. Vitamin D is part of the necessary supporting apparatus that enables the enzyme deiodinase to convert T4 (inactive thyroid hormone) into T3 (the active type). It is also thought that vitamin D is necessary for healthy immune system functioning.
Cardiologist and hormone expert Dr. Rob Carlson believes that vitamin D is especially important for thyroid patients:
I feel that screening for vitamin D deficiency should be strongly recommended for all thyroid patients. Vitamin D is required for thyroid hormone production in the pituitary gland, and is involved in the early stages of triiodothyronine or T3 binding to its receptor and initiating receptor activity. In the presence of low levels of circulating vitamin D3, our body’s ability to produce and regulate thyroid hormones may be hindered. And low levels are common, especially between September and May, in areas above 35 degrees latitude (the border between North Carolina and Georgia), and in those who avoid the sun or use sunscreen. I recommend using vitamin D3 gelcaps, which are very inexpensive and easy to take.
Vitamin D deficiency is so rampant that this is one vitamin level that you should have tested. Dr. Sara Gottfried likes to see vitamin D levels in the 50 to 80 ng/mL range, and Dr. Kent Holtorf feels that a level of at least 80 is optimal for immune health and weight loss.
Probiotics
Probiotics are supplements that contain the “good” bacteria found in fermented foods such as miso and dairy products such as yogurt and some cheeses. We are meant to have these bacteria in sufficient quantities in our intestinal system. One of the more well-known probiotic bacterium is acidophilus, the live cultures found in yogurt. According to a report in the European Journal of Clinical Nutrition, the probiotic bacteria known as Bifidobacterium lactis HN019 boosts the activity of various disease-killing immune system cells in healthy adults. Probiotics help proper digestive functioning, which enhances the immune system. They also promote a healthy balance of bacteria in the digestive system.
You can eat yogurt, but the concentration of live cultures in many brands of yogurt is not typically high enough to get a substantial effect—plus many people are sensitive to dairy. So a daily probiotic supplement is your best option. Some probiotic supplements can be expensive and require refrigeration, but I recommend a patented formula from Enzymatic Therapies, the Probiotic Pearls. This tiny pearl-shaped supplement contains a guaranteed level of live bacteria in the millions and requires no refrigeration.
Another reason to take probiotics is that they can help prevent absorption of some xenoestrogens—toxic substances that have estrogen-like effects, such as bisphenol A (BPA).
(Note: If you have a history of mitral valve prolapse or heart valve irregularities, check with your practitioner before starting any probiotics. There are a small number of cases of heart infection linked to probiotic intake in people with preexisting heart conditions.)
Zinc
Zinc is important for thyroid hormone production and conversion, and 15 to 25 mg of zinc a day can help ensure optimum zinc delivery to the thyroid. Zinc, along with selenium, can also help prevent the decline of T3 when you are on a lower-calorie diet. (Before you supplement with zinc, check to see if it’s already included in your multivitamin.)
Selenium
Research has shown that selenium is an important mineral for thyroid function. It activates an enzyme responsible for controlling thyroid function by the conversion of T4 to T3. Stress and injury appear to make the body more prone to selenium-deficiency. Supplemental selenium appears to offset the potentially damaging effect of high iodine intake on thyroid function, according to one study. Also, selenium supplementation has been shown to reduce inflammation in patients with autoimmune thyroiditis. Too much selenium can be dangerous, so multivitamin and additional supplementation should never exceed a total of 400 mcg per day. (Before you supplement with selenium, check to see if it’s already included in other supplements you are taking.)
L-tyrosine
L-tyrosine is an amino acid that contributes to the process of creating and releasing thyroid hormone, and low levels can make it difficult for the thyroid to function properly. It is a common component of many thyroid support supplements that combine several nutrients in one capsule. Tyrosine supplements at the level of 85 to 170 mg a day may be helpful to the thyroid.
Guggul
Guggul (Commiphora mukul) is a plant that has been used in Ayurvedic medicine as an anti-inflammatory, antiobesity, thyroid-stimulating, and cholesterol-lowering agent. Its active ingredient is Z-guggulsterone. Guggul is considered particularly important for prevention of a sluggish metabolism, and studies have shown that Z-guggulsterone may increase the thyroid’s ability to take up the enzymes it needs for effective hormone conversion. It also increases the oxygen uptake in muscles. Some people find that guggul is overstimulating, so you need to be careful with this supplement.
Iron
Iron is critical to thyroid function, and if the body is low in iron, the thyroid gets shortchanged. Iron is used to support the production of T4 and T3 and the conversion of T4 to T3. When iron is in short supply, however, iron will forgo supporting the thyroid in favor of its role in red blood cells.
To determine if you have a sufficient iron level, the best test is for ferritin, a protein that stores iron and releases it in a controlled fashion.
Sara Gottfried, MD, prefers that patients get their iron from food:
If someone is not vegan, I’d recommend grass-fed beef and organic lamb. Leafy greens, especially kale, chard, and watercress, are also good sources of iron. For iron supplementation, sometimes I will use glandulars like Integrative Therapeutics Iron Complex. Because people can have trouble absorbing iron, I also sometimes recommend Floradix liquid, which is a ferrous gluconate form that is better absorbed, but somewhat more costly.
Some experts suggest that you eat a diet rich in vitamin C, because it helps the body absorb iron more effectively.
It’s important to remember that if you take an iron supplement, you need to take it at least three to four hours apart from your thyroid hormone replacement medication, because the iron can interfere with thyroid drug absorption.
Essential Fatty Acids
Essential fatty acids (EFAs) cannot be produced in the body, so you must get them through diet or supplements. The key essential fatty acids are:
• Omega-3s. These include alpha-linolenic acid (ALA), eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA). They are found in fish from cold, deep oceans. Some popular fish in this category include mackerel, tuna, herring, flounder, sardines, and salmon. Other sources include linseed oil, flaxseeds and flaxseed oil, black currant and pumpkin seeds, cod liver oil, shrimp, oysters, leafy greens, soybeans, walnuts, wheat germ, fresh sea vegetables such as seaweed, and fish oil. Usually your body can convert ALA into EPA, then into DHA.
• Omega-6. These include linoleic acid and gamma-linolenic acid (GLA). They are found in breast milk, sesame seeds and sesame oil, safflower seeds and safflower oil, cottonseed and cottonseed oil, sunflower seeds and sunflower oil, corn and corn oil, soybeans, raw nuts, legumes, leafy greens, black currant seeds, evening primrose oil, borage oil, spirulina, and lecithin. Linoleic acid can be converted into GLA.
According to Dr. Udo Erasmus, author of Fats That Heal, Fats That Kill, imbalances and deficiencies in essential fatty acids are the cause of, a trigger for, or a contributing factor to many diseases and conditions, and addressing those deficiencies through proper foods or use of healthy oils can have huge implications for health. He believes that essential fatty acids are critical to thyroid function because (1) they are required for the structural integrity of the membrane of every cell, (2) they increase energy levels in the cell, and (3) there is some evidence that essential fatty acids, especially omega-3s, improve the body’s ability to detect and respond to thyroid hormone effectively.
Erasmus also points to the role that EFAs play in preventing and reducing inflammation. In particular, essential fatty acids make hormone-like eicosanoids, substances that regulate immune and inflammatory responses, and omega-3s in particular have anti-inflammatory effects that can slow autoimmune damage. Inflammation of the thyroid is central to many cases of autoimmune thyroid disease, and inflammation is generally seen in almost all autoimmune diseases. Erasmus believes that if protein reactions lead to inflammation, allergies, and autoimmune disease, essential fatty acids seem to help prevent the proteins from becoming hyperactive and triggering these various immune reactions.
Nutritionist and naturopath Dr. Ann Louise Gittleman, author of Eat Fat, Lose Weight and the bestselling Fat Flush series of books, believes that good fats are essential to good health and weight loss, and that today’s low-fat diets are counterproductive. Dr. Gittleman says, “Even as we have cut back on fat in the last decade, weight has steadily increased, an average of eight pounds per person. We may be eating less fat, but we are eating more calories.” Ultimately, Dr. Gittleman, like many other nutritional experts, believes that if you include good fats in the diet, you rev up the body’s fat-burning potential and you stay full longer, so you eat fewer calories without feeling hungry.
Overall, EFA supplements appear to be an important part of any weight-loss effort for the following reasons:
• EFAs help your body metabolize stored fat more efficiently.
• EFAs help reduce the output of inflammatory markers from fat tissue and reduce inflammation in joints and muscles.
• EFAs can help reduce insulin resistance.
• EFAs can help balance blood sugar.
• EFAs can help reduce appetite.
• EFAs can improve cholesterol levels.
• EFAs can help reduce blood pressure.
• EFAs help keep hair, skin, and nails healthy.
In addition to adding more of the foods that contain these essential fatty acids, some of the ways you can add EFAs to your diet include:
• Fish oil supplements are a popular choice for adding omega-3s to your diet. Go for a toxin-free, decent-tasting oil or a “burpless” capsule. Carlson’s, Barlean’s, and Enzymatic Therapies are known for their high-quality, pure oils and supplements. Enzymatic has my favorite burpless capsules—called Eskimo Oil—and Barlean’s has a liquid fish oil with a lemon flavor that tastes surprisingly like lemon pudding. (Even my children will take it!)
• Flaxseeds and flaxseed oil are another choice for omega-3s. You can add flaxseed to meals, either in the oil form or as freshly ground seeds. Flaxseed oil is also available in capsules. Some people like to make salad dressing out of the oil or add it to soups or smoothies. Taking flaxseed oil with each meal helps slow down digestion and modulate blood sugar fluctuations (which helps with insulin levels).
• Evening primrose oil and borage oil are good sources of omega-6s. These are usually taken as supplements. GLA is thought to help and activate brown fat, a kind of fat that helps generate heat and burn calories.
OTHER THYROID ISSUES
Watch Goitrogens
Goitrogens are products and foods that promote goiter formation and can act like antithyroid drugs in disabling the thyroid and causing hypothyroidism. Specifically, goitrogens inhibit the body’s ability to use iodine, block the process by which iodine is used to produce the thyroid hormones T4 and T3, inhibit the actual secretion of thyroid hormone, and disrupt the peripheral conversion of T4 to T3.
If you are hypothyroid due to thyroidectomy—such as for thyroid cancer, a goiter, or nodules—don’t be concerned about goitrogens. If you still have a thyroid, however, you need to be careful not to eat raw goitrogens in large quantities. The enzymes involved in the formation of goitrogenic materials in plants can be partially destroyed by cooking. Eating cooked goitrogenic foods is probably not a problem for most people, though if you are a heavy consumer of cooked goitrogens and have a difficult time balancing your thyroid, you may want to consider some dietary changes.
The following list contains some of the more common and potent goitrogens (particularly when consumed raw):
• Cassava
• Broccoli
• Cabbage
• Kale
• Millet
• Radishes
• Rutabaga
• Babassu (fruits from a type of palm tree native to the Amazon)
• Turnips
• Brussels sprouts
• Cauliflower
• Kohlrabi
• Mustard
• Watercress
Understand Soy
Experts can’t seem to agree on the subject of soy, a goitrogen, and there is heated debate about the potentially harmful effects of overconsumption of isoflavone-intensive soy products. Soy contains isoflavones, which have some structural similarities to estrogens and in large enough quantities function in the human body like a weak estrogen. Soy also acts as an antithyroid agent, working against the thyroid by inhibiting thyroid peroxidase (TPO), which disturbs proper thyroid function.
There are concerns about adult consumption of soy products. Inhibition of thyroid peroxidase can be expected to generate thyroid abnormalities, including goiter and autoimmune thyroiditis. One U.K. study involving premenopausal women gave participants 60 grams of soy protein per day for one month. This was found to disrupt the menstrual cycle, with the effects of the isoflavones continuing for a full three months after the soy was stopped. Another study found that intake of soy over a long period causes enlargement of the thyroid and suppresses thyroid function. Isoflavones are also known to negatively affect fertility and sex hormones, and in some animal studies have been shown to produce serious health effects including infertility, thyroid disease, and liver disease.
Soy is also a common allergen, and concerns are growing about the impact of genetically modified (GM) soy on health and hormones.
If you don’t have a thyroid, as is the case for thyroid cancer patients and others who have had the thyroid surgically removed, some soy food is probably fine for you. Avoid processed soy foods like bars, shakes, and soy-based snack foods, along with genetically modified soy. Do be careful about consuming high levels of soy, however, because even in the absence of a thyroid gland, soy binds to thyroid hormone and can reduce the effectiveness of your medication.
If you still have a thyroid gland, you’ll want to be more careful about using too much soy, especially soy pills, powders, and supplements. Daily overconsumption of soy foods may contribute to the worsening of your thyroid problem, and the high concentration of isoflavones found in some soy products transforms them from a food into something more like a drug.
If you want to eat some soy, again, avoid highly processed and genetically modified soy, and stick to tempeh, soy sauce, miso and other fermented forms of soy foods that are least likely to affect you negatively.
Reduce Toxic Exposures
In the past, fluoride was used as a treatment for hyperthyroidism, because it has the ability to suppress thyroid function. In one study, it was shown that 2.3 to 4.5 mg of fluoride per day was a successful treatment for hyperthyroidism. In areas where water is fluoridated, typical fluoride intake ranges from 1.6 to 6.6 mg/day, which in some cases exceeds the dosage used for medical treatment of hyperthyroidism. This means that for some of you, ingested fluoride is slowing down your thyroid gland.
What can you do? Drink water that is not fluoridated. A reverse osmosis filter can remove fluoride from tap water. Use a fluoride-free toothpaste. And consider refusing fluoride treatments at the dentist. (These treatments have not been clearly demonstrated to be helpful in adults for reducing or preventing cavities anyway.)
Perchlorate, a chemical by-product of the manufacture of rocket fuel and explosives, is known to disrupt thyroid function and cause other health problems, is increasingly the focus of public, media, and government attention. Perchlorate has contaminated areas of the U.S. water supply, most commonly in the western part of the country. Eating lettuce or other vegetables and fruits irrigated with perchlorate-contaminated water may expose some consumers to high levels of the toxin; this produce is sold around the country. Perchlorate is also a component of fertilizers and can contaminate foods grown with them. There’s not much you can do to avoid eating perchlorate-contaminated foods, except to grow your own produce and water it with water that you’ve had tested for perchlorate contamination. If you drink well water, you should also have that water tested, and if you live in an area near a current or former production facility for rockets, explosives, or fireworks, consider having your water independently tested. Most important, become aware of the issue, and monitor the status of perchlorate legislation through the comprehensive site www.perchlorate.org.
Bisphenol A (abbreviated as BPA) is a compound used to make plastic and resins. Some of the most common sources of exposure to BPA include the lining of cans used for foods and soft drinks; polycarbonate plastics used in eating or drinking; and infants drinking from polycarbonate plastic bottles. Besides avoiding canned foods and using BPA-free water bottles, for example, toxicology experts also recommend avoiding microwaving food in plastic containers, putting plastics in the dishwasher, or using harsh detergents on plastics, to avoid leaching of BPA into food. Dr. Ann Louise Gittleman recommends choosing glass jars instead of cans. As noted, some studies have shown reduced absorption of BPA in people who take probiotic supplements.
Mercury exposure comes through amalgam (silver-colored) dental fillings and through some larger fish that concentrate high levels of mercury. Mercury levels can be tested by a holistic physician or nutritionist using hair analysis. If you have excessive levels of mercury, some experts recommend chelation—the process of helping the body excrete excess metals and minerals. This can be done through intravenous infusion or herbal supplements. In some cases, practitioners recommend removing amalgam fillings and replacing them with composite materials that contain no mercury. This is controversial, because it can be very expensive. Some patients have reported that their thyroid problems and other symptoms were greatly relieved with removal of amalgam fillings.
Naturopath Dr. Ann Louise Gittleman explains the health impact of chronic overexposure to electromagnetic frequencies (EMF), electrical pollution, and radiation in her groundbreaking book Zapped. In the book, Dr. Gittleman says to think back to your grandparents’ house and count up the total number of major electrical and electronic appliances in each room. Often a home might have contained a television, clock radio, stereo, oven, dishwasher, and phonograph. Now, we have large-screen televisions, wireless Internet systems, cordless telephones, game systems, computers, laptops, BlackBerry devices, iPads, cell phones, and a whole host of other gadgets and appliances. According to Dr. Gittleman, there is evidence that EMF exposure can be a chronic stress to the body, which can then suppress both adrenal and thyroid function. Her book provides detailed guidelines on how to minimize and protect against EMF exposure in daily life.
Radiation is also a definite danger to your thyroid. New research is now linking an increased risk of thyroid disease to multiple X-rays without adequate protection. Some experts are suggesting that you ask your dentist to avoid regularly scheduled X-rays unless there is a medical reason to perform the X-ray, and when dental X-rays or mammograms are necessary, ask for a thyroid collar—a small lead collar placed around your neck—that protects the thyroid gland against radiation.
Treat Infections
Infection is also thought to be a trigger for some thyroid problems. The food-borne bacteria Yersinia enterocolitica, for example, has been associated with elevated levels of thyroid antibodies, a sign of autoimmune thyroid disease.
A laboratory analysis by Genova Laboratories (see Resources) can help detect intestinal bacterial overgrowth that could be contributing to underlying immune system problems that may be fueling your thyroid condition. Harmful bacteria are typically treated with antibiotics; a holistic practitioner may suggest a special diet, nutritional supplements, and herbs that function in an antibiotic-like capacity.
Deal with Iodine Excess or Deficiency
Iodine supplementation is a controversial topic for thyroid patients. Too little iodine can cause a variety of thyroid problems. But the opposite problem—too much iodine—is also a risk factor for triggering or worsening thyroid problems. The key is in knowing if you need iodine supplementation, and if so, how best to take it.
Holistic or nutritional practitioners sometimes assume that every thyroid patient needs iodine, or an iodine-containing herb such as bladder wrack, seaweed, or kelp. But there is controversy over the amount of iodine deficiency in the United States. On one hand, statistics show that one-fourth to one-third of Americans may have some degree of iodine deficiency. On the other hand, some practitioners, such as Michigan’s Dr. David Brownstein, one of the pioneers in iodine testing and therapy, says that the vast majority of his thyroid patients test positive for iodine deficiency. According to Dr. Brownstein, his thyroid patients who show suboptimal iodine levels and receive iodine supplementation treatment usually find that their symptoms improve.
Should you take iodine? Answering that question requires that you be tested and, if you are deficient, carefully trying iodine supplementation under the direction of a practitioner.
The key way to evaluate your iodine levels is the urinary iodine clearance test. Dr. Brownstein does iodine testing with his patients, and he has those who are iodine-deficient follow a protocol for iodine supplementation that uses a specialized combination of iodine and iodide designed to ensure maximum use of the nutrient. The combination is found in a pill format, known as Iodoral, and in a liquid, called Lugol’s solution.
Dr. Brownstein has outlined an entire program for iodine testing and supplementation in his book Iodine: Why You Need It, Why You Can’t Live Without It, and I highly recommend that anyone interested in iodine testing and supplementation read this book to learn how to get properly tested and safely supplement with iodine.
Some practitioners and patients have found that even if a mild iodine deficiency is documented, iodine-containing supplements and herbal products aggravate hypothyroid symptoms. In my own case, I have a mild iodine deficiency according to the tests, and I have tried iodine on numerous occasions. Within a day or two, however, I always feel exhausted, with a swollen, irritated neck, and after a week, I am barely functional. I have found, however, that I respond well to iodine-rich sea vegetables and iodine-rich foods such as shellfish, so perhaps the obstacle is a sensitivity to processed iodine rather than iodine in food.
Iodization of salt and foods has helped eliminate epidemic goiter and cretinism in areas that are iodine-deficient, but excess inorganic iodine may contribute to thyroid imbalances in other areas where there is sufficient iodine. One gram of salt contains 76 mcg of iodine, and we need approximately 100 mcg of iodine per day. The average person in the United States, however, actually consumes as much as 3 grams of salt, so some of us may be overdosing on iodine. If you have an excess of iodine, one way to cut back on iodine intake is to stop buying commercially iodized salt (salt that has potassium iodide) and use sea salt instead. An added plus is that sea salt tastes better!
Consider Coconut Oil
If you search the topic “thyroid” on the Internet or read some of the women’s magazines, you’ll find ads touting coconut oil as a cure for thyroid disease and a weight-loss miracle food and supplement. Coconut oil is controversial, however.
Nutritionist Bruce Fife, author of The Healing Miracles of Coconut Oil, is a firm believer in coconut oil for thyroid patients. He says, “Coconut oil by itself is not a thyroid cure. But when used as part of a thyroid-enhancing program it can be invaluable in improving some forms of hypothyroidism and even bring about complete recovery.” Fife believes that coconut oil can rev up the metabolism, and he suggests replacing all refined vegetable oils with it, including margarine, shortening, and hydrogenated oils. He also recommends using coconut products and foods such as coconut milk as much as possible in cooking.
Coconut oil contains medium-chain triglycerides (MCTs), which are a special type of saturated fat. It’s theorized that MCTs may promote weight loss by increasing the burning of calories.
Research on the topic is contradictory. One Canadian study found that medium-chain fatty acids (MCFAs) such as those found in coconut oil are quickly oxidized in the liver, and this speed of oxidation leads to greater energy expenditure. No weight loss, however, was associated with the demonstrated increase in energy expenditure. Another study put a group of women on a very low-carbohydrate diet for four weeks. Half received a regular fat supplement; the other half received an MCT supplement. Those on the MCT supplement had increased fat burning and less loss of muscle mass during the first two weeks, but these benefits declined during the last two weeks of the trial. Other trials showed that MCTs and coconut oil failed to enhance weight loss.
You can see if it works for you. And remember that the way to use coconut oil is not to add a few tablespoons to your diet on top of your regular foods, including fats. If you want to see if it’s going to help, you need to cut out most of your other fats and oils and substitute coconut oil.