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Graves’ Disease, Hashimoto’s, and The Triad Of Autoimmunity

In past articles and blog posts I have briefly mentioned the triad of autoimmunity.  This is also known as the “three-legged stool” of autoimmunity, and it consists of a genetic component, an environmental trigger, and an increase in intestinal permeability (a leaky gut).  The theory is that all three of these are factors in the development of an autoimmune condition such as Graves’ Disease or Hashimoto’s Thyroiditis.  And if this is the case, then these factors need to be addressed when trying to restore someone’s health.

What I plan on doing in this blog post is to discuss the individual components of this triad, and hopefully give you a better understanding of what you can do to address the individual components.

Component #1: Genetics.  With regards to the three components of the triad of autoimmunity, genetics of course is the one component that can’t be modified.  This is the reason why I try not to use the word “cure” when I talk about treating these conditions naturally.  So when I talk about restoring one’s health back to normal, or reversing the autoimmune component, the goal is to get the person into a state of remission, and after this has been accomplished the next goal is to help them maintain a state of wellness.

But since the genetic component can’t be modified, you might wonder how it’s possible to get someone into a state of remission AND to help them maintain their health.  Perhaps this can best be explained by looking at a different autoimmune condition, Celiac disease [1].  With Celiac disease, the autoimmune trigger is gluten [2].  Of course I’ll talk in greater detail about environmental triggers shortly, but I’m bringing this up here because if someone with Celiac disease completely avoids gluten, then they will remain in remission from this autoimmune condition on a permanent basis.  This is true even though nothing can be done to change the genetics associated with Celiac disease.

Sticking with the example of Celiac disease, another thing to keep in mind is that just because someone has a genetic predisposition for Celiac disease doesn’t mean they will develop this condition.  In fact, even if someone with the genetic markers for Celiac disease eats gluten, this doesn’t guarantee that they will develop Celiac disease.  It’s a similar situation with those people who have Graves’ Disease and Hashimoto’s Thyroiditis.  Those with a genetic marker for these conditions, as well as other autoimmune conditions, won’t necessarily develop the specific condition unless they are exposed to an environmental trigger and they also have a leaky gut.

Component #2: Environmental trigger.  As I just discussed, while having a genetic predisposition seems to be necessary for the development of thyroid autoimmunity, other factors are also necessary, which of course is the basis behind the “triad of autoimmunity”.  So in addition to having a genetic predisposition, an environmental trigger is also necessary to cause the development of Graves’ Disease or Hashimoto’s Thyroiditis.  Earlier I spoke about Celiac disease, and unlike most other autoimmune conditions, with Celiac disease we know that the environmental trigger is gluten.  And while it’s not easy for many people to completely avoid gluten, it still is a huge advantage knowing what the specific autoimmune trigger is.

This is what makes it challenging to help people with other types of autoimmune conditions, including Graves’ Disease and Hashimoto’s Thyroiditis.  With these conditions the environmental trigger can differ from person to person.  The following are just a few examples of environmental triggers of thyroid autoimmunity:

So how do you find the environmental trigger?  As I mentioned earlier, this can be challenging, but it’s usually accomplished through a combination of a good health history and the appropriate testing.  For example, when I was diagnosed with Graves’ Disease, stress [3]was a big factor in the development of my condition.  And this was verified through an adrenal saliva test I ordered, which showed that I had depressed cortisol levels, a depressed DHEA [4], and a depressed secretory IgA [5].  And while stress is a big factor with many others with autoimmune thyroid conditions, some people have other triggers.

Sometimes the person will test positive for multiple triggers.  For example, someone might choose to get an adrenal saliva test along with a comprehensive stool panel, and the results of the two tests reveal compromised adrenals and multiple infections.  Of course it is possible that only one of these factors was the “true” environmental trigger, but it’s challenging to know which is the primary trigger, and of course either way the goal should be to address all of these imbalances.  In other words, if someone has both adrenal problems and an infection, while it’s possible that dealing with a lot of stress weakened the person’s immune system and led to an infection, which in turn was the autoimmune trigger, the goal should be not only to eradicate the infection, but to help the person improve the health of their adrenals.

Component #3: Leaky gut.  Dr. Alessio Fasano is the researcher who came up with the theory that having an increase in intestinal permeability is a necessary factor in autoimmunity.  A few years ago I admittedly questioned this theory in a blog post I wrote entitled “Is a Leaky Gut Present In All Autoimmune Thyroid Conditions? [6]”  A number of years ago I did more frequent testing for a leaky gut on my patients, and in this post I discussed how some people with elevated autoantibodies tested negative for a leaky gut, which either meant that the testing wasn’t completely accurate, or that Dr. Fasano’s theory was incorrect.

This blog post was written almost three years ago, and while Dr. Fasano’s theory still hasn’t been proven, it is widely accepted by many well known healthcare professionals.  And I agree that the mechanisms behind it make sense, which is why these days I don’t frequently test my patients for a leaky gut, and instead assume that this is a factor in those with Graves’ Disease and Hashimoto’s Thyroiditis.  After all, everything comes down to risks vs. benefits, and in my opinion it’s a greater risk to not give gut support to someone who has a leaky gut than to put someone who might not have a leaky gut on a gut repair protocol.  In other words, it isn’t harmful to treat someone for a leaky gut, even if they don’t have a leaky gut.

Removing The Leaky Gut Trigger

It’s important to understand that in order to heal the gut, it’s also necessary to find out the factor which caused the leaky gut in the first place.  This is where it can get confusing at times, as the “leaky gut trigger” can be the same as the environmental trigger I mentioned above, although this isn’t always the case.  For example, earlier I spoke about Celiac disease, and in this case gluten not only is the environmental trigger, but gluten also has been proven to cause an increase in intestinal permeability in everyone, regardless of whether or not they have a sensitivity to gluten.  In any case, with Celiac disease, gluten is both the “environmental” trigger and the “leaky gut” trigger.

However, there are situations where the leaky gut trigger might differ from the environmental trigger.  For example, someone with a genetic predisposition to Graves’ Disease or Hashimoto’s Thyroiditis might have a history of taking antibiotics, which can cause a leaky gut.  So this person has a genetic predisposition and a leaky gut, but the autoimmune process hasn’t started yet since they haven’t been exposed to an environmental trigger.  Then one day this person gets infected with Yersinia enterocolitica, which in this case is the environmental trigger, and they develop thyroid autoantibodies.  So in this example the antibiotics were the “leaky gut trigger”, but not the environmental trigger.

Differentiating Between The Environmental and Leaky Gut Trigger

The truth is that it can be challenging to differentiate between the environmental and leaky gut trigger.  In the example given above, while the excessive use of antibiotics might have caused the leaky gut, it’s also possible that the infection (Yersinia enterocolitica) caused the leaky gut.  So while gluten is both the environmental trigger and the leaky gut trigger in Celiac disease, it’s probably safe to say that in many cases of Graves’ Disease and Hashimoto’s Thyroiditis, the environmental trigger and the leaky gut trigger are also the same, although this isn’t always the case.  Hopefully you don’t find this to be too confusing, but the overall point is that the ultimate goal should be to remove anything that can be either an environmental trigger or a leaky gut trigger.

What Is Still Unclear About Environmental Triggers

While over the last decade we have learned a lot more about the different environmental triggers associated with autoimmunity, there is still a lot we don’t know.  For example, the research shows that Yersina Enterocolitica is a potential trigger of both Graves’ Disease and Hashimoto’s Thyroiditis (1) [7] (2) [8].  However, does this mean that everyone who has a genetic predisposition for thyroid autoimmunity and also has a leaky gut will develop Graves’ Disease or Hashimoto’s when exposed to this specific bacteria?

It would seem that this isn’t the case.  For example, not everyone who has a genetic predisposition to Hashimoto’s or Graves’ Disease has a negative reaction to iodine.  So this is one example of an environmental trigger which doesn’t trigger thyroid autoimmunity in everyone with a genetic predisposition (and a leaky gut).

Another example involves gluten, as this seems to be an environmental trigger in some people with autoimmune thyroid conditions, but not others.  In fact, you might have read posts in Facebook groups or in forums from people with Graves’ Disease or Hashimoto’s Thyroiditis who got into remission upon eliminating gluten alone.  On the other hand, there are people who have gone 100% gluten free for many months without getting into remission, which suggests that gluten isn’t an environmental trigger in everyone.  However, I did mention earlier that the research shows that gluten can cause a leaky gut in everyone.  So it can be argued that gluten is a leaky gut trigger in everyone, but not necessarily an environmental trigger in everyone.

Addressing The Triad To Achieve A State of Remission

In order for anyone with Graves’ Disease and Hashimoto’s Thyroiditis to achieve a state of remission it is necessary to identify and remove the environmental trigger, and to do things to heal the leaky gut.  The good news is that achieving this is very possible, but the bad news is that a relapse is also possible in those that don’t continue to live a healthy lifestyle.  For example, if stress was a big factor in the development of your autoimmune thyroid condition, while you can’t completely eliminate the stress from your life, you can do things to improve your stress handling skills.

Similarly, if the environmental trigger was an infection such as H. Pylori or Blastocystis Hominis [9], while getting rid of this infection is important, doing things to improve the health of the immune system is also necessary to prevent these and other infections from reoccurring in the future.  Improving the health of the immune system is perhaps even more important if the trigger was a viral infection such as Epstein Barr [10], which can’t be eradicated, but can be kept in a dormant state.  Of course since most people have been infected with Epstein Barr it can be argued that it is critical for everyone to do everything they can to have an optimally-functioning immune system.

And of course in order to have a healthy immune system you need to have a healthy gut, and so healing the leaky gut is not only essential to get into remission, but it’s also a necessary component of a healthy immune system.  As for how to heal a leaky gut, in addition to removing the “leaky gut trigger” you also want to heal the gut, which can be accomplished through both food and supplementation.  I’m not going to get into detail about this here, as I have discussed this in other articles and blog posts.

In summary, the triad of autoimmunity theorizes that three factors are necessary to develop any autoimmune condition.  These include a genetic predisposition, an environmental trigger, and a leaky gut.  Although not being able to modify the genetic component is the reason why we can’t cure conditions such as Graves’ Disease and Hashimoto’s Thyroiditis, the expression of our genes can change, and we of course can address the other two components, which can put the person into a state of remission.  And it is also is very possible to maintain a state of wellness by having a healthy gut and minimizing your exposure to environmental triggers.