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Should Ashwagandha Be Avoided In Those With Graves’ Disease and Hashimoto’s Thyroiditis?

Recently I attended an autoimmune conference via livestream, and one of the presenters was talking about the different herbs that can be beneficial in people with autoimmune conditions.  One of the herbs he spoke about highly was ashwagandha, which is an herb I absolutely love.  However, ashwagandha is also a member of the nightshade family, and those with autoimmune conditions are supposed to avoid nightshades.  And so the question I plan on answering in this blog post is whether or not those with autoimmune thyroid conditions should avoid taking ashwagandha.

But before I answer this question, I first want to answer this question: why would someone with an autoimmune thyroid condition want to take ashwagandha in the first place?  Ashwagandha, which is also known as Withania somnifera, is an adaptogenic herb.  It helps to support both the hypothalamic-pituitary-adrenal (HPA) and hypothalamic-pituitary-thyroid (HPT) axes.  As a result, it can help people who have HPA axis dysregulation as a result of chronic stress, and by supporting the HPT axis it can also help to support thyroid function.

However, we need to remember that Graves’ Disease and Hashimoto’s Thyroiditis aren’t thyroid conditions, but are autoimmune conditions.  And so we also need to consider the effects of ashwagandha on the gut and immune system.  In the opening paragraph I mentioned how ashwagandha is part of the nightshade (Solanaceae) family, and how nightshades are excluded from an autoimmune Paleo diet.  But while it might make sense to avoid nightshade vegetables since they have compounds which can cause inflammation, does it make sense to avoid an herb like ashwagandha that has anti-inflammatory properties?  I’ll answer this question later on in this post.

What Are Some of The Health Benefits Of Ashwagandha?

If you’re wondering why ashwagandha is commonly recommended by healthcare professionals, it’s because this herb has many different health benefits.  Here are just a few of the benefits of ashwagandha:

Helps With Stress and Anxiety.  This is probably the main reason why many natural healthcare professionals recommend ashwagandha.  Without question this is one of the primary reasons why I sometimes recommend ashwagandha to my patients, as besides seeing some wonderful benefits of ashwagandha in some of my patients, the research shows that ashwagandha can help people to better adapt to stress and anxiety (1) (2).  Of course taking ashwagandha isn’t meant to be a replacement for eating well and incorporating mind body medicine techniques, but it can help to provide additional support in those who are dealing with high levels of stress and anxiety.

Modulates the Immune System and Reduces Inflammation.  This is one of the main arguments for using ashwagandha in those with autoimmune conditions.  Even though this herb is part of the nightshade family, and while nightshades can cause inflammation in some people, there is a lot of research which shows that ashwagandha has anti-inflammatory properties (3) (4) (5).  And some of these studies even involve autoimmune conditions, such as rheumatoid arthritis (6) (7).  One of these studies showed how ashwagandha significantly suppressed lipopolysaccharide (LPS) induced production of proinflammatory cytokines TNF-alpha, IL-1beta, and IL-12p40 in both normal individuals and patients with rheumatoid arthritis (7).  Another study showed that ashwagandha can help with chronic renal dysfunction by reducing inflammation (8).

Helps With Insomnia.  Ashwagandha also can help some people who are dealing with insomnia.  One way it does this is by lowering cortisol levels, although one study showed that this herb might help with insomnia by increasing levels of the neurotransmitter GABA (9).  However, a recent study from 2017 shows that triethylene glycol, which is an active component of ashwagandha, might be a sleep-inducing component of this herb (10).  However, the study mentioned that this component is in the leaves of ashwagandha, and usually the root is used in most ashwagandha supplements.

Improves Sexual Function and Fertility.  One study I came across showed that ashwagandha can help to improve sexual function in women (11).  I’m sure some of this is due to the effect of ashwagandha on the HPA axis, as in order to have healthy sex hormones you need to have healthy adrenals, and for more information on this I would read a blog post I wrote entitled “The Negative Impact of The Pregnenolone Steal“.  There is also evidence that ashwagandha can help males with a low sperm count (12).

Cognition.  A few studies show that ashwagandha can help to improve cognition and might even be helpful with certain neurodegenerative diseases, including Alzheimer’s disease (13) (14) (15).

Muscle strength and recovery.  One study I came across showed that taking an ashwagandha supplement is associated with significant increases in muscle mass and strength (16).

A Few Things To Know Before Purchasing An Ashwagandha Supplement

There are a few things you should know before you purchase an ashwagandha supplement.  First of all, you want to make sure you are purchasing a supplement that uses ashwagandha root.  Although most manufacturers of ashwagandha supplements do use the root, there are some that solely use ashwagandha leaves.  And while I did mention the study earlier that spoke about how triethylene glycol is found in the leaves, most of the studies demonstrating the beneficial effects of ashwagandha have used the root.  Of course if you can find a formulation that has both the leaves and the root then this is an option to consider, although using a product that just has the root should be fine in most cases.  In addition, typically the higher the concentration of withanolides the better, and this should be listed on the product label.

Why Are Nightshades Excluded From An Autoimmune Paleo Diet?

For more detailed information on nightshades you can read an article I wrote entitled “Nightshades and Thyroid Health”.  The main problem with nightshades is that they have compounds which can cause problems  in those with autoimmune conditions.  These compounds include lectins, alkaloids, and glycoalkaloids.  And the reason why these are problematic is because they can cause inflammation, and in some cases can even lead to an increase in intestinal permeability.  In other words, consuming nightshades might cause or contribute to a leaky gut, which is theorized to be a factor in all autoimmune conditions.

Based on this information it makes sense to look at some of the compounds found in ashwagandha.  According to the research, the roots of ashwagandha contain several alkaloids, withanolides, a few flavanoids and reducing sugars (17) (18) (19).  The active compounds reported in ashwagandha include the following (19):

  • Sitoindosides VII–X
  • 5-dehydroxywithanolide-R
  • Withasomniferin-A, 1-oxo-5β
  • 6β-epoxy-witha-2-ene-27-ethoxy-olide
  • 4-(1-hydroxy-2,2-dimethylcyclpropanone)-2,3-dihydrowithaferin A
  • 2,3-dihydrowithaferin A
  • 24,25-dihydro-27-desoxywithaferin A
  • Physagulin D (1→6)-β-d-glucopyranosyl-(1→4)-β-d-glucopyranoside
  • 27-O-β-d-glucopyranosylphysagulin D
  • Physagulin D, withanoside I–VII
  • 27-O-β-d-glucopyranosylviscosalactone B
  • 4,16-dihydroxy-5β
  • 6β-epoxyphysagulin D
  • Viscosalactone B
  • Diacetylwithaferin A

Although I did do some research on these compounds, I admit that I need to do more.  I didn’t realize how many active compounds are in ashwagandha.  From the research I have done so far, most of these compounds should be beneficial in people with Graves’ Disease and Hashimoto’s Thyroiditis.  After all, the compounds in ashwagandha can help those dealing with stress and anxiety, which describes many people with these conditions.  And of course ashwagandha can have a positive effect on immune system health by decreasing inflammation, which is also a factor in thyroid autoimmunity, as well as other autoimmune conditions.

However, even though these compounds have beneficial effects, this doesn’t mean that everyone with an autoimmune thyroid condition can safely take ashwagandha.  If you do some searching on your own you’ll no doubt find some people with autoimmune conditions who had negative symptoms when taking ashwagandha.  On the other hand, you’ll also come across people with Graves’ Disease and Hashimoto’s Thyroiditis who have benefited from taking ashwagandha.  And this pretty much describes most of my patients, as while I don’t give ashwagandha to everyone, most of my patients who have taken ashwagandha haven’t had any negative side effects.  On the other hand, over the years I’ve had a few patients who didn’t do well when taking ashwagandha.

What’s interesting is that some people who don’t do well when eating nightshades such as tomatoes, eggplant, and peppers have no problems taking an ashwagandha supplement.  Is it possible that ashwagandha is causing inflammation in these people, but just not causing any overt symptoms?  Of course this is a possibility to consider, but I will add that it seems that most people who don’t do well when eating the nightshades experience overt symptoms, and I find this to be the case with those who don’t do well when taking ashwagandha supplements as well.

Should YOU Avoid Ashwagandha?

Sarah Ballantyne, author of the Paleo Approach, does a lot of research with regards to the autoimmune Paleo diet, and she excludes ashwagandha from the AIP diet.  However, in one of her posts she did mention (under the comments section) that many people who can’t tolerate nightshades seem to do okay with ashwagandha, and I also find this to be the case with many of my patients.  Over the years I have had many patients with autoimmune thyroid conditions do fine with ashwagandha.

Does this mean that taking ashwagandha is completely safe for those with Graves’ Disease and Hashimoto’s Thyroiditis?  I wouldn’t necessarily say this, as while many people with autoimmune thyroid conditions do fine with this herb, there are some people who do have a negative reaction.  As a result, when following a strict AIP diet it probably is a good idea to avoid ashwagandha during this time.  But of course everything comes down to risks vs. benefits, and there are times when I’ll recommend ashwagandha to a patient with thyroid autoimmunity.  Most of the time this won’t cause any problems, but of course if the person does experience a negative reaction, or if they don’t seem to be progressing when taking ashwagandha, then they obviously should stop taking it.

In summary, although those with autoimmune conditions such as Graves’ Disease and Hashimoto’s Thyroiditis are supposed to avoid nightshades, many people do fine when taking ashwagandha.  This herb has numerous health benefits, such as helping people to better adapt to stress and anxiety, reduces inflammation, helps with insomnia, cognition, muscle strength and recovery, and can even improve sexual function and fertility.  However, there are some people that don’t do well when supplementing with ashwagandha, and if this describes you then of course it is best to avoid it.

Can A Health History Detect Your Thyroid Triggers?

When it comes to trying to find out the cause of one’s thyroid or autoimmune thyroid condition, testing can play a very important role.  This is why I recommend testing to just about all of my patients with Graves’ Disease and Hashimoto’s Thyroiditis.  However, one shouldn’t underestimate the importance of a comprehensive health history.  While many times doing a thorough health history alone won’t identify the autoimmune trigger, it can still provide some important clues.

What I plan on doing in this blog post is to discuss some of the more important components of a health history.  While I hope that most people reading this are working with a natural healthcare professional who will conduct a thorough health history, if this isn’t the case I would go through each of these components on your own.  In fact, regardless of whether or not you are working with an expert I think it’s a good idea to read through this information, as doing so might help to identify certain triggers.  Another benefit of a thorough health history is that it can help determine which tests are required to find certain imbalances which are either directly or indirectly responsible for your condition.

It’s also important to understand that completing a thorough health history might require you to fill out multiple forms.   It depends on the healthcare professional you’re working with, as some doctors will have all of the information on a single form, while others will require multiple forms to be completed.  Some offices will allow you to fill out all of the patient information electronically, while this won’t be the case for others.

Components of A Comprehensive Health History                   

Lifestyle factors.  This is one of the main reasons that more and more people are developing autoimmune thyroid conditions.  Some of the more common lifestyle factors which can either directly trigger autoimmunity, or make someone more susceptible to autoimmunity, include the following:

  • High stress levels
  • Low stress handling skills
  • Drinking alcohol on a regular basis
  • Consuming a lot of sugar
  • Overtraining
  • Excess caffeine consumption
  • Insufficient sleep

Medications and supplements.  Certain medications such as antibiotics, NSAIDs, and acid-blockers can make someone more susceptible to developing an autoimmune condition by having a negative effect on the health of the gut.  While most nutritional supplements and herbs won’t trigger or exacerbate an autoimmune thyroid condition such as Graves’ Disease or Hashimoto’s Thyroiditis, there are possible exceptions.  For example, some natural healthcare professionals recommend for people with Hashimoto’s to avoid Echinacea and chlorella out of fear that these will further enhance the immune system response, thus exacerbating, or possibly even causing an autoimmune condition.  However, this is controversial, and I spoke about this more in past blog post entitled “Echinacea: Harmful for Hashimoto’s, Beneficial For Graves’ Disease?

Past procedures and surgeries.  While most medical procedures and surgeries won’t trigger thyroid autoimmunity, certain procedures may make someone more susceptible to developing autoimmunity.  For example, while there is a concern over estrogen dominance, estrogen also has a protective effect with regards to immune system health.  And while I didn’t find any evidence of a correlation between getting a hysterectomy and developing Graves’ Disease or Hashimoto’s Thyroiditis, there is evidence that a hysterectomy can be a factor in other autoimmune conditions, such as systemic lupus erythematosus (1).  Other surgical procedures might also increase the risk of autoimmunity, such as bariatric surgery (2).  Keep in mind that I’m not suggesting that women should never get a hysterectomy, as there definitely is a time and place for these and other surgical procedures.  And I think it’s safe to say that most of the time these and other medical procedures won’t trigger thyroid autoimmunity, but it’s still a factor we need to consider when gathering information.

Infections (current and past).  Certain infections can play a role in the development of autoimmune thyroid conditions.  As a result, it’s good to know if someone with Graves’ Disease or Hashimoto’s Thyroiditis had a previous infection.  Of course just because someone had a previous infection prior to developing an autoimmune thyroid condition doesn’t mean that the infection was the trigger.  But it still can be beneficial to know if someone had an infection.

For example, there is a correlation between H. Pylori and thyroid autoimmunity, especially with regards to Graves’ Disease.  As a result, if someone with Graves’ Disease tested positive for H. Pylori a few months or years prior to being diagnosed with Graves’ Disease, this doesn’t confirm that this was the trigger.  However, it is possible that this infection was a trigger, and even if the person had received treatment to eradicate this infection, it probably would be a good idea to do an updated test for H. Pylori.

Family history.  Although genetics isn’t the most important factor in the development of an autoimmune thyroid condition, it is a factor.  And while you can’t change your genes, I still think it is beneficial to find out if there is a family history of a thyroid or autoimmune thyroid condition in someone who has Graves’ Disease or Hashimoto’s Thyroiditis.  Although the natural treatment approach might not differ much for someone who does have a strong family history of thyroid autoimmunity, if a person with Graves’ Disease or Hashimoto’s Thyroiditis has multiple family members with an autoimmune thyroid condition then they might want to be a little more strict with the diet and other lifestyle factors not only while restoring their health, but while trying to maintain a state of wellness.

Symptoms.  While you usually can’t rely on symptoms for detecting the autoimmune trigger, this doesn’t mean that one’s symptoms should be ignored.  For example, many people with Hashimoto’s Thyroiditis are overweight, but some people with Hashimoto’s Thyroiditis have the opposite problem.  In other words, some people with Hashimoto’s have difficulty gaining weight.  And if this is the case then one possible cause is a malabsorption problem, which in turn can be due to a pathogenic infection, or a condition such as small intestinal bacterial overgrowth.  Speaking of infections, if someone has extreme fatigue, along with migrating muscle and joint pain, then Lyme disease might be the culprit.

Of course certain symptoms can have multiple causes.  For example, if someone with Hashimoto’s Thyroiditis has extreme fatigue, then this can be due to low thyroid hormone levels, adrenal fatigue, one or more nutrient deficiencies, a pathogenic infection, or even blood sugar imbalances.  And while testing might be necessary to determine the cause of the fatigue, asking the right questions can also help.  Below are some of the signs and symptoms people with Hashimoto’s Thyroiditis commonly have:

  • Trouble concentrating/memory difficulties/brain fog
  • Fatigue
  • Cold hands and feet
  • Weight gain
  • Bloating/belching/gas
  • Constipation
  • Hair loss
  • Lowered libido
  • Hot flashes and/or night sweats

And these are some of the signs and symptoms people with hyperthyroidism and Graves’ Disease commonly have:

  • Increased resting heart rate
  • Heart palpitations
  • Weight loss
  • Increased appetite
  • Tremors
  • Loose stools or diarrhea
  • Hair loss

These are other signs and symptoms some people with both hypothyroid and hyperthyroid conditions can experience:

  • Sweet cravings
  • Caffeine cravings
  • Headaches/migraines
  • Muscle pain/joint aches
  • Bloating/belching/gas
  • Stomach burning
  • Dry eyes and/or dry skin
  • Increased frequency to food reactions
  • Intolerance to smells
  • Multiple smell and chemical sensitivities
  • Indigestion and fullness last 2-4 hours after eating
  • Sense of fullness during and after meals
  • Coated tongue
  • Dizziness when standing up quickly

Exposure to Environmental Toxins.  We live in a toxic world, and most people are exposed to hundreds, if not thousands of different chemicals on a regular basis.  Because of this, if an environmental toxin is the trigger, then many times it can be challenging to find out what the triggering chemical is.  While you can spend money to test for certain environmental toxins, including heavy metals, as well as other chemicals, you can’t test for all of the chemicals you’re exposed to.  And so rather than spend a lot of money testing for environmental toxins, sometimes the best approach is to 1) minimize your exposure to environmental toxins, and 2) do things to eliminate chemicals from your body.

With that being said, sometimes you can find out some valuable information about environmental toxins during a thorough health history.  For example, mercury is a potential trigger of thyroid autoimmunity.  As a result, a natural healthcare professional who conducts a health history should find out if their patients with autoimmune thyroid conditions has mercury amalgams.  The presence of these amalgams doesn’t mean that this is the autoimmune trigger, although there of course is a possibility that this is the case.

Recently I had a patient who had very high cadmium levels on a hair mineral analysis.  Upon further investigation the patient told me that his work environment involves exposure to certain chemicals, and cadmium was one of them.  And while there isn’t a correlation in the literature between cadmium and thyroid autoimmunity, this doesn’t mean that high cadmium levels can’t be a factor.  For example, even if a certain environmental toxin isn’t a direct trigger of thyroid autoimmunity, this doesn’t mean that it can’t indirectly cause autoimmunity by compromising the immune system.

The truth is that we don’t know everything about environmental toxins and autoimmunity.  As a result, when conducting a health history, it’s foolish to just focus on the environmental toxins that have been proven to trigger autoimmune thyroid conditions.  Keep in mind that being exposed to one or more environmental toxins can result in a loss of self tolerance, which in turn can make someone more susceptible to developing an autoimmune thyroid condition.  I spoke about this in an article I wrote entitled “Thyroid Autoimmunity and Loss of Self Tolerance”.

When conducting a health history I recommend asking the patient (or you can ask yourself if you are conducting your own health history) the following questions with regards to environmental toxins:

  • Do you consume conventionally grown fruits and vegetables on a regular basis?
  • Do you consume conventionally raised animal products on a regular basis?
  • Do you consume fish or seafood on a frequent basis?
  • Do you consume foods with artificial colors, flavors, and/or preservatives on a regular basis?
  • Do you frequently use conventional cleaning chemicals, hand sanitizers, air fresheners, and other scented products?
  • Do you smoke or are you often exposed to second-hand smoke?
  • Do you have mercury amalgams, root canals, crowns, dental implants, etc.?
  • Do you have a history of heavy alcohol use?
  • Do you have a history of heavy use of recreational or prescription drugs?
  • Have you been exposed to new construction materials or furniture?
  • Are you frequently exposed to adhesives, paints, solvents, and other air-borne chemicals?
  • Do you live near a cell phone tower or high-voltage power lines?
  • Have you been frequently exposed to herbicides, pesticides, and/or fungicides?
  • Do you jog or ride your bike along busy streets?

Sex hormones/Reproductive health history.  Sex hormone imbalances can be a factor in thyroid and autoimmune thyroid conditions, and here is some of the information I ask for on my health history forms:

  • Do you currently take, or have you taken oral contraceptives or bioidentical hormones?
  • Do you currently take, or have you had an intrauterine device (IUD)?  If yes, was it a copper or hormonal IUD?
  • How many live births have you had?
  • Were they natural births or Cesarean sections?
  • Is there a history of ovarian cysts?
  • Is there a history of uterine fibroids?
  • Is there a history of endometriosis?
  • Is there a history of fibrocystic breasts?

Estrogen dominance can be an autoimmune trigger, and estrogen dominance is also a common factor with ovarian cysts, uterine fibroids, endometriosis, and fibrocystic breasts.  As a result, if someone checks off one of these then I will suspect problems with estrogen metabolism.  This is also one way to determine if testing of the sex hormones is necessary.  For example, if a cycling woman has irregular menstrual cycles, moderate to severe cramping, and a history of ovarian cysts, uterine fibroids, and/or endometriosis, then one can argue that testing the sex hormones might be necessary in this situation.

Completing A Food Diary Can Be Very Valuable

In addition to completing a health history, I find that having the patient put together a food diary can be valuable.  After all, certain foods can act as triggers, or can make someone more susceptible to autoimmunity by increasing the permeability of the gut.  I would recommend putting together at least a one-week food diary.  And the reason for this is because a person’s eating habits can vary depending on the day of the week.

So hopefully you understand the importance of conducting a thorough health history.  While doing tests can help to detect the underlying cause of your condition, doing a comprehensive health history can provide a lot of value as well.  First of all, a good health history can help to determine what tests are necessary to obtain, as well as what diet the person should follow, supplements they should take, etc.  And there are times when a thorough health history can help to detect the thyroid or autoimmune thyroid trigger.  If you choose not to work with a healthcare professional I would recommend to conduct your own health history.

What’s Your Experience With Selenium?

Recently I wrote an updated article on selenium.  In the article I mentioned how many people take selenium supplements, and if this describes you I’d like to know what your experience with selenium has been.  I realize that it’s not always easy to know if a specific supplement is helping, especially when most people are taking more than one supplement at the same time, which frequently is the case.  But if you noticed some positive changes when taking selenium I’d like to know.

So if you noticed an improvement in any of your symptoms while taking selenium please share it below in the comments section.  This can include an improvement in hypothyroid symptoms such as fatigue, brain fog, cold hands and feet, or other symptoms.  And of course if you have hyperthyroidism or Graves’ Disease and experienced an improvement when taking selenium please let me know!  If you didn’t experience an improvement in symptoms but noticed a decrease in your thyroid antibodies after adding selenium please let me know!  If you happened to experience any negative symptoms when taking a selenium supplement please let me know!  If you don’t take a selenium supplement but are instead relying on food sources of selenium you of course can also comment below if you’d like.  Thank you so much for sharing your experience with everyone.

Can SIBO Trigger Thyroid Autoimmunity?

Many people reading this are familiar with small intestinal bacterial overgrowth, which is also known as SIBO.  This involves an overgrowth of bacteria in the small intestine, and can lead to symptoms such as bloating, gas, and abdominal pain, along with diarrhea and/or constipation.  Although SIBO is more common in people with Hashimoto’s Thyroiditis, I have also seen it in patients with Graves’ Disease as well.  But can SIBO trigger an autoimmune thyroid condition?

Numerous pathogens have been associated with thyroid autoimmunity.  This includes H. Pylori, Yersinia enterocolitica, Lyme disease, Epstein barr, and parasites such as Blastocystis Hominis.  However, it’s important to understand that SIBO isn’t a pathogenic infection.  This condition involves having good bacteria in the wrong place, as most of the bacteria should be located in the large intestine, and only a small amount should be located in the small intestine.  But for numerous reasons that I’ll discuss in this blog post, there can be an overgrowth of bacteria in the small intestine.

As a result, small intestinal bacterial overgrowth itself doesn’t seem to be an autoimmune trigger.  However, there are a few things to keep in mind.  Some cases of SIBO are due to an autoimmune process, which I’ll describe below, and having one autoimmune condition can make someone more susceptible to having another autoimmune condition.  So perhaps having SIBO can lead to another autoimmune condition such as Graves’ Disease and Hashimoto’s Thyroiditis, but the correlation hasn’t been made yet.  But even if this isn’t the case, SIBO can cause an increase in intestinal permeability (a leaky gut), and this in turn can set the stage for the development of an autoimmune thyroid condition.

What Causes SIBO?

There are numerous factors which can cause someone to develop SIBO, and so let’s take a look at some of these:

1. Dysfunction of the migrating motor complex (MMC).  This is the main reason why people develop SIBO.  The MMC is a small wave that cleanses the small intestine of debris.  And so if the MMC isn’t working properly then bacteria and other debris are no longer swept through the lumen of the small intestine.  Food poisoning is the most common cause of a dysfunctional MMC, but other causes include hypothyroidism, diabetes, or an infection such as C. difficile, giardia, or Lyme disease.  Certain drugs such as opiates and antibiotics can also affect the MMC.

2. Altered anatomy.  This can interfere with the clearance of bacteria.  For example, adhesions due to surgery or endometriosis are potential causes of SIBO.  Other anatomical anomalies include a narrowing of the small intestine, fistulas, and diverticuli.

3. Hypochlorhydria (low stomach acid).  Millions of people take acid blockers, and this is a big problem.  Besides being necessary to break down nutrients, stomach acid also can help to eradicate harmful pathogens, and prevent the overgrowth of bacteria.  However, you don’t need to take acid blockers to have low stomach acid, as having a hypothyroid condition alone can result in the decreased production of stomach acid.  Stress can also decrease the production of stomach acid.

4. Absent or inefficient Ileocecal valve.  The ileocecal valve is the barrier that separates the small intestine from the large intestine.  It prevents backflow from the large intestine into the small intestine.  If this is absent or dysfunctional then it can cause the bacteria from the large intestine to migrate into the small intestine, thus leading to SIBO.

What Is The Relationship Between IBS and SIBO?

Infectious gastroenteritis, more commonly known as food poisoning, can result in the production of toxins by bacteria that can damage the nerves which play an important role in gut motility.  The specific name of the toxin is cytolethal distending toxin (CDT).  What happens is the immune system forms antibodies to this toxin (called anti-CDTb antibodies), but anti-vinculin antibodies are also produced.  Vinculin is a protein that helps connect the interstitial cells of Cajal (ICC) so that they can communicate properly to help the MMC .  When someone has the CDT-b toxins these harm the ICC, and in a case of mistaken identity the immune system attacks vinculin, which has a negative effect on gut motility.

So to summarize, food poisoning is the most common cause of irritable bowel syndrome with diarrhea (IBS-D).  This in turn has a negative effect on gut motility, and the problem with gut motility is what leads to small intestinal bacterial overgrowth.  There is a blood test called IBSchek by Commonwealth Laboratories that can determine if someone has IBS-D associated with anti-CDTb and anti-vinculin antibodies.

How Is SIBO Diagnosed?

Although one’s symptoms can provide a lot of valuable information, if SIBO is suspected then it is a good idea to test.  And the way it is detected is through a breath test.  With the breath test the patient fasts overnight, and then in the morning they will start with a baseline breath test, followed by the consumption of a substrate (i.e. lactulose or glucose).  After the baseline breath test they will measure a breath sample approximately every 20 minutes, and what the lab is looking for is bacterial fermentation, and it measures this fermentation by measuring the levels of hydrogen and methane. In other words, if someone has SIBO, there will be more fermentation, which will lead to higher levels of hydrogen, methane, or both gases. Let’s take a look at the two main breath tests used:

Lactulose breath test.  Lactulose can’t be absorbed by humans, but can be broken down by bacteria.  As bacteria consume lactulose they produce hydrogen and/or methane gases, which are measured with the breath test.  This is most commonly used because it can diagnose SIBO in the distal end of the small intestine.

Glucose breath test.  The glucose breath test seems to be more accurate, but the reason this test isn’t as commonly used is because glucose is absorbed in the beginning of the small intestine.  As a result, if someone has SIBO that is occurring in the distal small intestine then it is less likely to be detected.  However, some bacteria don’t ferment lactulose, and as a result, if SIBO is suspected yet the lactulose test comes back negative then you should consider doing a glucose breath test.  Another option is to do both the lactulose and glucose tests initially, although many labs don’t offer both types of testing.

Can A Stool Panel Detect SIBO?

Hydrogen and methane are produced by bacteria, and this is what’s being measured on the breath tests.  Methanobrevibacter smithii is a bacteria that accounts for most of the methane production in the body.  Some comprehensive stool panels test for this “methanogenic” bacteria, and if this is high then this might suggest that someone has SIBO.  However, this isn’t conclusive, and the breath test remains the gold standard for determining if someone has SIBO.

What Health Conditions Are Associated With SIBO?

Below I have listed some of the other health conditions associated with SIBO.  This doesn’t mean that SIBO is always responsible for the development of these conditions, but if you have any of the following conditions then SIBO is a possible cause.

  • Acne Rosacea
  • Chronic fatigue syndrome
  • Fibromyalgia
  • Inflammatory bowel disease (Crohn’s disease, ulcerative colitis)
  • Interstitial Cystitis
  • Restless legs syndrome
  • Rheumatoid arthritis

What’s The Ideal Diet For Those With SIBO?

Although I like my patients with Graves’ Disease and Hashimoto’s to start on an autoimmune paleo diet, in the past I have written blog posts which discuss how there is no diet that fits everyone perfectly.  And the same concept applies with SIBO.  While all cases of SIBO involve the overgrowth of bacteria into the small intestine, the bacteria will differ from person to person.  As a result, one person with SIBO might be able to tolerate foods that someone else with SIBO can’t tolerate, and vice versa.  In addition, some people might be able to eat small quantities of a certain food, but if they eat larger quantities they experience bloating and gas.  With that being said, there are certain diets that people with SIBO should consider following, although there will be some modifications depending on the person.

Below I’m going to discuss the different diets that are recommended for patients with SIBO.  The primary goal of each of these diets is to feed the person while starving the bacteria.

Low FODMAP diet.  This probably is the most well known diet when it comes to SIBO, and because of this, many healthcare professionals will put their patients with SIBO on this type of diet.  FODMAP stands for fermentable oligosaccharides, disaccharides, monosaccharides and polyols.  Examples of high FODMAP foods include fermented foods (i.e. sauerkraut), starch (grains, beans, starchy vegetables), soluble fiber (grains, beans, fruits, vegetables), sugar (fruit, agave), and resistant starch (legumes, whole grains).

This doesn’t mean that everyone with SIBO needs to avoid all of these foods.  For example, some people with SIBO are able to tolerate sauerkraut, while others can’t eat any fermented foods without experiencing gas, bloating, and other symptoms.  Some people are able to eat small amounts of these foods, while others are unable to tolerate certain foods altogether.  And so you need to listen to your body.

Specific Carbohydrate Diet.  The Specific Carbohydrate Diet (SCD) is similar to a Paleo diet in that it allows meat, fish, eggs, nuts, seeds, vegetables, and fruit.  However, it differs in that it does allow some lactose-free dairy and certain beans.  The dairy products that are allowed include yogurt, aged cow and goat cheeses, butter, ghee, and cottage cheese.  The allowed beans include white beans, navy beans, lentils, split peas, lima beans, kidney beans and black beans.  In order to make the beans easier to digest you want to soak them overnight.  For more information I would read the book “Breaking The Vicious Cycle”, or you can visit the website

GAPS diet.  GAPS stands for Gut and Psychology Syndrome, and the diet was developed by Dr. Natasha Campbell-McBride.  The diet is very similar to the Specific Carbohydrate Diet, and involves minimal supplementation.  The only legumes allowed on the GAPS diet include lentils, split peas and white navy beans, and they need to be soaked first.  Dairy is initially eliminated, but then the person is allowed to slowly reintroduce ghee, followed by butter, yogurt, sour cream, kefir, hard cheese, and cream.  One of the main differences between the GAPS diet and the Specific Carbohydrate Diet is that the GAPS diet involves going through a 6-stage introduction diet before moving onto the “full” GAPS protocol, which is usually followed for one or two years.

SIBO Specific Diet.  This is a diet created by Dr. Allison Siebecker, and is a combination of the Specific Carbohydrate Diet and the low FODMAP diet.  While it’s a great diet for those who have SIBO, it’s important to understand that this a very restrictive diet, and as a result, Dr. Siebecker first recommends to try one or more of the other diets listed above first, and if you don’t do well with the other diets then you might want to consider giving this diet a try.   For more information I would visit

Elemental diet.  The elemental diet can be the most effective diet when it comes to alleviating the symptoms of SIBO.  However, it is arguably the most challenging diet to follow.  It’s considered an antimicrobial approach because the goal is to starve the bacteria, but supply the person with sufficient nutrients in an easily absorbed form.  It essentially consists of protein, fat, carbohydrates, amino acids, vitamins, minerals, and either glucose or maltodextrin.  You can get a premade formula from a company such as Integrative Therapeutics, or if you visit and visit the resources page you can get a recipe to make your own.  The elemental diet can help to lower both methane and hydrogen levels and typically you want to follow it for 2 or 3 weeks, and then do another breath test immediately upon completion of it.

Should Someone With Graves’ Disease or Hashimoto’s Also Follow An AIP Diet?

Many people with Graves’ Disease and Hashimoto’s Thyroiditis follow an AIP diet, and they might want to know if they should continue following an AIP diet when trying to address SIBO.  So for example, should they follow an AIP diet and a low FODMAP diet?  Doing this is extremely difficult, and what you usually want to do is prioritize the eradication of SIBO.  In other words, it’s usually okay to stray from the AIP diet while trying to address SIBO, and this falls into the “Remove” category of the 5-R protocol I mentioned in a previous blog post.  Then once the bacterial overgrowth has been “removed” you can focus more on gut healing by following the AIP diet, along with eating gut-healing foods (i.e. bone broth) and taking certain nutrients (i.e. L-glutamine).

Eradicating SIBO Through Drugs and Herbs

In order to eradicate SIBO there are two main methods used: prescription antibiotics and natural antimicrobials.  Let’s look at the pros and cons of each.

Prescription antibiotics.  Rifaximin is the antibiotic most commonly recommended for SIBO.  While I’m not a big fan of antibiotics, Rifaximin is different than most other antibiotics.  First of all, it stays in the small intestine, which means that it doesn’t harm the beneficial bacteria in the large intestine like most other antibiotics do.  In fact, there is evidence that Rifaximin can actually increase good bacteria (i.e. bifidobacteria) in the large intestine.  In addition, bacterial resistance isn’t too common when using Rifaximin.  With that being said, not everyone with SIBO will respond to Rifaximin.

Herbal antimicrobials.  I personally prefer to use herbal antimicrobials when dealing with SIBO.  Some of the natural agents which can help to eradicate SIBO include berberine, oregano oil, neem, and allicin.  Keep in mind that while garlic is a high FODMAP food, most people with SIBO can tolerate an allicin supplement, although not everyone.  Although I personally haven’t used pomegranate as of writing this blog post, Dr. Nirala Jacobi has a lot of experience with SIBO and has been experimenting with pomegranate as an antimicrobial.  As for whether the herbs are as effective as Rifaximin, there actually was a study that showed that herbal therapy is equivalent to Rifaximin for treating SIBO (1).  However, just as is the case with Rifaximin, not everyone with SIBO will respond to the herbal antimicrobials.

What To Do When Rifaximin or The Natural Antimicrobials Don’t Work

So what should be done if someone takes either Rifaximin or the natural agents and doesn’t improve?  Well, it is important to do another SIBO breath test after completing a round of treatment.  On the retest, if the gas levels have decreased a good amount but are still high then it makes sense to do another round of the Rifaximin or natural antimicrobials, regardless if the person’s symptoms have improved or not.  On the other hand, if the gas levels haven’t improved then it probably is wise to try a different treatment approach.  If the gas levels have normalized and the person is still symptomatic then this is usually an indication that there is something else going on besides SIBO, and additional testing might be indicated.

The Role of Prokinetics In Preventing a Relapse

Prokinetics help to stimulate the MMC, and since most cases of SIBO are caused by a dysfunctional MMC, taking prokinetics can be important to prevent a relapse after receiving treatment for SIBO.  It’s also important to understand that the MMC works in a fasting state, and so while I commonly recommend for patients to eat regularly throughout the day to help stabilize the blood sugar levels, those with SIBO probably shouldn’t snack in between meals, and should go at least 12 hours overnight without eating.

As for what prokinetics you should take, I used to recommend an herbal formulation called Iberogast, but it seems as this is being discontinued.  Ginger can be a good prokinetic, and 5-HTP also can be helpful.  Many reading this are familiar with low dose naltrexone, and this can also act as a prokinetic.  For those who aren’t familiar with LDN you can read the article I wrote entitled “Low Dose Naltrexone and Thyroid Autoimmunity“.  Erythromycin is commonly used as an antibiotic, but in very low doses it can also help to stimulate the MMC (2).

How long should someone take a prokinetic for after SIBO has been eradicated?  It depends on the person, as most will need to take it for at least 3 to 6 months.  And if someone has autoimmunity to vinculin then they might have to take prokinetics on a permanent basis.  I mentioned earlier how if someone has the CDT-b toxins these harm the ICC, and in a case of mistaken identity the immune system attacks vinculin.  And until we figure out how to stop the autoimmune process then the person will most likely have to continuously take prokinetics.

Can Someone With Graves’ Disease or Hashimoto’s Get Into Remission By Eradicating SIBO?

As I mentioned earlier in this post, SIBO doesn’t seem to be a direct trigger of thyroid autoimmunity.  However, SIBO can cause an increase in intestinal permeability, which is a factor in autoimmune conditions such as Graves’ Disease and Hashimoto’s Thyroiditis.  Because of this, one can argue that if someone has SIBO and a leaky gut, then in order to heal the gut it is necessary to eradicate SIBO, and if the trigger is also removed then this can put the person into remission.  And so while eradicating SIBO might be necessary for healing a leaky gut, in order to get someone with an autoimmune thyroid condition into remission it is still necessary to find and remove the trigger.

In summary, small intestinal bacterial overgrowth can be present in people with Hashimoto’s Thyroiditis and Graves’ Disease.  The most common cause of SIBO is dysfunction of the migrating motor complex.  SIBO is usually diagnosed with either the lactulose or glucose breath test, although false negatives are possible with either test.  Some of the common diets recommended for those with SIBO include the low FODMAP diet, the Specific Carbohydrate Diet, the GAPS diet, the SIBO Specific Diet, and the Elemental diet.  Although antibiotics such as Rifaximin are commonly given to people with SIBO, herbal antimicrobials can be equally effective in many people.  And taking prokinetics can be important to prevent a relapse from occurring after receiving treatment for SIBO.

Book Review: Hashimoto’s Protocol

Many reading this are familiar with Dr. Izabella Wentz, as she is the author of the bestselling book “Hashimoto’s Thyroiditis: Lifestyle Interventions for Finding and Treating the Root Cause”, and she also hosted the Thyroid Secret Documentary, which I was grateful to be a part of.  Dr. Wentz sent me an advanced copy of her new book “Hashimoto’s Protocol”, which I recently finished reading.  And so I decided to dedicate a blog post to review her book.

Note: For those who aren’t interested in reading this entire review, I do want to let you know upfront that Dr. Wentz is offering a free autoimmune paleo diet 2-week recipe plan, which you can get by clicking here.

First of all, I’d like to start off by saying that this is a lengthy book with plenty of great information!  The book consists of almost 400 pages, and while this includes sections you are unlikely to read (i.e. bibliography), even if we omit the bibliography, the acknowledgements, etc., you’re still left with approximately 350 pages of excellent content.  And so this is not a book that most people will knock out it a day or two.  She also offers an audio version of the book on Audible, which I probably would have purchased had I not been sent a free copy of the book.  While I love reading books, I must admit that I’m an Audible fanatic!

When I first learned about the title of the book, one of the first concerns I had was that this book was just going to focus on diet and supplements.  And don’t get me wrong, as she does talk a lot about diet, and there definitely are a lot of different nutritional supplements she talks about as well.  But this isn’t just a book on diet and supplements, as she talks about other lifestyle factors, some of the different methods of testing, and she even dedicates a chapter on how to optimize thyroid hormone levels.

This Book Actually Discusses Multiple Protocols

Another concern I had when I first learned about the title of the book is whether Dr. Izabella would just focus on a single protocol for Hashimoto’s.  After all, the title of the book is “Hashimoto’s Protocol”, which suggests that it discusses a single protocol.  Of course I should have known better, and if I counted correctly she actually discusses nine different protocols.  This might sound overwhelming, but keep in mind that not everyone with Hashimoto’s needs to follow all of these different protocols, and I’ll talk more about this shortly.

Dr. Izabella’s book is divided into three parts.  The first part is entitled “Getting To Know Hashimoto’s and the Root Cause Approach”.  In this section she starts off by talking about her Hashimoto’s success story, and then discusses the symptoms, diagnosis, and origins of Hashimoto’s.  The last chapter of this section then discusses how the root cause approach can help you to recover your health.

The second section of the book discusses the “Fundamental Protocols”.  This consists of three protocols that include the following:

1. The Liver Support Protocol.  This is a two-week protocol that focuses on reducing your exposure to toxic substances while simultaneously supporting the liver.  The goal is to 1) remove foods which can be potential triggers, 2) add supportive foods, 3) reduce toxic exposure, and 4) support detoxification pathways.

2. The Adrenal Recovery Protocol.  Dr. Izabella talks about a five-step adrenal recovery protocol, which according to her takes approximately 4 weeks to follow.

3. The Gut Balancing Protocol.  This is a six-week protocol, although Dr. Izabella does mention that you should reevaluate your gut function after this time, and so there is a chance it can take longer than this.

Dr. Izabella recommends for everyone to follow the fundamental protocols in order to help improve the health of the liver, adrenals, and gut.  According to Dr. Izabella, following these protocols should take approximately 90 days combined.  One thing I found interesting is that whereas most natural healthcare professionals focus on the health of the gut initially, Dr. Wentz first focuses on improving the health of the liver.  Of course this also involves certain dietary changes, and so essentially people are still doing things to improve the health of their gut through diet while also supporting the liver.

Root Cause Assessments

It’s also important to mention that each of these fundamental protocols comes with a separate assessment.  For example, before following the liver support protocol it is recommended to complete a liver assessment, which will help to establish your current level of toxicity.  The adrenal assessment helps to determine your risk for impaired adrenal function, and there is also an assessment for determining your gut health.

In the last chapter of the second section she talks about “Advanced Root Cause Assessments”.  These are additional assessments that can help you identify your personal triggers and prioritize the next steps of your protocol.  These include the thyroid hormone assessment, nutrition assessment, traumatic stress assessment, infections assessment, and toxins assessment.

Advanced Protocols for Hashimoto’s

The third section of her book talks about numerous advanced protocols.  I’m not going to discuss all of them, but here are two that I found to be pretty interesting:

Thyroid hormone optimizing protocols.  Here Dr. Izabella discusses five unique strategies that will assist with optimizing your thyroid hormone levels.  Not surprisingly one of these involves taking prescription thyroid hormones, but there are four other methods.  One of these includes low level laser therapy.  I was thrilled to see her discuss this, as I wrote a blog post on cold laser therapy and thyroid health in September of 2015, and then when I attended Dr. Izabella’s Thyroid Masterimind meeting one month later I learned even more great information about how this can benefit thyroid health in those with Hashimoto’s Thyroiditis.  Anyway, Dr. Izabella gives a specific protocol for cold laser therapy in this chapter.

Protocols for Overcoming Traumatic Stress.  Dr. Izabella explains how some people will continue to have adrenal dysfunction despite their best efforts to balance blood sugar and reduce present stressors, and she says that this is likely due to a long-standing history of traumatic stress.  She mentioned that 20% of her readers with Hashimoto’s reported that their symptoms started after the death of a loved one.  And while most people will benefit from certain mind body medicine techniques such as yoga and meditation, she talks about how some will need to go beyond these to resolve issues related to traumatic stress.  She gives a protocol for resetting your stress response, and an advanced adrenal support protocol.

Are Specific Supplements and Recommendations Given?

I’m sure some will wonder if Dr. Izabella gives specific recommendations in her book.  The answer is a resounding “YES”!  Not only does she give specific doses, but she also lists specific supplement companies.  In addition, when Dr. Izabella discusses some of the tests she recommends she also names some specific companies that offer the testing.

Does This Book Take The Place Of Working With A Natural Healthcare Professional?

Another question you might have is if you can reverse your Hashimoto’s Thyroiditis condition just by reading this book alone.  Although most people with Hashimoto’s can greatly improve their health by reading this book, even Dr. Izabella recommends working with a natural healthcare professional.  In fact, she recommends working with a team of experts that includes the following:

  • An open-minded and supportive physician
  • Functional medicine practitioner
  • Compounding pharmacist
  • Biological dentist
  • Health coach
  • Support network (family members, friends, a coach, a therapist, etc.)

The reason why she recommends working with a team of experts is because while there are specific recommendations given in this book, the truth is that everyone is different.  For example, while many people notice a dramatic improvement in their health by following an autoimmune paleo diet, this isn’t the case with everyone.  In fact, some people with autoimmune thyroid conditions feel worse when following this type of diet.  And the same concept applies with nutritional supplements and herbs.  There are a lot of different supplements and herbs listed in this book, but this doesn’t mean that everyone with Hashimoto’s Thyroiditis should take all of them.

Plus, while many people can benefit from following the fundamental protocols discussed in the book without doing any testing, in many cases testing will be necessary to detect the underlying cause.  For example, one of the reasons why I recommend adrenal saliva testing is because different people will have different adrenal patterns, and you can’t always rely on symptoms to tell which pattern someone has.  And while one of Dr. Izabella’s advanced protocols focuses on infections, doing certain testing (i.e. blood test, comprehensive stool panel) frequently is necessary in order to detect the presence of a specific pathogen.

Is There Anything About The Book I Didn’t Like?

While I can’t say that there were aspects of the book that I didn’t like, there were a few points I didn’t agree with.  I will say that overall I agree with most of the information in her book, and it’s important to keep in mind that different natural healthcare professionals will have different opinions. But for the most part Dr. Izabella and I take a similar approach with regards to Hashimoto’s patients. I greatly enjoyed reading her book, and I think it is a wonderful resource that everyone with Hashimoto’s Thyroiditis should have.

In summary, I thought The Hashimoto’s Protocol was an excellent book, and if you have Hashimoto’s Thyroiditis I would highly recommend that you check this out.  If anyone reading this review has also read Dr. Izabella’s Hashimoto’s Protocol book, please feel free to leave your comments below to let others know what you think.  And just as a reminder, you can get a free Autoimmune Paleo Diet 2-Week Recipe Plan by clicking the link below.

Click Here to Get Your Free Autoimmune Paleo Diet 2-Week Recipe Plan

Can Vaccines Trigger Thyroid Autoimmunity?

There is a lot of controversy over vaccinations, and it’s not uncommon for a patient who has a thyroid or autoimmune thyroid condition to ask me what I think about vaccines.  I’m personally not a big fan of vaccines, and this is not a topic that I have written about in the past, other than a blog post I wrote on the flu shot a few years ago.  And it probably isn’t going to be a topic that I write a great deal about in the future.  However, for those who are interested in learning about the risks of vaccinations, I encourage you to register for the upcoming Truth About Vaccines documentary that is taking place from 4/12/17 to 4/18/17.  It’s from the same creators of the Truth About Cancer documentary series, and you can click here to register for this free event.

Will they be talking at all about autoimmune thyroid conditions such as Graves’ Disease and Hashimoto’s Thyroiditis?  I’m honestly not sure, but I have done some research in this area, and there aren’t too many studies which have looked into the relationship between vaccines and thyroid autoimmunity.  Apparently cases of Graves’ disease and Hashimoto’s thyroiditis following hepatitis B vaccine have been reported to the Vaccine Adverse Events Reporting System (VAERS), although one study I came across didn’t see an increased risk of Graves’ Disease or Hashimoto’s Thyroiditis following receipt of hepatitis B vaccine (1).  But the problem is that there are very few studies involving vaccines and thyroid autoimmunity, and as sad as it is to say, you can’t trust many of the studies out there dismissing vaccines as being harmful, and the reason for this is because many of them involve a conflict of interest.

For example, there has been a lot of controversy over whether vaccines can cause autism.  In June 2014, a meta-analysis of case-control and cohort studies showed that vaccines are not associated with autism, and that the components of vaccines at the time (i.e. thimerosol) or multiple vaccines are not associated with the development of autism (2).  But according to investigative reporter Sharyl Attkisson there was a conflict of interest, as the study was created from a firm that lists major vaccine makers among its clients.  I don’t know if vaccines cause autism, but it’s scary when you look at some of the ingredients included in vaccines.

According to the Centers for Disease Control and Prevention, the following are some of the common substances found in vaccines (3):

  • Aluminum
  • Antibiotics
  • Egg protein
  • Formaldehyde
  • Monosodium glutamate (MSG)
  • Thimerosal (a mercury-containing preservative)

Keep in mind that the CDC is in favor of vaccines, and they claim that the amount of these chemical additives found in vaccines are very small.  While this may be true, this doesn’t mean that they are safe.  For example, the amount of mercury used in mercury amalgams is very small as well, but there definitely is a correlation between thyroid autoimmunity and mercury (4) (5).  And while the current research doesn’t show a direct correlation between aluminum and autoimmune thyroid conditions, aluminum is a known environmental toxin that can stimulate the immune system, and has been linked to neurotoxicity (6) as well as Alzheimer’s disease (7).  Formaldehyde is also a harmful chemical, and many people reading this are aware of the problems associated with Monosodium glutamate (MSG).

If you are interested in learning more about vaccines, then I highly recommend for you to attend the Truth About Vaccines documentary.  Here are some of the questions that will be answered:

  • Do vaccines confer immunity?
  • Are there natural options to vaccination?
  • What questions should you ask before you vaccinate?
  • Were vaccines responsible for the declines in polio, pertussis, smallpox, etc?
  • What about the flu shot and the HPV vaccine?
  • Why do outbreaks occur in mostly vaccinated populations?
  • Why are some states considering implementing forced vaccine legislation?
  • What are possible adverse vaccine reactions?
  • Are vaccines linked to cancer?
  • Can vaccines cause permanent damage?
  • What are all of your options?

Click Here to register for The Truth About Vaccines documentary.  Also, please feel free to share your thoughts about vaccines in the comments section below.


Graves’ Disease vs. Subacute Thyroiditis: What’s The Difference?

Most cases of hyperthyroidism are autoimmune in nature.  So when someone finds out that they have hyperthyroidism for the first time, there is a pretty good chance that they will be diagnosed with Graves’ Disease.  However, this isn’t always the case, as some people with hyperthyroidism have multinodular toxic goiter, which frequently doesn’t involve an autoimmune component.  And some people with hyperthyroidism have subacute thyroiditis.  And that will be the focus of this blog post, as I’ll be discussing the differences between Graves’ Disease and subacute thyroiditis.

With regards to the symptoms, both Graves’ Disease and subacute thyroiditis present with similar symptoms.  As a result, one usually can’t use the typical symptoms of hyperthyroidism to differentiate between the two conditions.  Here are some of the symptoms those with Graves’ Disease and subacute thyroiditis commonly experience:

  • Elevated resting pulse rate
  • Heart palpitations
  • Tremors
  • Weight loss
  • Increased appetite
  • Goiter
  • More frequent bowel movements
  • Sweating
  • Hair loss

But are the symptoms of hyperthyroidism as severe in someone who has subacute thyroiditis when compared to someone who has Graves’ Disease?  The symptoms can be severe, as the resting heart rate can get very high, and on a blood test the thyroid hormone levels can be just as high as in someone who has Graves’ Disease.  In fact, over the years I’ve had a few Graves’ Disease patients who presented with what I would consider to be mild hyperthyroidism.  On a few occasions I have even worked with people who have subclinical Graves’ Disease.  In other words, they will have a depressed TSH with elevated thyroid stimulating immunoglobulins, but they will have normal thyroid hormone levels and/or won’t experience the hyperthyroid symptoms I listed above.

Two Main Types of Subacute Thyroiditis

1. Subacute granulomatous thyroiditis.  This is also known as De Quervain’s thyroiditis, and is very painful.  In fact, it is the most common cause of someone having a painful thyroid gland.

2. Subacute lymphocytic thyroiditis.  This typically doesn’t involve any pain, and is often mistaken for Graves’ Disease.

Both of these conditions seem to be caused by a viral infection of the thyroid gland.  This causes inflammation, which in turn damages the thyroid follicles, and this causes thyroid hormone to be released into the bloodstream, which in turn results in the symptoms of hyperthyroidism.  The hyperthyroidism usually lasts anywhere from a few weeks to a few months, and it is usually followed by a period of hypothyroidism that can last six months or longer, and in some cases can be permanent.

Three Ways To Differentiate Graves’ Disease From Subacute Thyroiditis

1. An elevation of TSH receptor antibodies.  Graves’ Disease is an autoimmune thyroid condition that is characterized by elevated TSH receptor antibodies.  Thyroid stimulating immunoglobulins are the most common type of TSH receptor antibody elevated in Graves’ Disease, and if someone with hyperthyroidism has these levels elevated then this confirms that they have Graves’ Disease, and not subacute thyroiditis.

2. The signs and symptoms of thyroid eye disease.  Some people with Graves’ Disease also have thyroid eye disease, which is when the immune system attacks the tissues of the eyes.  This can lead to symptoms such as eye pain, swelling, and/or bulging of the eyes, also known as exophthalmos.  And so if someone with hyperthyroidism has one or more of these signs/symptoms then in all likelihood they have Graves’ Disease.  Keep in mind that most people with thyroid eye disease have very high levels of thyroid stimulating immunoglobulins, and so if you have the signs and symptoms of thyroid eye disease I would definitely make sure to test the TSI levels.

3. An elevated radioactive iodine uptake test.  Many endocrinologists will recommend the radioactive iodine uptake test, which involves swallowing a very small dosage of radioactive iodine.  In most cases of Graves’ Disease the radioactive iodine uptake test will be elevated, while in subacute thyroiditis the uptake test will usually be low.

If someone has elevated thyroid stimulating immunoglobulins then there really is no good reason to do the RAI uptake test.  But how about if someone with hyperthyroidism tests negative for these antibodies, and doesn’t have the symptoms of thyroid eye disease?  Well, in this case one can make a better argument for getting this test, although I must admit that I’m still not a big fan of this test.

Treating Graves’ Disease vs. Subacute Thyroiditis

The conventional medical approach for treating Graves’ Disease usually consists of antithyroid medication, radioactive iodine, or thyroid surgery.  With subacute thyroiditis, since this usually leads to hypothyroidism, most medical doctors will manage the patient’s symptoms through antithyroid medication and/or beta blockers.  While Methimazole is a common choice for managing the hyperthyroid symptoms in Graves’ Disease, with subacute thyroiditis many medical doctors prefer to use beta blockers.  And the reason for this is because the person with subacute thyroiditis is likely to become hypothyroid within a short period of time, and if they are taking Methimazole then this will make them even more hypothyroid.  Of course taking the person off of the Methimazole will decrease the severity of the hypothyroidism, but many medical doctors still choose not to put these patients on antithyroid medication.

As for treating these two conditions naturally, the goal with Graves’ Disease is to detect and remove the autoimmune trigger.  This topic is too detailed to discuss here, but I have written numerous articles which discuss this, and I also regularly conduct webinars that focus on natural treatment methods for Graves’ Disease.  I will say that managing the symptoms is similar in both of these conditions, although as is the case with Graves’ Disease, antithyroid herbs such as bugleweed need to be used cautiously due to the person eventually becoming hypothyroid.  Motherwort might be a better option in those with subacute thyroiditis, although if this doesn’t help to lower an elevated heart rate then bugleweed can be used.  If this is the case then the person wants to make sure to carefully monitor their symptoms, and it probably would be a good idea to do a follow-up blood test within four weeks.

Since subacute thyroiditis is caused by a virus, it still makes sense to do things to improve the health of the immune system.  And the reason for this is because viruses usually can’t be eradicated, which means that a person can have subacute thyroiditis multiple times.  For more information on viruses I would refer to an article I wrote on viruses entitled “Which Viruses Can Trigger Thyroid Autoimmunity?”.

So hopefully you have a better understanding of the difference between Graves’ Disease and subacute thyroiditis.  Both of these conditions present with similar symptoms, including an elevated resting pulse rate, heart palpitations, weight loss, increased appetite, and frequent bowel movements.  Two main types of subacute thyroiditis include subacute granulomatous thyroiditis and subacute lymphocytic thyroiditis.  Three ways to differentiate Graves’ Disease from subacute thyroiditis include 1) an elevation of TSH receptor antibodies, 2) having the signs and symptoms of thyroid eye disease, and 3) having an elevated radioactive iodine uptake test.  With both Graves’ Disease and subacute thyroiditis, improving the health of the immune system is the key.

5 Things To Know About Candida and Thyroid Health

Although some people enjoy reading longer articles and blog posts, others are interested in learning the most important points.  And so every now and then I will be releasing a “5 things to know” blog post.  With this post I will choose a topic that has interested my email subscribers in the past, and I’ll discuss five things you should know about this specific topic.  This blog post will focus on five things you need to know about Candida overgrowth.

So let’s get started…

1. Many people with Graves’ Disease and Hashimoto’s Thyroiditis have a Candida overgrowth.  It’s very common for people with thyroid and autoimmune thyroid conditions to have an overgrowth of Candida.  And while some healthcare professionals frequently do testing for Candida, others will look for signs and symptoms of a yeast overgrowth and then treat based on these symptoms.  I fall somewhere in between, as while I do like testing to confirm that someone has a Candida overgrowth, doing so can be expensive if you’re paying out of pocket.  And while many people will get tested for Candida antibodies in the blood, it’s possible to have a false negative.  In other words, negative Candida antibodies in the blood don’t rule out a Candida overgrowth.  As a result, some people choose not to test and simply follow an anti-Candida diet, and perhaps take some natural antifungal agents.  Some of the signs and symptoms of a Candida overgrowth include brain fog, sweet cravings, gas and bloating, fatigue, dizziness, skin conditions, bad breath, and a thick white coating of the tongue.  Keep in mind that not everyone who has a Candida overgrowth will experience all of these signs and symptoms I listed.

2. Organic acids testing is a great method of testing for a Candida overgrowth.  Although blood and stool are probably the two most popular methods of testing for Candida by clinicians, I find that organic acids testing is the most accurate.  False negatives seem to be more common with blood and stool testing.  Organic acids testing is a urine test that assesses certain urine metabolites, and while there are a few different companies that offer this test, Great Plains Labs has the advantage of testing for oxalate metabolites.  Oxalates are found in certain foods, but they are also byproducts of yeast and mold.  And so in addition to looking at the yeast and fungal metabolites on an organic acids test such as arabinose, one can also get an idea of the severity of the Candida infection by looking at the level of oxalate metabolites.  And while eating foods high in oxalates such as spinach, nuts, soy, and raspberries can cause an increase in these oxalate metabolites, if someone has very high levels of arabinose and oxalate metabolites then this is usually a good indication of a moderate to severe Candida overgrowth.

3. Avoiding fruit and fermented foods isn’t always necessary when dealing with a Candida overgrowth.  Of course everyone with a Candida overgrowth (and even those without this problem) should avoid refined sugars, and until you have resolved the Candida overgrowth problem it is also a good idea to avoid some natural sugars such as honey and maple syrup. With regards to fruit, I have found that many people who have a mild to moderate case of Candida overgrowth can eat one or two servings of low sugar fruit on a daily basis without a problem.  On the other hand, those with a more severe Candida infection might need to completely avoid fruit.

As for fermented foods, although some sources recommend for those with Candida overgrowth to avoid all fermented foods, in my experience most people with a Candida overgrowth can eat some of these foods.  This is especially true with regards to eating fermented vegetables such as sauerkraut, kimchi, and pickles.  If someone also has small intestinal bacterial overgrowth (SIBO) then these foods might be problematic, but otherwise they usually don’t cause problems for those dealing with a Candida overgrowth.  On the other hand, the microbial community of kombucha consists of not only bacteria, but strains of yeast as well, including Candida albicans (1).  As a result, it is wise for those with a Candida overgrowth problem to avoid drinking kombucha.

4. Candida can be a factor in thyroid autoimmunity.  As for whether Candida is a direct trigger for autoimmunity, this remains controversial.  In a past article I wrote entitled “Candida and Thyroid Autoimmunity” I discussed how there is evidence that Candida can result in an increase in proinflammatory cytokines, which are increased in autoimmunity.  I also mentioned a few studies that showed evidence of Candida causing an increase in autoantibodies, although there is no evidence I’m aware of which specifically shows a link between Candida and the autoimmune thyroid conditions Graves’ Disease and Hashimoto’s Thyroiditis.  An increase in intestinal permeability (a leaky gut) is a factor in autoimmunity, and even if Candida isn’t a direct trigger of autoimmunity, it can be a factor in autoimmunity by increasing intestinal permeability.

5. Rotating antifungal supplements and herbs can be effective for tough cases of Candida.  There are a lot of natural agents that have antifungal activity.  This includes oregano oil, caprylic acid, berberine, garlic, saccharomyces boulardii, golden seal, uva ursi, olive leaf, and black walnut.  And while taking one or more of these agents on a daily basis can help with the eradication of yeast, with tough cases you might need to rotate these.  So for example, one week you can take oregano oil and caprylic acid, and the next week you can take caprylic acid and berberine, the next week berberine and garlic, etc.  It’s also important to know that Candida albicans can form biofilms, and this in turn can make them resistant to antifungal medication and herbs.  As a result, taking biofilm disruptors can be beneficial, which I discussed in a blog post entitled “What Does Biofilm Have To Do With Thyroid Health?

So hopefully you have a better understanding of Candida after reading this blog post.  Just keep in mind that it can take awhile to address a Candida overgrowth problem.  Also remember that having some Candida is normal, but an overgrowth is likely to occur in individuals who take antibiotics or have a compromised immune system.  As a result, improving the health of the gut flora and overall health of the immune system will play a key role in overcoming Candida overgrowth, as well as preventing it from coming back.

What’s Your Experience With Natural Thyroid Hormone?

Recently I wrote an article entitled “Comparing The Different Brands of Natural Thyroid Hormone”, and I thought it would be interesting to see the experiences some people have had with natural thyroid hormone medication.  Although it’s true that the goal should be to address the cause of the problem, some people with hypothyroidism and Hashimoto’s Thyroiditis do need to take thyroid hormone medication.  While most endocrinologists recommend synthetic T4, many do better when taking desiccated thyroid hormone medication.  But of course everyone is different, and there are some who don’t do well when taking natural thyroid hormone.

Anyway, if you have taken Armour, Nature-Throid, WP Thyroid, or a different brand of desiccated thyroid hormone, please let me know what your experience was.  If you felt better and would recommend natural thyroid hormone to others please let me know!  And if you didn’t have a good experience with natural thyroid hormone please let me know!  Thank you so much for sharing your experience with everyone.

How To Optimize Detoxification: Part 2

This is the second of two blog posts discussing how to optimize detoxification.  The reason why I put together these posts is because many people do things to detoxify their liver, but most don’t have a good understanding of phase one and phase two detoxification.  And while you don’t need to be an expert in this area to do a liver detoxification, having a basic understanding of the pathways involved can help you to have a better detox.  In the last post I focused on phase one detoxification, and in this post I’m going to focus more on phase two detoxification.

Before talking about phase two detoxification, I want to briefly summarize phase one detoxification.  If you recall, phase one detoxification is a process of biotransformation, as it’s when the liver transforms fat soluble compounds into reactive intermediates with the help of CYP enzymes.  In phase two these reactive intermediates are then turned into water soluble molecules so that they can easily be excreted in the bile and feces.

Phase two involves six different pathways.  And while I hope you found the first blog post on phase one detoxification to be interesting (and not too confusing), since phase two is more nutrient-dependent I’m hoping that you will find this post to be even more valuable.  After all, while the biotransformation process involved in phase one is of course very important, most people who do a liver cleanse are focusing more on phase two detoxification by eating certain foods, along with taking certain supplements and herbs.

The Six Different Pathways Of Phase Two Detoxification

Remember that phase one results in the production of a reactive intermediate.  Conjugation is the process where a substrate is coupled with the reactive intermediate, which in turn makes this less active and water soluble.  This allows the toxin to be easily excreted, and the actual excretion is considered to be phase three detoxification.  So with that being said, let’s go ahead and look at the different phase two detoxification pathways.  And probably the most important factor to pay attention to with each pathway is the nutrients involved.

1. Glucuronidation.  This process involves a few steps, and if you recall, earlier I mentioned that conjugation involves the substrate coupling with the reactive intermediate that is produced in phase one, and this makes the xenobiotic/chemical less active and more water soluble.  With glucuronidation, when the substrate is conjugated with the reactive intermediate it leads to something called a glucuronide.  This process also involves an enzyme called Uridine 5′-diphospho-glucuronosyltransferase, which is also known as UGT.  There are different types of UGTs, and these enzymes help to catalyze the conversion of the compounds into water soluble molecules.

Some of the compounds that are conjugated in this pathway include bilirubin, thyroid hormone, and the steroid hormones.  So glucuronidation helps with the detoxification of thyroid hormone, along with other hormones.  If someone has reduced glucuronidation the person won’t be able to detoxify these compounds, which can lead to numerous problems.

But why would someone have reduced glucuronidation, or a reduction in any of the other pathways?  Well, there can be a few reasons.  One reason is because they are not consuming the required nutrients to support that pathway, which I’ll discuss shortly.  Another reason is because someone can have a genetic defect that affects the enzymes involved in these pathways.  An example of this is seen with Gilbert’s syndrome, which involves a genetic defect in UGT1A.  This results in an impaired ability to conjugate bilirubin with glucuronic acid, and as a result can lead to jaundice.  One potential sign of Gilbert’s syndrome on a blood test is when someone has consistently elevated bilirubin levels.  If someone has this genetic defect then they not only can have problems conjugating bilirubin, but other compounds as well.

Ideally you want to try to do things to induce, or accelerate glucuronidation.  Some of the nutrients and phytonutrients that can help accomplish this include quercitin, curcumin, resveratrol, milk thistle, grape seed extract, and hawthorn.  You also want to make sure to consume omega 3 fatty acids, and magnesium.  Probiotics and calcium d-glucarate can help to inhibit beta glucuronidase, which I’ll briefly discuss below.  Foods which support glucuronidation include apples, kale, broccoli, and watercress.

What is Beta-glucuronidase?

Beta-glucuronidase is an enzyme produced by bacteria in the gut.  You ideally want to have low levels of this, and the reason for this is because if this enzyme is active then it results in uncoupling of the substrate and the phase one intermediate, and the toxin therefore gets reabsorbed into the enterohepatic circulation, which isn’t a good thing.  In fact, elevated beta-glucuronidase is associated with an increased risk of certain types of cancers.  One of the ways to test for beta-glucuronidase is through the Metametrix comprehensive stool panel.  Some of the nutrients and herbs which can inhibit this enzyme include broccoli, Brussels sprouts, apricots, watercress, calcium d-glucarate, milk thistle, and licorice.

The Role of Thyroid Hormone In Glucuronidation

Thyroid hormone is also involved in glucuronidation, as T3 influences some of the UGT enzymes (UTG1A1 and UTG1A6).  Vitamin A also plays an important role in this (1).  As a result, even if someone has sufficient T3 levels, but has a vitamin A deficiency, then this will have a negative effect on glucuronidation.

2. Sulfation.  Sulfation involves multiple steps, but the end result is conjugation with the substrate, which as you know by now will make the xenobiotic inactive and water soluble.  An enzyme called 3-phosphoadenosine-5-phosphosulfate is a coenzyme involved in sulfation.  An enzyme called sulfite oxidase catalyzes the conversion of sulfite to sulfate, which is necessary to break down sulfur-containing amino acids such as methionine and cysteine.  What’s important for you to understand are the nutrients required in this pathway, and vitamin B6 and molybdenum are required cofactors for this enzymatic reaction.  As a result, a deficiency of either one of these can cause problems with this pathway.  Having problems with sulfation can result in food sensitivities, chemical sensitivities, or an intolerance to acetaminophen.

3. Methylation. I’m not going to get into detail about methylation, but I did speak about this process in an article entitled “Methylation, MTHFR, and Thyroid Health“.  With regards to detoxification, methylation involves conjugating phase one intermediates with methyl groups.  Three of the more important nutrients required to help support methylation include folate, vitamin B12, and vitamin B6.  These are the main cofactors of S-Adenosyl-l-methionine (SAMe), which is the main methyl donor.  Once again, for more detailed information on methylation I would read the article I wrote on this topic.

4. Glutathione Conjugation. Many people reading this are familiar with glutathione, which is an antioxidant that helps to protect us from free radicals, but also plays an important role in phase two detoxification.  N-acetylcysteine is a precursor of glutathione that I commonly recommend to my patients to help support phase two detoxification.  Another option is to take an acetylated or liposomal form of glutathione.  There are also numerous cofactors of glutathione, including selenium, magnesium, niacinamide, vitamin C, and alpha lipoic acid.  Fruits and vegetables usually contribute over 50% of dietary glutathione.  In addition, having healthy butyrate levels can also lead to healthy glutathione S transferase levels.  Butyrate is a short chain fatty acid that is produced by the gut flora.

5. Amino Acid Conjugation.  Not surprisingly, amino acid conjugation requires amino acids such as glycine, taurine, and glutamine.  Of these, glycine is the amino acid most commonly used for amino acid conjugation, although taurine is also commonly used.  So in order to support amino acid conjugation you want to make sure you are eating enough protein.

6. Acetylation. Acetylation involves conjugating toxins with acetyl Co-A.  If someone has a condition such as multiple chemical sensitivity then they will usually be a “slow” acetylator.  Acetylation is involved in eliminating excess histamine, serotonin, and sulfa drugs.  Nutrients which enhance acetylation include Vitamin C, B1, B2, B5, magnesium, and lipoic acid.  N-acetyltransferases (NATs) are drug-metabolizing enzymes that play a role in this pathway.

How Do You Get All Of The Nutrients To Support Phase Two Detoxification?

As for how to get the necessary nutrients to support phase two detoxification, you want to get as many of these nutrients through diet.  Eating plenty of fruits and vegetables is of course important, but you also want to make sure you eat sufficient protein as well.  While you want to get as many nutrients as you can through your diet, taking nutritional supplements and herbs can also help to support phase two detoxification.  Throughout this post I listed nutrients associated with each of these pathways.  So for example, to support glucuronidation I mentioned food sources such as apples, kales, and broccoli, but you can also supplement with curcumin, resveratrol, or milk thistle. Similarly, diet plays an important role in methylation, although if someone has an MTHFR defect then they might need to supplement with methyl folate or other supplements.

So hopefully you have a better understanding of phase two detoxification.  In phase two detoxification, the reactive intermediates that were formed in phase one are made water soluble so that they can be excreted. There are six different pathways associated with phase two, including glucuronidation, sulfation, methylation, glutathione conjugation, amino acid conjugation, and acetylation.  You want to get most of the nutrients to support these pathways through diet, although taking certain nutritional supplements can be beneficial at times.

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Here are some of my patients with thyroid and autoimmune thyroid conditions who have benefited from following a natural treatment protocol.

I was concerned about an ongoing "mental fog" and forgetfulness I had - which is one of the symptoms of Hashimoto's. I was having trouble losing weight and also felt very low in energy. Since following Dr. Osansky's recommendations I have found that I have a greater sense of calm - something I didn't expect from the treatment and changes in diet and lifestyle. In addition to getting my Hashimoto's under control, I have enjoyed other health benefits as well. I no longer suffer from anemia, my Vitamin D levels are normal and my immune system is strong. My thyroid blood tests also improved. Although it's a commitment and initial expense, it is completely worth it in the long run. Given the alternative (taking thyroid medication for the rest of your life), in my opinion it's a no brainer. If you give a natural treatment protocol a fair chance you'd be surprised at how much more empowered you'll feel about your illness and treating it. A natural treatment protocol is an effective solution that puts you in the driver's seat when it comes to your health. Traditional methods do the exact opposite.

Maria DeSimmone
Howard Beach, NY

Since following the natural treatment protocol I have all of the energy that I had before Graves' Disease, and not being on the meds feel wonderful. Being able to do all of the things that I used to do is fantastic, as we all take so many things for granted in life, and our health/body is very sensitive so what we feed it is so important, good in good out. Little by little my blood work came back to the normal range (within 4 to 6 months) but you have to follow the protocol.

Michael Addario
Albany, NY

When I first began the natural treatment plan for my autoimmune hypothyroid condition my top five symptoms were chest pain (diagnosed with costochondritis), fatigue, memory loss, stomach upset, and muscle weakness. No matter how much rest I got, I was still tired. Additionally I did not sleep well either. Originally, I didn't feel much different. I believe the reason for that to be because I was only taking a portion of the recommended natural supplements, as well as the fact that I had only changed some of my diet. When I really got serious about making changes is when I began to really see improvements. Although this does require a change in lifestyle, I feel much better today. The natural treatment protocol allowed me to delve deeper into the root of the problem and address it so that I will hopefully not need to be on these supplements for the rest of my life. I have already cut back on some of my supplements since my last blood work results.

Adah Thompson
Rossville, GA

Through my own research, I discovered that there are many side effects to radioactive iodine treatment. However, every visit to the endocrinologist ended with them stating that this was the only treatment for Graves Disease. In fact, one endocrinologist yelled at me and stated that I had to have the procedure done by November because of the dangerous side effects of the medication. I found Dr. Osansky’s website and read all his articles. I was immediately convinced that he could help me because one of his articles described his symptoms and it seemed as though he was describing my symptoms. I wanted a doctor who had this experience and could tell me what to expect.

Since starting the natural protocol, I feel full of energy. I look forward to seeing my students instead of dreading each day. My eating habits have totally changed. I can actually function when I get home. I used to sleep during the two week Christmas holidays, but this year I actually painted, cleaned and exercised. It has truly been a lifestyle change. My blood tests show tremendous improvement. In fact the same endocrinologist who yelled at me sent me a letter indicating that I should immediately start lowering the Methimazole.

Norma Lopez
Houston, TX
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