A functional nutrition approach to Hashimoto’s thyroiditis

Photo Cred: Farhad Ibrahimzade/Unsplash

By Kellie Blake, RDN, LD, IFNCP

I recently had a patient who sought nutrition counseling after her endocrinologist explained she would likely be on medication for the rest of her life for hypothyroidism. She had done some reading on her own and decided she wasn’t satisfied with that option, so she contacted me in hopes of working toward medication-free management.

Hashimoto’s thyroiditis, an autoimmune disease, is the most common cause of hypothyroidism. While it’s unclear how many people suffer from Hashimoto’s, hypothyroidism is thought to affect 5 percent of the population, mostly women between ages 30 and 50 years old. Initially, patients may not experience symptoms, but the progressive destruction of the thyroid gland is happening, nonetheless. Over time, patients begin to suffer the hallmark symptoms of hypothyroidism including weight gain, dry skin, fatigue, increasing cholesterol levels, gastrointestinal alteration, cold sensitivity, hoarseness, and muscle and joint pain.

As reported in Food-Associated Autoimmunities, patients with autoimmune diseases like Hashimoto’s often have autoantibodies for six to eight years before the full onset of the disease. Conventional treatment almost always involves waiting for the full expression of hypothyroidism and then providing primary thyroid hormone replacement for the lifetime. On the other hand, early identification of this autoimmune process allows for nutrition and lifestyle-related changes that may reverse the underlying disease process thus preventing full disease expression. Not only is quality of life improved, but patients may be able to forgo a lifetime of daily hormone replacement medication and prevent further destruction of other body tissues as is common in those with autoimmunity.

Hashimoto’s patients who have already advanced to hypothyroidism can take advantage of the same nutrition and lifestyle interventions to reverse their symptoms and possibly come off medication. In one clinical trial reported in Experimental & Clinical Endocrinology & Diabetes, women with Hashimoto’s thyroiditis who followed a gluten-free diet for six months experienced a reduction in thyroid antibodies and an increase in vitamin D levels when compared to controls. In another trial, reported in the journal Endocrine, 75.9 percent of the study participants with Hashimoto’s thyroiditis were found to be lactose intolerant. After following a lactose-free diet, participants experienced decreased levels of thyroid stimulating hormone (TSH).

While gluten- and dairy-free diets can initially be helpful, I find a complete program to restore gut microbiome balance and a healthy intestinal lining to be the most beneficial for any patient with autoimmune disease. As part of this personalized plan, I work with patients to control lifestyle factors that contribute to the autoimmune process such as toxins, sleep, movement, and stress.

Case Study

Loren was diagnosed with Hashimoto’s thyroiditis after the birth of her first child. Through her research, she discovered the potential benefit of changing her diet, but her primary care provider and endocrinologist had both told her she didn’t need to restrict any foods. Loren decided to try avoiding gluten, sugar, and soy and noticed improvement in her symptoms. She had been a lacto-ovo vegetarian for most of her life but was not opposed to adding poultry back in and she reported feeling hungry all the time on the gluten-free diet.

Loren was taking 50 micrograms of levothyroxine, 25 micrograms of vitamin D3 when she remembered, and a topical medication for eczema daily. Loren is five feet six inches tall and said she was in her desired weight range at 137 pounds. Loren was not exercising due to fatigue and said she had excess stress in her life related to her family situation. She was not sleeping well and admitted to getting in bed around 11 p.m. and scrolling social media until she fell asleep. Loren worried about being able to simultaneously meet her nutritional needs and cook meals her family would eat. She had no other past medical history but said she had suffered numerous ear and strep infections as a child. Her initial symptom score of 76 indicated severe symptoms and she reported a recent increase in anger and anxiety.

The initial plan for Loren was to target her increased intestinal permeability, suspected food sensitivities, and unmanaged stress:

1. A full elimination diet for at least four weeks, which included adding a variety of greens to her morning smoothie; eating at least nine servings of vegetables per day with half leafy greens; and adding in poultry while also focusing on high quality vegetarian protein sources such as hempseeds, nut butters, nuts and seeds, beans, quinoa, and vegan protein powder.
2. Stress management practice daily to target stress hormone levels. Five minutes of meditation twice daily, once in the early morning and once in the afternoon.
3. Sleep hygiene techniques to include being in bed by 10:30 p.m. with no blue light exposure within one hour of bedtime and no food intake within three hours of bedtime.
4. Nutritional supplementation to include magnesium glycinate 240 milligrams about 30 minutes before bed to promote relaxation and sleep, vitamin B complex and vitamin C 1,000 milligrams per day due to increased needs related to stress, L-glutamine five grams per day to heal the gut lining, a multi-strain probiotic to reinoculate the gut, and 2,000 milligrams omega-3 per day to target inflammation and meet needs based on the vegetarian diet.
5. Suggested lab work to include a full thyroid panel including antibodies, vitamin D, celiac panel, CBC, and CMP. GI Map stool testing and salivary cortisol testing were offered.

After four weeks, Loren reported she didn’t feel exponentially better than before, but she did seem to have a little more energy and she noticed a difference in the tingling and numbing sensations in her arms and hands. She had not noticed any change in the eczema symptoms. 

Loren followed the elimination diet closely but had not been practicing the stress management technique. While she had done well with the bedtime routine for the first week, she had gotten back into old habits. Loren said she missed eating eggs and cheese and she was struggling with meal prep. She was taking all the recommended supplements, minus the L-glutamine powder due to breastfeeding. She had not had her lab work completed and she declined the stool testing and salivary cortisol testing. Her symptom score was down from 76 to 44 indicating good progress.

The follow-up plan included:

1. Continue the elimination diet for four more weeks. I gave her the option to add eggs back in but encouraged her to monitor for negative symptoms. Additionally, her updated plan included adding in one-half cup of raw nuts per day to increase healthy fat intake; adding in two tablespoons olive oil per day to target inflammation and hunger; and increasing serving sizes, focusing on green, leafy vegetables due to report of hunger.
2. Continue with all supplements except the L-glutamine powder.
3. Focus on meditation, with at least one five-minute session immediately upon waking.
4. Focus on the sleep hygiene techniques previously recommended.
5. Consider having recommended lab work completed.

After eight more weeks, Loren reported a 10-pound weight loss. She said her energy level was improved, but she was still tired at the end of the day, especially when she was breastfeeding her daughter. She still had eczema on her hands, but not quite as severe. Her bowel movements were normal and her thyroid peroxidase antibodies were within the normal range at 2.4 IU/mL. Her TSH was 1.04mcIU/mL and free T4 was 1.14ng/dL and she remained on her hormone replacement medication.  Loren did not have other lab work completed. She also reported not telling her endocrinologist about her nutrition and lifestyle-related changes due to fear of what her provider would say.

Loren followed the elimination diet closely but was starting to eat more processed foods like grain-free chips and pretzels. She added eggs and peanuts back and said she didn’t experience any negative symptoms. Loren said she was working to increase leafy greens and water intake and she started walking for exercise twice per week. She was still struggling with avoiding blue light before bed and wasn’t consistent with her supplements, but her stress level had improved due to some family-related changes. Her symptom score remained at 42, improved overall but still with moderate symptoms.

The follow-up plan included:

1. Transition to a mitochondrial food plan that is low-grain, gluten- and dairy-free, and moderate in healthy fat. Add eliminated foods back one at a time but continue gluten and dairy-free.
2. Add in two high intensity interval training sessions and one weight training session per week in addition to walking to target fatigue.
3. Continue with recommended supplements.
4. Consider using blue light blocking glasses at night if unable to stop looking at the cell phone.
5. Practice daily stress management technique.
6. Speak with physician about a medication weaning trial.

Loren has made some progress and reports feeling better overall. While she has been very consistent with the meal plan, she has been less so with the other very important lifestyle factors. I have encouraged her to implement all the recommended strategies to experience more complete healing.

References

Asik, M. (2014) Decrease in TSH levels after lactose restriction in Hashimoto’s thyroiditis patients with lactose intolerance. Endocrine. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/24078411/

Krysiak, R. (2019) The Effect of Gluten-Free Diet on Thyroid Autoimmunity in Drug-Naïve Women with Hashimoto’s Thyroiditis: A Pilot Study. Experimental and clinical endocrinology & diabetes : official journal, German Society of Endocrinology [and] German Diabetes Association. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/30060266/

Vojdani, A. (2019) Food-Associated Autoimmunities: When Food Breaks Your Immune System (1^st ed). A&G Press