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Thyroid Myths and Truths Presenter: Chris Kresser The following transcript and information is not intended to take the place of medical advice and/or treatment from your personal physicians. Sean: Welcome back to The Second Opinion Series. I have the honor of hanging out with one of the smartest guys that I know. Hes a functional medicine practitioner and the author of this book here, Your Personal Paleo Code. Hes been on Dr. Oz, and Fox & Friends. And hes here to talk about the myths and truths about thyroid health. Chris Kresser, welcome! Chris: Sean, good to see you. Sean: Man, welcome to the series. Very good to see you, as well! Chris: Always a pleasure. Sean: Youre going to talk about myths and truths. But before we get to that, I know theres a lot of people in our audience who are dealing with health issues. And theyve been dealing with them for a long time, havent been getting the help that they really need. Talk about your story because its a really good one of overcoming health challenges. Chris: Yeah. So I took off in my early twenties to see the world. It was an around the world trip I had planned. And I was in Indonesia doing some surfing. And I got the classic tropical illness, so vomiting, diarrhea, fever. I was delirious. I dont even really remember much about what was going on those few days. And the acute episode passed pretty quickly. But as I continued to travel it became clear that it was evolving into a longer term, chronic illness. Sean: Wow. Chris: So I actually had to cut my trip a little bit short and come back to the states to try to figure out what was going on. And it really ended up being a ten-year process to recover my health. And during that period, I tried everything you can possibly imagine.

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Thyroid Myths and Truths Presenter: Chris Kresser Sean: What did you try? Chris: Well, first of all, I tried conventional medicine because that was kind of the default. And I saw a bunch of doctors. Nobody had a really clear diagnosis. A lot of people suspected parasites. So they gave me antibiotics. And I would feel better at first, then I would feel worse afterwards. And then I had already had some experience with natural medicine. So I started to see acupuncturists, homeopaths, nutritionists. I was a macrobiotic vegan at one point, which a lot of people are surprised at. I wrote a book about the Paleo diet. I was a vegetarian. I did the raw food approach. I mea, I tried every special diet you can imagine. I had a cupboard of supplements that I called my supplement graveyard, which it was basically. And Im sure a lot of people listening can relate. Sean: Theres a lot of those out there. Chris: Yeah, thousands of dollars worth of supplements Id tried that didnt work that I just kept in the cupboard thinking maybe they would someday. Sean: Right. Chris: You know, it just became clear at some point along the long that nobody was more invested in my health than me. And if I was going to figure this out, I needed to really take it into my own hands. So I went back and studied Chinese and integrative medicine, first in San Diego, actually, and finished my degree in Berkeley. And then just dove into the scientific literature, started to do my own research, which I was trained to do in school fortunately, and come to my own answers through a lot of experimentation, trial and error, and some really expert guidance along the way. I figured out a system that worked for me that included a nutrient-dense, low-toxin, anti-inflammatory diet, which I describe in the book. But also, lifestyle, getting adequate sleep, appropriate type of physical activity for me and my constitution, sun exposure, bringing more pleasure and connection into my life, bringing more play into my life, which I think is important. And, of course, smart supplementation. So when I put all

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Thyroid Myths and Truths Presenter: Chris Kresser that together, I really started recovering my health. And I decided to turn that experience into something that could help others. Sean: Yeah, its helping a lot of people. So youre feeling good now? Chris: I feel great! Sean: Fantastic! And youre helping other people feel good, as well. Lets tackle these myths. First and foremost, people are going to their doctor, their conventional western doctor. And they might go online and look for thyroid systems. And theyve got every single one of them. And they go to the doctor and the doctor run some tests. And these tests come back normal. Chris: Yeah. Sean: So the first myth for you is that those tests are actually accurate. Chris: Right. So often the doctor will just run one test and that test is thyroid stimulating hormone or TSH. Sean: What is that? What does that mean? Chris: Yeah. So all hormones regulation in the body works on negative feedback. So we have like this control tower in the brain, the pituitary gland. And its job is to monitor levels of hormones, including thyroid hormone. And when it sees the thyroid hormones low, it produces more of something called thyroid stimulating hormone or TSH. And if thyroid hormone is high, it will produce less of that. So its a compensatory system to keep TSH in the normal range. And that thyroid stimulating hormone acts on the thyroid gland and tells it to produce more or to produce less. And thats the basic way that it works. So the thinking is, Hey, if we just test level of thyroid stimulating hormone, we can know how the thyroid is functioning just by testing that one single marker. If its high, it means the thyroid is under-functioning because its telling the thyroid to produce more.

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Thyroid Myths and Truths Presenter: Chris Kresser Sean: I gotcha. Chris: And if its low, it means theres too much thyroid function. So its telling it to put the brakes on and chill out. And it makes sense, right? But the problem isWell, there are a couple of problems. Number one, there are a lot of thyroid dysfunction patterns that will show up with normal TSH or maybe low, normal, or slightly high normal TSH. So, for example, lets say your pituitarys telling your thyroid gland to produce the right amount of thyroid hormone, but after that thyroid hormone gets produced, its not entering the cells the way that it should. Sean: So something is going on downstream? Chris: Somethings going on downstream. And ninety-four percent of thyroid hormone thats produced in the thyroid gland is produced as T4, which is one of the main kinds of thyroid hormone. But the thyroid hormone thats really active in the body, the one that does all the things that thyroid is supposed to do is T3. And T4 has to be converted into T3 to work properly. So what if that conversion isnt working well? What if the thyroid glands are making plenty of T4, but that T4 isnt getting converted into T3? And thats, in fact, a really common pattern because inflammation suppresses that conversion of T4 to T3. And, as you know, inflammation is an epidemic problem right now. Sean: So the lack of conversion of T4 to T3, that doesnt show up on the TSH test? Chris: It may not show up on the TSH test. You could have sort of low, normal levels of T3 and thats notYour TSH might be slightly elevated. But the typical lab range isnt going to show that. So that brings us to the next problem about TSH. Sean: Yeah, lab range.

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Thyroid Myths and Truths Presenter: Chris Kresser Chris: Yeah, I know you know about this. So theres a conventional lab range that we see, like if you get a lab testLabcorp, Quest, whateverand it comes back and theres a range printed right on the sheet. And if youre in that range, youre normal. So the problem with many of these rangesand this is particularly true with TSHis theyre often determined just by taking a group of people, testing their levels, and then doing a bell curve analysis. And everyone whos in that fat part of the bell curve is determined to be normal. But the problem is a lot of people in these tests have hypothyroidism. The early test where they determine the range for TSH, they didnt exclude people with hypothyroidism. And they didnt do any additional testing to figure out people who didnt even know they had hypothyroidism because for every one person thats diagnosed with hypothyroidism, you have at least two or three people that are undiagnosed. And thats a known fact. So we have this huge group of people. A lot of them have diagnosed known hypothyroidism, and then a much larger number who have undiagnosed hypothyroidism. And their skewing the range of what a normal TSH is because they all have high TSH. Sean: Huh! Thats how that works, huh? Chris: Thats how it works. So the normal range is like 0.45 to about 4.5. And it varies from place to place, which is weird in itself. Like why would the range be different in Alabama than it is in New York? Sean: That makes no sense at all. Chris: You could be hypothyroid in New York City, but not in California. I mean, that doesnt make any sense. So, yeah, its too broad. Its 0.45 to 4.5. But when you look at studies that actually excluded people who had known hypothyroidism and had did testing to find people who had undiagnosed hypothyroidism, it turns out the normal TSH is about 0.5 to about 2.0 or 2.2. Sean: So theres people at 3, 4, 4.5. And the doctors saying youre fine, but theyre really not?

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Thyroid Myths and Truths Presenter: Chris Kresser Chris: Absolutely! I just had a patient yesterday. He came in to me. Had all the classic hypothyroid symptoms: cold hands and feet, hair loss, dry skin, brain fog, constipation. I mean, she was like the textbook case of hypothyroidism. And she said, Ive seen four or five different doctors. And they just keep telling me my thyroids fine. And I looked at her TSH. And it was 3.56, which again is in the normal range, and well within it. Its a full point below the 4.5 upper end of the range. And, yet, when I tested her T3, it was very low. It was actually below the lab range. And her TSH, as I mentioned, was above what a normal TSH is in healthy people. So this is a big problem. Sean: I can feel the frustration with our audience right now who are thinking about their scores. What do they say to their doctors about this, though? Chris: Yeah, that is tricky. I wish I had a better answer for it because a lot of doctors, unfortunately, arent aware of this research. Its there. Its there for anyone whos looking for it. But doctors are some of the busiest people in the professional world. Theyre seeing patients forty hours a week. Theyve got all kinds of work outside of their patient time. And I feel for them too. Its like, they need to have a life outside of their work. Sean: Right. Chris: And a lot of them just dont have time to stay current with the scientific literature. And that should be what their professional organizations are doing and the American Society for Clinical Endocrinology. And groups like that actually have published some different guidelines that recommend a lower end of the range. But its not trickling down into the trenches where most doctors are working. And then in terms of specialists, my experience has been that sometimes specialists are the least open to changes because theyre the most invested in the current paradigm, like theyve reach the highest place in the dominant paradigm. And so theyre the least open to those ideas shifting. Sean: They dont want to admit to being a little bit wrong.

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Thyroid Myths and Truths Presenter: Chris Kresser Chris: Yeah, because thats their specialty. Thats that their expertise. So I recommend generally for people to seek out a functional medicine practitioner, perhaps a naturopath because typically these folks tend to be a little bit more informed on these recent changes and a little bit more open to treating what we could call subclinical problems, which means its not full-fledged outside of the lab range hypothyroidism. But its outside of what the research suggests would be an optimal range. Sean: What about T4 and T3? Where should those be? Chris: Yeah, so the issue with T4 and T3, in my opinion, isnt so much the range, although, it is important. Its whether youre testing them at all. So, first of all, as I mentioned, a lot of doctors will just run TSH. And if its normal, thats the end of the story theyre not going to go any further. So making sure that T4 and T3 are getting tested, particularly T3, which is the most important form of thyroid hormone. But then theres another layer, which is the difference between total T3 and T4, and free T3 and T4. So this can be a little bit confusing. But the easiest way to say it is all the hormones that are produced by glands, including the thyroid gland, are bound to proteins. And the reason for that is that hormones are fat-soluble. And the blood is mostly water. And so in order for a fat-soluble substance to be transported around the blood, it has to be hitched up to a protein so the protein can carry it around. Its like a transport service. So these proteins are like taxis. Sean: Like a taxi. Chris: Yeah, and they take the nutrients and the hormones all around the body and deliver them to the cells and the tissues where theyre needed. So its possible to have normal total T4 and T3. So the gland is doing its job in producing the right amount of T4. And even the conversion of T4 to T3 is happening okay. But when the proteins should be cleaved off and the hormones are transformed from total hormones bound to the protein to free hormones, which is what actually enables them to enter the cell, they cant get into the cell when theyre bound to those proteins.

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Thyroid Myths and Truths Presenter: Chris Kresser So the protein has to be cleaved off. And then the free hormones go into the cell and do what theyre supposed to do. And if that doesnt happen right, you could have high normal TSH, normal total T4 and total T3, but low free T4 or free T3. And youre still going to have thyroid symptoms. And thats not going to be caught in the typical lab testing that people do. Sean: How does that happen? How do they stay bound? Chris: So thats not completely understood, actually. But it is thought that inflammation plays a role in that. Stress and dysregulations of the adrenal axis, the hypothermal pituitary adrenal axis, which is what governs our response to stress and our tolerance to stress. Changes in that axis can be problematic. And then a hormone imbalance, like sex hormone imbalance, progesterone, estrogen, elevations in sex hormone binding globulin, which is another kind of protein carrier, can affect it. So it gets a little complex when we start going into that level of detail. But, I would say in general its more related to like a systemic problem than the thyroid itself. Sean: Ive interviewed a lot of people on my radio show about thyroid health. And one thing that always comes up is thyroid antibodies. People arent being tested for that. Talk about it. Chris: Yeah, so thats another big problem. In functional medicine, as you know, Sean, were always looking for the underlying cause of the problem. And were trying to address it at that level instead of just suppressing symptoms. And with integrative or holistic medicine, sometimes what happens is people are still suppressing symptoms. But theyre just using herbs or supplements to do it instead of drugs, which is definitely an improvement in many cases. But its not the real core principle of a functional approach, which is get to the bottom of the problem. And so the main cause of hypothyroidism in the U.S. is Hashimotos. Sean: Whats the percentage on that? Chris: Theres a big controversy about that, actually. Theres studies that have shown that up to ninety percent of people with hypothyroidism have thyroid antibodies. But I actually havent found that to be true in my practice. I test everyone who has poor thyroid function for antibodies. And I

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Thyroid Myths and Truths Presenter: Chris Kresser dont find them in ninety percent. And there are a lot of other research studies which suggest the percentage is way, way lower than that. But it is pretty much universally agreed that Hashimotos is the primary cause of hypothyroidism. So more likely than any other cause for people in the U.S. In the developing world, its iodine deficiency. But in the industrialized world its Hashimotos. And this an autoimmune disease. And what happens is the body starts attacking the thyroid gland as if it were a foreign tissue or invader. And so the lab tests that you want to do for this are thyroid antibodies. So thats thyroid peroxidase and anti-thyroid globulin antibodies for Hashimotos, and then TSI antibodies for Graves disease, which is the autoimmune condition that causes hyperthyroidism. Sean: For the audience, is it TPO? Is that the abbreviation for it? Chris: TPO. Thyroid peroxidase is TPO. Sean: And the other one is? Chris: And the other one is thyroglobulin, which often goes by TG. Sean: TG. Okay, gotcha. Chris: Yeah, TG. And so you really want to get these antibodies tested because if you are positive for these antibodies it means you have Hashimotos. Or it certainly suggest that you do. And the treatment focus will shift. So the reason why theyre not tested often in the conventional world is it doesnt change their treatment plan. Whether you have Hashimotos or some other cause of hypothyroidism, theyre just going to give you a thyroid hormone. It doesnt matter because they dont have any way of treating the autoimmune dysfunction with Hashimotos. With a more serious autoimmune condition thats life threatening like MS or rheumatoid arthritis or Crohns disease, theyll use steroids. But with Hashimotos its deemed that thats too much. The

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Thyroid Myths and Truths Presenter: Chris Kresser cost benefit ratio is too great. And so theres nothing that they do. But in functional medicine, we do address the autoimmune condition. So its important for us to know that its present because it will change how we treat the particular thyroid condition. Sean: Well talk more about that later. The next myth: iodine. Ive heard that people who have Hashimotos should avoid iodine. Is that true? Chris: Yeah. I would say its possibly true. So theres been a lot of focus on this in the last couple of years. In the developing world, as iodine is added to saltbecause iodine deficiency is so common in the developing worldyou see rates of Hashimotos go up considerably. And so the idea was, Wow, iodine is triggering or exacerbating or flaring Hashimotos. So anyone with thyroid issues should avoid iodine. The problem with that research was that it ignored the important role of selenium. So in a lot of these populations where they were giving them iodine, they were also selenium deficient. And selenium protects against the potentially toxic effects of iodine because without getting too detailed, it helps convert hydrogen peroxide that is produced in the thyroid during the making of thyroid hormone into water, which is non-toxic, of course. And if theres not enough selenium that hydrogen peroxide doesnt get converted into water. And it can damage the thyroid gland and provoke this autoimmune attack. So as long as youre getting enough selenium, which a lot of Americans do, and as long asWell, as long as youre getting enough selenium or as long as a whole population is getting enough selenium, it shouldnt be a problem. And when you look at the studies, thats what holds up. Still I do suggest that people exercise caution if they have Hashimotos or any hypothyroid condition and they start adding iodine. They should start with a really low dose. They should build up really slowly over time. And I recommend they supplement with about 200 micrograms of selenium a day just to mitigate any potential harm that could be caused. Sean: The supplementation, is that oral? Or they rub it into the skin?

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Thyroid Myths and Truths Presenter: Chris Kresser Chris: Yeah. Yeah. Selenium is fine orally. Its pretty well absorbed. Theres some interesting studies that show that 200 micrograms of selenium a day is beneficial for people with Hashimotos, even if theyre getting enough selenium in their diet. As long as youre not over doing it, youre not taking more than that, youre not exceeding 400 micrograms a day of selenium, its pretty to safe to do that. And a lot of my patients get a benefit. Sean: What about the iodine supplementation? Chris: So I generally recommend starting with like kelp tablets with maybe 200 or 300 micrograms of iodine, which is a pretty low dose. And then depending on the extent of iodine deficiency, you might go as high as 6.25 milligrams, 12.25 milligrams. Some people advise even going up to fifty milligrams. But I wouldnt do that outside of the supervision of someone whos familiar with iodine supplementation. Sean: Do you recommend they maybe go into the doctor every month to kind of check their levels, their TSH? Im sorry, not TSH, the antibody levels? Chris: I dont generally recommend tracking antibodies that regularly because they fluctuate a lot. And there are some interesting things about the immune system that mean that antibodies going up can sometimes mean a sign of improvement, which is just bizarre. But sometimes theres this part of the immune system that is overrepresented or maybe over stimulated thats suppressing antibody production. And then as the immune system starts to balance out, antibodies will temporarily go up for a little while. So I think long-term antibodies can be helpful as a marker, but not every month. Thats probably too frequent. Sean: Next myth, cruciferous vegetables. They havewhat is it?oxalic acid? Chris: Well, theyre goitrogenic. This is the problem. So a goiter is a swelling of the thyroid gland. And iodine deficiency is one of the most common causes of goiter. And you see it a lot in the developing world because of the rates of iodine deficiency there. And cruciferous vegetables in moderate amounts, they have chemicals in them that inhibit the uptake of iodine into the thyroid gland.

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Thyroid Myths and Truths Presenter: Chris Kresser So if your intake of iodine is already low, which it is for a lot of Americans, then the cruciferous vegetables will sort of block that iodine from being taken up into the thyroid gland. And it can lead to an iodine deficient condition, and then possibly a mild swelling, which is a goiter. In high amounts, cruciferous vegetables actually interfere with the uptake of iodine into thyroid hormone itself, which is a much more serious problem because even iodine supplementation cant reverse that. So it sounds scary, right? Like, Oh, my gosh. We should not eat broccoli or bok choy or cauliflower?! which are super healthy vegetables. And then there are other goitrogenic foods like millet and yuca. Sweet potatoes actually have some goitrogenic compound. Sean: Soy is one, right? Chris: Soy is a huge goitrogen. Millet is actually the worst. But, again, when you look a little bit deeper into it, the story becomes a little more complex. So number one, cooking destroys some of the goitrogenic compound in these vegetables. Sean: Youre not eating broccoli raw? Chris: I wouldnt recommend it for people who have a thyroid problem. Sean: Right. Chris: Yeah. So steaming destroys thirty percent of the goitrogens. And boiling and then discarding the water that the vegetables were boiled in destroys up to ninety percent. And then fermentation changes it. It actually increases the goitrogens. But it decreases substantially the presence of these compounds called nitriles, which are even more harmful for the thyroid. So I think the net effect of fermentation is actually positive, even though its slightly increasing the goitrogenic compounds.

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Thyroid Myths and Truths Presenter: Chris Kresser And then just supplementing with iodine or making sure youre getting enough by eating sea vegetables. So like kelp flakes or wakame, arame, hijiki. These sea vegetables, you can put in soup or you can use as a flavoring for stews. Or you can use kelp flakes in place of salt, which is a really good way to get iodine into your body. Sean: Where do people find those? Chris: Any Asian food store, any health food store like Whole Foods. Every Whole Foods Ive ever seen will have kelp flakes. Typically, theyre in the same place where the Asian foods, with the coconut oil and the rice noodles and stuff. Theyre typically are all in the same place. And this is a big issue because the only real sources of iodine in the dietand in the American dietwas iodized salt. And all of us health conscious people are not eating iodine salt. Sean: Right. Chris: Were eating sea salt. And theres good reasons to do that. But the downside is that if youre not eating sea vegetablesWhich lets face it, not a lot of people are. Sean: Sea vegetables taste good! Chris: I love them! I love them. But you know when I tell people to eat sea vegetables theyre like, Huh? Sean: Its just different. But once they try it, they like it? Chris: Most people do. Fish head soup, excellent source of iodine. But again, Im going to venture not a lot of people in the U.S. are eating fish head soup at this point. In the Asian communities, definitely. But not in sort of mainstream America. Sean: Ive never gone to somebodys house and they were making fish head soup.

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Thyroid Myths and Truths Presenter: Chris Kresser Chris: Yeah. And then pastured dairy actually has some significant amounts of iodine in it. But the majority of dairy consumed in the U.S. comes from factory cows that are eating grains and not pasture raised. So a lot of people are iodine deficient for this reason. So if you just supplement with a little bit of iodine using kelp tablets or you make sure youre eating these sea vegetables, thats usually enough to offset the potentially goitrogenic effects of these cruciferous foods and substances. But I do recommend not eating raw cruciferous vegetables for that reason. Sean: I dont think anybody does, anyway. Chris: Stay away from the raw cabbage. I mean, raw cabbage, sometimes people will eat on a salad. Dont go crazy with the cruciferous. You know, like dont eat broccoli twice a day every day if you have a thyroid problem and only lightly steam it because its still going to have a significant amount of goitrogens. But if you follow those guidelines, theres no reason to avoid those foods. And I dont recommend that you do because theyre totally loaded with other nutrients that are beneficial. Sean: Soy and millet, you mentioned. Chris: Yeah. Sean: Avoid? Chris: Probably best to avoid for people with thyroid issues. I mean, there are other reasons to avoid soy and millet, as well. Millet, if you dont soak it, the nutrients arent very biodegradable. And it can be irritating to the gut if you have an inflamed gut, which a lot of people with thyroid issuesespecially autoimmune thyroid issuesdo. And soy in small amounts, traditional fermented soy like tempeh or miso are no problem, I think. But when youre eating large amounts of processed and refined soy, not a good idea.

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Thyroid Myths and Truths Presenter: Chris Kresser Sean: So weve covered three myths. Lets jump into some truths. Heres one for you. Thyroid meds are not enough for people with Hashimotos. Whats your take? Chris: I think thats generally true. So by thyroid meds, I mean replacement thyroid hormones. Things like Synthroid, Levothyroxine, Armour, even the natural desiccated thyroid. And as I was saying earlier, in the conventional world if you have Hashimotos, thats still going to be the basic treatment: give you thyroid hormone to bring your thyroid levels up. And I actually do think thats necessary in many cases. And the reason is that when you have Hashimotos because of the ongoing immune attack against the thyroid gland you start to lose thyroid tissue. And thyroid tissue is where the thyroid hormone is produced. And, unfortunately, at least as far as we know, that tissue doesnt grow back. So if youve had Hashimotos for a while, which a lot of people do before its actually discovered, theres a good chance that youve lost some of your thyroid tissue, and therefore some of your ability to produce thyroid hormone. So I do think thyroidI see a lot of patients who come to me with Hashimotos and say, I really want to get off my thyroid medication. And I say, Well, Im not sure that really should be the best goal. The goal is to maybe minimize the amount of thyroid medication that you need. We can try to get you off of it, if thats actually whats possible. But thyroid hormone is so important. I mean its used by every single cell of the body. Its so important that you dont want to be in a situation where youre producing less than you need. So thats the pros of thyroid hormone replacement in Hashimotos. But you dont want to stop there. Thats the point Im trying to make here because we need to focus on the underlying problem, which is the immune dysregulation. And so theres a whole bunch of things we can do from a functional medicine perspective. One is diet. So we want to remove anything from the diet that could potentially aggravate the immune system. And I recommend typically as a starting place, an autoimmune Paleo approach, which would be the basic Paleo approach where youre eliminating grains and dairy. And one of the reasons for that is that people who have Hashimotos have a much higher prevalence of gluten intolerance and lactose intolerance, which well talk about a little more.

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Thyroid Myths and Truths Presenter: Chris Kresser Sean: Is that grains, all grains? Or just grains with gluten? Chris: I think all grains at least to start with. Im not saying that you have to necessarily strictly avoid all grains, even properly prepared, soaked, fermented grains forever. But you should at least do a thirty-day period where you do that. And then you additionally remove dairy strictly. You remove eggs. And you remove nightshades because those can potentially trigger an autoimmune reaction in some people. So thats the starting place. At the end of that period, you can reintroduce some of those foods and see how they actually affect you. Then, we want to do things in general that are going to balance and regulate the immune system and specifically, were focusing on these immune cells called the T-regulatory cells and one way to think of them is sort of like the orchestra directors of the immune system. They make sure that all of the different sides or aspects of the immune system are in balance and are in the state of dynamic balance, and one side is becoming too overactive and the other side isnt becoming too overactive. Sean: They regulate. Chris: Yeah, they regulate the whole situation. And what we know from studies is that people with autoimmune disease, including Hashimotos, tend to have low levels of these T regulatory cells. So we want to do everything we can to boost T regulatory cell production and function. And there are a few ways to do that from a functional medicine perspective. One is optimizing vitamin D levels. So we know that low vitamin D will lead to poor T-regulatory cell function. And thats very common, of course, in our culture. So for people with autoimmunity, I recommend a range of maybe 30 to 60 blood levels of vitamin D. And I cant recommend a specific dose because you have to go in and get tested, see where your levels are, and then supplement or change your diet to get back in that range. Sean: Whats the name of the test that they should be asking for? Chris: 25 D is the blood level.

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Thyroid Myths and Truths Presenter: Chris Kresser Sean: Okay. Chris: And you can even get that test on your own now. There are companies that will send you a kit and you just do a little finger prick, put a drop of blood. And theyll test it for you. You can order it through directlabs.com. So you want to be in that 30 to 60 range. And if youre too low, you want to do maybe 2,000 to 4,000 IU a day until you get back up into that range. Sean: Is it enough for somebody just to go outside and get some sunlight? Or is that not enough? Chris: Ah, it can be. But their inflammation suppresses the conversion of sunlight to vitamin D, which unfortunately a lot of people dont know about. So if youre inflamed, which you typically would be with Hashimotos, you might not produce as much vitamin D from sunlight as a person without autoimmune disease. Obesity also suppresses that conversion of sunlight to vitamin D. So if youre overweight, youre not going to produce as much vitamin D as you would otherwise. And then skin tone has a big effect, as well as solar angle. So like in San Diego in the summer, someone whos really pale is going to produce a lot of vitamin D in a short amount of time. But someone whos darker skinned in Boston in the winter where the solar angles really low, theyre not going to produce very much at all. So sunlight can be reliable in certain situations for certain people. But depending on the season and skin tone and the solar angle, you may need to supplement. Sean: Gotcha. Chris: So thats vitamin D. The next is glutathione, which I know you know a lot about. Its the master antioxidant in the body. And one of its main roles is to help balance and regulate the immune system. And, again, in all of those cases of autoimmune disease, a lot of people have low glutathione levels. So we need to boost those back up. My favorite way to do that is a liposomal form of glutathione, which is a nanoparticle preparation thats absorbed intact inside of the cell, which is where glutathione needs to get to in order to do its thing. You can take precursors like N-

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Thyroid Myths and Truths Presenter: Chris Kresser acetyl cysteine or alpha lipoic acid. Whey protein is a pretty potent glutathione precursor. So theres a lot of different ways to do that. And then anotherand this is actually going into the pharmaceutical realmanother way of powerfully regulating T reg cell production is something called low dose naltrexone. So this is a low dose of a drug called naltrexone that boosts our internal production of endorphins. These are these feel good chemicals like the runners high or sex. Orgasm produces a lot of endorphins. They mediate our experience of pleasure. But not only that, we now know that all white blood cells have receptors for these endorphins, which suggest they play an immunoregulatory role. And this is why Im constantly telling people to have more fun and bring more pleasure into their life because its actually good for your immune system. So its not just because its fun, which is part of the reason. But if you have more fun and you bring more pleasure and connection into your life, your immune system is going to function better. Sean: Having fun is healthy! Chris: Having fun is good for you. Sean: I like that. Chris: Now, feeling good is good for you. So thats a really important thing. You can take this low dose of medications. Its very safe. Of course, you need to see your doctor to get a prescription for it. But theres no known significant side effects or risks. And it works really well for people. As a functional medicine guy, I dont typically recommend medication. But my benchmark is whatever does the most amount of good and causes the least amount of harm. Sean: Right. Chris: And if thats a medication, so be it, as long as it fits that definition.

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Thyroid Myths and Truths Presenter: Chris Kresser I was just going to say, the last part of improving T reg cell function is the gut. And, of course, we can never have a discussion about health these days without talking about the gut. And thats as it should be because we now know that the gut just plays an enormous role in both health and disease. And so it turns out that the gut flora or gut bacteria help to regulate our immune system, as well. They promote T regulatory cell function. There was, in fact, a study that just came out showing that butyrate, which is a short-chain fatty acid thats produced by the gut bacteria, has a profound effect on T regulatory cells. Sean: Really? Chris: Yeah. Sean: First time hearing that one. Chris: Yeah, making sure you eat plenty of fermentable fiber, which increases the production of gut bacteria that produce in turn, butyrate is a really great way of optimizing your immune function. Sean: Eating fermentable fiber, where does that come from? Chris: Starchy vegetables like sweet potatoes, yams, plantains, taro, potatoes. Things like onions, Jerusalem artichokes, garlic. Resistant starch, which a lot of people have been talking about lately, which you get from cooking potatoes and then cooling them or eating like a gluten-free potato starch as a supplement. And just eating a wide-range of fruits and vegetables, which have these fermentable fibers, thats the best way to do it. And then butyrate you can also get by eating butter. Its present in butter in its form because the cows have produced it. Sean: Oh, okay.

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Thyroid Myths and Truths Presenter: Chris Kresser Chris: Their gut bacteria produces butyrate. And then it comes out in their milk, which ends up in the cream that is churned to make butter. So then youve got butyrate that way. So you can get it from butter. You can get it from your own gut bacteria. Sean: Weve talked a lot about Hashimotos. And I know that autoimmune conditions can be rooted in the gut. Talk about that connection. Chris: Yeah. So I think part of it is related to what we were just talking about. So lets say youre not eating a lot of fermentable fiber. Youre not eating fermented foods. And your intestinal bacteria is low, your beneficial bacteria is low, then youll have low levels of butyrate. Butyrate is anti-inflammatory in addition to helping regulate the immune system. So that can lead to a chronic state of inflammation in the gut. It can lead to a leaky gut. And now is where we get into autoimmunity. If your gut is leaky, that means large proteins that would typically not escape the gut are able to get through those gaps and tight junctions in the gut. Its almost like a sieve. And they get right through into the bloodstream. And then your immune system, which is not accustomed to seeing these proteins, it starts attacking them. And then that attack is the basis of autoimmunity in a lot of conditions. And some scientists like Alessio Fasano, who is a pioneer in gluten intolerance research, has gone as far as saying that having a leaky gut is a precondition to developing autoimmune disease. And Im not sure if thats true. Its a pretty controversial stance. But it does at least convey some of the importance of the relationship between gut health and autoimmune disease. Sean: Is it kind of like a case of mistaken identity where the immune system is attacking a particular protein? And then at some point says, Well, that protein looks a lot like the thyroid. Lets go attack that, too? Chris: That is one theory. And there is some support for that. But theres also been some research that suggests that may not be happening. Thats called molecular mimicry, what you were just talking about. And theres certainly some support for that.

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Thyroid Myths and Truths Presenter: Chris Kresser And an extension of that is certain foods that we might react to like gluten, there are other foods that have proteins that are similar to gluten. And we cross-react to those foods, like lactose or other proteins and other grains, for example. And, again, thats a controversial concept. But Ive seen it enough in patients that there is at least, something to it, whether weve got the exact mechanism right. In terms of practicalities we know enough to help people feel better. And thats the main thing. Sean: And healing the gut is just essential? You want to make sure you heal that gut? Chris: Its absolutely crucial! Absolutely crucial! Sean: All right, lets jump into another truth. Now, this one goes, Theres no one-size-fits-all approach when it comes to thyroid medication. Chris: Right. So a lot of times a patient will go in. Theyll get tested. And maybe they do trigger hypothyroid. Theyre outside of even the normal lab range. Theyve got a TSH of 9. And their doctor says, Okay, Im going to give you Synthroid. I mean thats the typical thing that happens. Synthroid, thats the brand name for Levothyroxine. Its a synthetic T4. So theyre givingAs I mentioned before, T4 ninety-four percent of the hormone produced by thyroid gland is T4. And so this is a synthetic form of T4. And in many ways that makes sense because hormones are powerful substances and you want to give the body a chance to regulate its own hormone production as much as possible. So when youre supplementing with a hormone or youre giving hormone as a medication, you want to start as far upstream as you can so you give the body the chance to decide how much its going to convert of that T4 into T3. If you give pure T3, the problem is thats like the end product. Thats the thing that has the big impact on thyroid function. And the body then has no chance. What if its too much? The body has no way of down-regulating the conversion because its already at the final product.

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Thyroid Myths and Truths Presenter: Chris Kresser And hyperthyroidism is actually much more serious than hypothyroidism because it increases heart rate. And that then increases the risk of heart attack. You can stroke out. And so doctors are understandably a little more hesitant to give pure T3 because there are some potential side effects and risks if someones overmedicating with T3, whereas with T4 its a lot less likely that thats going to happen because the body can put the brakes on the conversion process. The problem is, as I mentioned before, what if you have that problem converting T4 to T3? Then you could take as much T4 as you want. And it might improve a little bit because you are converting some. But youre not going to get an optimal effect because your T4 levels will go up. But your T3 levels wont go up substantially. So for that person, Synthroid or Levothyroxine is probably not a very good choice. And I see a ton of patients in that situation. They come to me. Theyre taking Synthroid. They may feel a little bit better. But their T3 levels are still low and theyre not feeling great. So for that patient, wed want to go in with, like if I was treating them, I would use like a natural desiccated thyroid hormone, which is just a freeze dried thyroid gland from a pig put into tablets or capsules. But if they were going to a doctor, they might get Armour or Nature Throid. This is a combination of T4 and T3 in a specific ratio that is supposed to mimic somewhat closely our own internal ratio of these hormones. And this is why a lot of people with Hashimotos do better with these T4/T3 combos because they have problems converting T4 to T3. So when you look up these thyroid support groups and you see people who are having Hashimotos, youll see a lot of them say, Everyone should be taking Armour or Nature Throid for this reason. In many cases that is true, where a T4/T3 combo will be better for people with Hashimotos, but not for everybody, necessarily. Some people may not have a problem with T4 to T3 conversion. And they might find that taking anything that has T3 in it is just way too stimulating. And I have seen this in some of my patients. And they do a lot better with just a straight T4 where their body can control that conversion process. So just like theres no one-size-fits-all approach to diet, I dont think theres any one-size-fits-all approach to thyroid medication.

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Thyroid Myths and Truths Presenter: Chris Kresser Unfortunately, a lot of doctors have their kind of favorite thyroid drug that theyre accustomed to using, whether youre talking about a naturopath or a conventional MD. And they just use that instead of looking at the labs and working with the patient to find out whats best for them. The last thing about the thyroid meds is the fillers that are used in them. And a while backyou might remember thisthere was this big uproar when Armour changed their formula. Sean: I remember that. Chris: Yeah. Yeah. And everybody thought it was because they changed the ratio of T4 to T3, the actual ratio of thyroid hormones. But that was unchanged and its been unchanged for a long time. I think its something like 4.22 to 1.00 in favor of T4. What changed was the filler. And all of these patients who had been taking it for years and having no problem with it and doing well all of a sudden started reacting to it. And in the conventional world, they didnt really even consider that as a possibility. But a lot of patients with Hashimotos have very sensitive immune systems. Sean: What was the filler? Chris: I dont actually remember. It was maybe a cornstarch before. And it changed. It didnt have gluten. But I think it was another substance that people were reacting to. I cant actually remember what the substance was. Sean: People had a noticeable change because of it, huh? Chris: Noticeable change. Sean: Interesting! Chris: Yeah. And as I was just saying, a lot of people with Hashimotos have very sensitive immune systems. Theyre sensitive to foods and ingredients like this. They tend to have leaky gut. And so yeah, something as simple as a filler in a medication that theyre taking can be an issue. So I really

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Thyroid Myths and Truths Presenter: Chris Kresser suggest that people hopefully can find a doctor or naturopath that is willing to work with them and experiment with different medications and not just get stuck in the idea of, This is the best one. And then, of course, lastly people can try taking desiccated thyroid, which as I mentioned is just a freeze driedgenerally pig, sometimes bovine cowthyroid gland thats powdered and put into capsules or tablets. So youre getting thyroid hormone thats naturally from the gland of one of these animals. Sean: Yeah, its a trip how that works. [Laughs] Chris: Yeah. And you want to make sure that the animals are not conventionally raised, that they are grass-fed animals that arent given a lot of hormones and stuff because that can concentrate in those glands. And people who already have sensitive systems dont want to be adding that stuff in. Sean: Chris , Ive seen in different forums people talking about standard dosages. The doctor will say, Take this amount. And its either too much or too little. How would somebody find the right dosage for themselves? Chris: Yeah, so thats, of course, something they need to work with their doctor on. But, in general, its the same idea. Just like theres no one-size-fits-all approach to the particular form of medication, theres no one-size-fits all approach to dosage. And, of course, doctors know this, too. But sometimes people arent really educated in how to find the right dose. But one thing they want to be doing is tracking their labs. So they want to be watching their TSH, making sure its coming back down into the normal range. And by normal, remember Im talking about below maybe 2.5, 2.2, not just below 4.5. And I want to make sure that the free T3 levels are coming up. The lower end of the range differs depending on the type of units used. But, generally, its a 2.0 for the lab range. I like to see people more closer to 2.5 for optimal function for free T3. And then their symptoms. You know youre taking too much typically if you feel like you just drank four cups of coffee. Youre plugged into a socket. Youre sweating. You feel hot. Youve got diarrhea

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Thyroid Myths and Truths Presenter: Chris Kresser or loose stools. Youre just totally agitated, cant relax. Youve got insomnia. These are the typical signs of too much thyroid hormone. Sean: Its obvious. Chris: Yeah. And, of course, people know what not enough feels like because thats why they started taking it in the first place. So, generally, cold hands and feet, hair loss, feeling kind of bloated, constipation, tired, brain fogged, those kinds of symptoms. Sean: You mentioned retesting. How often? Chris: Generally, a doctor will usually leave about four to six weeks in between dose changes. And theyll typically recommend not necessarily changing the dose abruptly, but maybe titrating a little bit down or up from one dose to the other. Sean: Gotcha. This has been great stuff! Last truth for you: gluten can make Hashimotos worse? Chris: That is true. A lot of people were skeptical about that when they first heard it. But theres a lot of peer-reviewed research that supports that. The incidence of gluten intolerance is higher in people with Hashimotos. And some studies have even shown that being on a gluten-free diet for six months can completely bring antibodies back to normal with no other changes at all. Just removing gluten from the diet can essentially reverse. We cant really say cure because that means that its gone forever and nothing you do can bring it back. But reverse the autoimmune disease meaning theres no evidence of it occurring anymore. Theres no antibody production thats visible on a test. So thats pretty remarkable, just one single dietary change. And I just read a study yesterday, actually, that showed that lactose intolerancelactose being the sugar in milk and dairy productsis much more common in people with Hashimotos, as well. And this study found that a restricted lactosenot necessarily a hundred percent lactose-freebut a restricted lactose normalized TSH in this population of patients that had Hashimotos and lactose

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Thyroid Myths and Truths Presenter: Chris Kresser intolerance. So their TSH levels were high, which indicated hypothyroidism. And after the reduced lactose diet, they came back down into the normal range. So if you think about it, it makes sense because these are the proteins that a lot of people are sensitive to, sugarlactose is a sugargluten is a protein. And if they have leaky gut, theres a higher chance that theyre going to have a sensitivity to these things. So it doesnt mean that everybody with Hashimotos should strictly avoid lactose. But it does mean they might want to consider getting tested for lactose intolerance through a lab like Cyrex Labs. And they may want to consider, as I mentioned in the beginning of this, to do a thirty-day period with no lactose at all. And then add it back in and see not only how they feel and how their symptoms change, but also how their labs changed, perhaps, if their TSH goes back up after adding lactose back in. Thats a problem. Sean: People feel a profound difference when they remove the gluten, the grains, the dairy from their diet for those thirty days. Chris: They do! They do! Sean: Its crazy when they add it back in, theyd always say, Oh, my God. I feel like I got hit by a bus. Chris: Right. Exactly! Sean: All the time. Its crazy. Chris: Yeah. You hear that a lot. There is one more thing I wanted to say about the thyroid antibodies. Theres about twenty to thirty percent of people who have Hashimotos who never test positive for the antibodies. So thats a little bit of a mystery still. It might have something to do with what I mentioned earlier, that part of the immune system thats over-stimulated that suppresses antibody production.

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Thyroid Myths and Truths Presenter: Chris Kresser In those cases, a thyroid ultrasoundgoing into the doctor and actually getting a scan of the thyroid glandthey can sometimes see nodules or a multi-nodular goiter, or something like that they can be suggestive of Hashimotos. So thats another way that Hashimotos can be diagnosed is doing an actual ultrasound of the thyroid. And sometimes if a patient I really suspect they have Hashimotos, but they keep turning up negative on antibody testsAnd Ill do at least two or three antibody test before I will go in that direction because Ive had several patients who Ive done one test and its normal. We test two months later and theyre high because as I mentioned they fluctuate quite a bit. I might recommend that they go get a thyroid ultrasound from their doctor. And weve been able to diagnose people that way, as well. Sean: Thats really good advice right there. Chris, youre a smart dude, man! Chris: Good to be with you, as always! Sean: I love your book. This is a fantastic book, Your Personal Paleo Code. Talk about this. Chris: Yeah, so this came out in January. It is really the product of this ten-year learning journey for me back then and return to health, and wanting to share what I learn with everybody, not only about the importance of nutrient-dense diet, but making our lifestyle more consistent with our Paleolithic heritage. And then Ive got ten bonus chapters on how to tweak your diet, your lifestyle, and your supplementation for particular health conditions, including thyroid disease. So when you buy the book, you get free access to those bonus chapters. And I give you really specific recommendations, some of the same stuff I do with my patients in the clinic. Sean: Talk about how that came about? The book was a lot longer than it ended up being, right? Chris: Yeah, so my editor, having never written a book, I said, Do you have any tips for writing a book? Because Ive written plenty of blog posts, but Ive never written a book. She said, Just sit

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Thyroid Myths and Truths Presenter: Chris Kresser down and write until youre finished with what you have to say. And I was like, Okay. So I sat down and I wrote. And I finished. And I did a word count. And it was like 770 pages. [Laughs] I was like, Oh, man! There might be like five of my fans that will read a 770 page book from me. But were trying to reach a bigger audience. Theyre like, Youre going to have to cut that down a little bit. So luckily about 250 of those pages were the bonus chapters on specific health conditions. And each of those could be a book in its own right. And not everyone, of course, will have all ten conditions. So we decided, lets just put them on the website and people who have those conditions can access them on the website. So thats the backstory. Sean: And the website is chriskresser.com, right? So they buy the book and theyll have Chris: Yeah, www.personalpaleocode.com is the website for the book. But you can access that through my main site. Sean: Perfect. Chris, thanks again. Chris: Good to see you again, man.