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Hi, this is Dr. Ruscio. Let’s discuss the connection between your gut and thyroid, which is a fairly profound connection, but oftentimes overlooked. The main point I’m hoping to impress upon you with these few data points is that if you’re floundering with thyroid symptoms or an ambiguous thyroid diagnosis, or you’ve been unable to find the ideal dose of medication, either to rectify aberrancies in TSH or T4, or in your symptoms, then an examination of your gut health is a very good idea because it may be your gut health that is actually causing this litany of symptoms. Let’s look at what the data shows so we can make a more confident decision to investigate our gut health.
The Implication of the Gut in Thyroid Issues
I’ll start with some data which associates your gut as implicated in causing problems with the thyroid. Up here on the screen, I will show a study from Poland. What you’re seeing in this chart is essentially the TSH, free T3, and Free T4 levels of a healthy group of controls as compared to those with SIBO and diarrhea, or SIBO and constipation. What I’ve highlighted here for you in orange is the real main thrust of this paper, which is the TPO antibody levels or the thyroid antibody levels, which assesses the degree of autoimmunity in the controls, was normal at 6.3. In the SIBO diarrheal group, it was abnormal or high just above the cutoff of about 35 at 39. Even higher yet still in the SIBO constipation group. So what we’re seeing here is an association between an elevation of thyroid antibodies or thyroid autoimmunity and small intestinal bacterial overgrowth. Now we should also be careful to point out that this elevation is not drastic. So one of the things that I think patients have a hard time adjudicating is, well, I have varying levels of TPO antibodies.
I know I may have positive antibodies. When do I know if my antibodies are in an acceptable range or when should I be worried about them? While the data to answer this question is a bit sparse. It does seem that 500 for the TPO antibodies is a reasonable cutoff value. So if you have thyroid autoimmunity and your TPO antibodies are below 500, that seems to be, in most cases, clinical and context there is important, but that’s just one guiding post to provide you as you’re trying to piece all this together. So continuing with the gut thyroid association, another paper published in the world journal of gastroenterology looked at 1800 patients and they were looking for what was most associated with SIBO. They examine gastrectomy, PPI therapy, essentially gastrointestinal surgery, stenosis or narrowing of the gut lumen (the hose that is your gut), gastro-paresis or essentially paralysis of the stomach muscles, neuropathy, nerve damage, immunosuppressive drug therapy, hypothyroid or hypothyroid on levothyroxine and/or type two diabetes.
What was shocking about this analysis was what was most associated with SIBO, not surgery, not stenosis, not immunosuppressive drug use, but being hypothyroid or being on levothyroxine. Now don’t stop taking levothyroxine. That would be a mistake. This association tells us that there seems to be something about aberrancies in the gut that may be driving these problems with the thyroid. Now, as an aside, what may be driving this is we know that roughly 30% of hypothyroid patients have an impairment in their ability to release hydrochloric acid. What may happen in these cases, and this has been posited by Dr. Richard McCallum, who has done some very elegant research in this area, bacteria from the oral cavity may be getting down into the small intestine and overgrowing. Because acid secretion in the stomach is not adequate, those bacteria make it through the stomach, into the small intestine can take up residence and start to colonize you. That hasn’t been firmly bore out but may explain the association that we’re seeing here. Those who have hypothyroidism have a decreased ability to release stomach acid that opens the door for SIBO. That may be why in this study of over 1800 patients, shockingly of all these factors examined, being hypothyroid or levothyroxine were the most associated with small intestinal bacterial overgrowth.
Continuing. What about H. pylori? You may have heard that there’s some association between various autoimmune conditions and H. pylori. So let’s look. A meta-analysis published in the journal Thyroid in 2013, and again, a meta-analysis will summarize the available data, so in this case, seven studies involving a total of 862 patients were summarized in this meta-analysis. Overall, and I will quote here “Overall, H. pylori infection was associated with autoimmune thyroid disease”.
So that’s very interesting and reinforces this posit that there’s a connection between the gut and the thyroid. One important caveat here because, as a countervailing perspective, we don’t want to run rampant and become heretical and how much blame we place on the gut as causing problems with the thyroid. As a countervailing point here, the association was significant for Graves’ disease, which causes hyperthyroidism. It did not seem to be significant for hypothyroidism or Hashimoto’s so still more here to learn. I don’t want to represent this connection as being 100% definitive, but certainly, the totality of the data suggests there is an association between the gut and the thyroid.
Improving Thyroid Autoimmunity by Treating H. Pylori
One promising study from Italy actually found treating H. pylori can improve thyroid autoimmunity. This was published in the journal Clinical Endocrinology. This table is a bit busy. I’ll just point you to the two yellow boxes. What you’re seeing here is the green group and the red group. The green group was a group that had H. pylori and Hashimoto’s and was treated. The red group had Hashimoto’s and H. pylori and was not treated. What the researchers tracked pre to post were changes in the TPO antibody levels. The green group averaged out to about 2000 units changed in their antibodies. Whereas the non-treatment group saw about 500 units of change. So that was considered non-significant in the non-treatment group. In the treatment group, the change in antibodies was significant. Now that’s only one study. Again, we don’t want to over-represent the connection here, but some promising data showing that in a reasonable fashion, if you have problems with your gut, if you can investigate those and take care of those, you may yield benefits from a thyroid perspective. Also, one promising case study from the Journal of Infection in Developing Countries. A patient who had an intestinal infection, Blastocystis hominins specifically, was treated with metronidazole for two weeks and antibiotics, and blastocyst hominins was eradicated. Their urticaria (chronic hives) and angioedema (redness) disappeared and at a four year follow up, there were no symptoms. The thyroid hormones normalized, and the thyroid antibodies declined.
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So definitely some interesting data published there. I’ll share one case study from my office. Laura presented with fatigue, insomnia, weight, gain, fuzzy thinking, or brain fog.
In her case, we changed her diet. Essentially put her on an elimination diet, similar to a paleo diet, but wouldn’t have to be a paleo diet per Also put her on probiotics. Over the course of a couple of months, she saw improvements in her fatigue, her insomnia, she lost weight and was more clearheaded while she required half the amount of levothyroxine. Now you may be saying, how could someone go on half the dose of thyroid medication and feel better? Well, we know that the intestinal tract, the small intestine specifically is where your thyroid hormone is absorbed. So if someone has impairment in their gastrointestinal function, they may not be ideally absorbing their medication. So the issue in the gut, may be causing malabsorption of medication on the one hand and some of these symptoms on the other. This is how we can see, by treating the gut with diet and probiotics in this case, she was able to half the dose of levothyroxine and also see an improvement in all of these symptoms, including weight.
So in summary here, thyroid conditions may be highly associated with the gut and preliminary data suggests GI treatment can improve thyroid conditions and associated symptoms. Now we’ll do a part two, where we’ll outline in more detail some of the treatment options, but I want to put a pin in this here so as not too overwhelmed with too much data. So more follow, we’ll link to part two. As a reminder, please, if you are not feeling well, if you’re struggling with thyroid nonresponsive labs or symptoms, then definitely give your gut health a look, because this is one area that does seem to allude patients and I think would really benefit people if there was a broader awareness of this gut thyroid connection.
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