Dr. Michael Ruscio, DC is a clinician, Naturopathic Practitioner, clinical researcher, author, and adjunct professor at the University of Bridgeport. His work has been published in peer-reviewed medical journals and he speaks at conferences around the globe.
Dr. R’s Fast Facts
Thyroid’s association to weight
Bottom line: If you are hypothyroid you have a 50/50 chance of losing 3-8lbs from thyroid hormone. Your highest likelihood of this is on a T4/T3 combo drug like Armour or Nature Throid or a straight T3 drug like Cytomel.
If you do not lose weight you should work with an FM doc to determine what the underlying cause of your weight loss resistance might be
People who are overweight are sometimes stereotyped to have a thyroid problem. However this is not always the case, in many cases overweight and obese may have higher levels of thyroid hormone. These changes may occur secondary to obesity.
However, some observational studies have also shown that as much as a 12 lbs. difference can occur between those with the highest and lowest TSH (highest TSH associated with weight gain).
Thyroid hormone as a treatment for weight loss
Systemic reviews have found thyroid hormone is not a suitable treatment for weight loss for those with normal thyroid function. Mainly because of the risk of inducing hyperthyroidism
In those with hypothyroidism – T4 medication (like Levothyroxine) appears to generally have little effect on weight loss. One population study estimated roughly 2.8 lbs. of weight loss. However another smaller study showed that 50% of patients on Levothyroxine may lose up to 8.5lbs.
In those with hypothyroidism – using T4/T3 combination medication (like Armour or Nature Throid) or using a pure T3 formula (like Cytomel) may yield 4 to 4.5 lbs. of weight loss compared to using a T4 only medication like Levothyroxine. About 50% of patients making this switch will also feel better overall.
If you are hypothyroid – there is a 50/50 chance of weight loss with T4 medication, which will likely be about 3lbs but there is a slight chance to lose up to 8lbs. Better data suggests that if you are hypothyroid using a T4/T3 combo medication or pure T3 medication will allow you to feel better overall and lose about 4lbs.
Dr. Ruscio tackles a listener question in this first part of a two part series on thyroid and weight loss. He explains why lab values and ranges might not be the best way to evaluate thyroid function and how thyroid hormone can affect weight loss.
Topics: Susan’s gluten story…..0:49 Episode intro…..3:39 Listener question…..4:21 Lab values and clinical outcomes…..5:10 Functional vs. autoimmune thyroid conditions…..7:30 Thyroid antibodies…..11:12 Thyroid hormone impact on weight…..14:34 Fast Facts – thyroid medication and weight loss…..17:21 Episode wrap-up…..26:13
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The following discussion is for educational purposes only, and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking to your doctor. Now, let’s head to the show!
Dr. Michael Ruscio: Hey, everyone. Welcome to Dr. Ruscio Radio. This is Michael Ruscio. I am here with the lovely Susan McCauley from EvolveNutrition.com. Hey, Susan. How are you?
Susan’s gluten story
Susan McCauley: I am recovering. I had a little gluten exposure this weekend, and I ended up not feeling too well yesterday.
DR: I know you are super gluten sensitive.
DR: So, you had a little bit of gluten, and I think you were saying some ice cream, right?
SM: Usually, if I have a chance to have handcrafted, grass-fed, organic ice cream, I usually take that person up on it.
SM: And I was up in San Fransisco, in the Mission District with some really good friends from high school. There was a nice ice cream store. I had chocolate – usually my go-to flavors are chocolate and vanilla because they don’t have Oreo cookie crumbles and all that. And I ate almost all of it. I got to the third-to-last bite and I bit down and it was crunchy. And I was like, “Ooh.” I think I just had some kind of cookie, and my friend was like, “Do you want me to go and find out?” I thought, ‘You know, this time I’m not going to know because I am going to leave it up to my body to tell me. And sure enough the next day, about I’d say almost exactly 24 hours later, I was pretty miserable for about eight hours. Now I’m just kind of the tiredness. But, I am on the mend.
DR: Good, good. Well, not good.
DR: Sorry, I’m good to the fact that you’re feeling better now, but it’s interesting that…I’m glad that you shared that because I think some people will find that interesting. And for people looking to sort out what their relationship to gluten is, you definitely give them a good example of what it looks like to be really gluten sensitive.
DR: I’d say you are someone who is highly gluten sensitive, with that kind of reaction.
SM: Yeah, I am. The funny thing is, I did call them to confirm because I wanted to make sure – what else could it be if it’s not the gluten?
SM: And she is like, “Yeah, it has chocolate wafers in it – it was called XXX Chocolate. I said, “I should have had the vanilla.” And the interesting thing was, she goes, “No. The vanilla has malt in it, which has gluten as well.” So she goes, “But, we really understand gluten, so just ask the next time you are in.” So, it was a really valuable lesson to me – I’m what I call advanced in dealing with gluten, but I still stumble every once in a while. Always ask, people; always ask those those questions.
DR: Yeah, if you learn you are super gluten sensitive.
SM: Yes, yes.
DR: Exactly. Well, live and learn, I guess, right?
SM: Oh yes, yes.
DR: And you were very scientific in your approach. I liked how you tried to factor yourself out of placebo-ing yourself.
SM: Yes, you know the mind is a powerful thing. I just wanted to make sure that I wasn’t just really getting sick because in my head I thought I had had gluten.
DR: Right, and there still may have been a slight placebo effect, but at least you did your best to try to guard against that.
DR: So, we have a really interesting listener question today. I think this listener question will be a great springboard into two topics that I’ve been wanting to talk about for awhile. They are chapters in the book that I have finished. I’ve wanted to get this information out there. They essentially break down to thyroid hormone’s impact on weight – meaning, if you take a thyroid hormone, what kind of impact will that have on weight, and/or what association does thyroid hormone have to weight? And also, what is the relationship to carbohydrates (with) your thyroid and weight?
DR: So, why don’t we play her question. And then we can muddle our way through this.
SM: Sure, hold on one second.
Listener Question: I am a 25-year-old woman who has trouble losing weight – with a Free T3 of 3.2-3.8. But, ironically, I am less sluggish and can lose weight when my Free T3 is 1.7.
This has happened more than once, so it seems that there may be a correlation. I’ve confirmed Hashimoto’s, so my thought is, is it possible for me to have antibodies to my own Free T3s? I am aware one can have antibodies to thyroid hormone receptor sites, and I’ve also considered the possibility that my fatigue and weight may be secondary to my adrenal fatigue and other issues, and just coincidental to the thyroid fluctuations?
Any thoughts on this would be helpful.
Lab values and clinical outcomes
SM: OK, there you have it.
DR: So, there it is. So she asked some really good questions. And I think one of the most important things that her question highlights is the fact that lab values don’t always correlate with clinical outcome or clinical presentation. There is a little bit of thinking that you want to have your T4 and your T3 levels as high as you can in the reference range because you’ll be the healthiest if that’s the case. As we’ll talk about a little later, there’s certainly some evidence showing that using a combination, that has a combination of T4 and T3, might be a better alternative than T4 alone. But, in running these really robust thyroid hormone panels on people for the past couple years, I have to say that thyroid hormone levels and the way someone feels don’t always correlate. I think it’s because the system is very complex. It’s rare that just one marker is going to tell you how someone is going to feel. Right, because we have thyroid hormone, we have steroid hormones, we have adrenal hormones, we have inflammation, we have receptor-site sensitivity, we have other things happening in the gut, we have the gut/brain connection, we have brain/gut connection, we have stress, we have happiness or fulfillment in your life – so we have multiple things that play into a scenario.
And so, a lab value is not always going to be something that tells you everything. Oftentimes, friends of mine want to send me their wives’ thyroid hormone levels, as if there is some secret ratio that I’ve figured out that is going to….
DR: It’s really not the case. It’s important that you are in the normal range. But, once you get into the normal range, from there I’ve rarely found that super-meticulous tinkering with the numbers is the most important factor.
Functional vs. autoimmune thyroid conditions
DR: Maybe I should zoom out and orient us to how I look at thyroid problems. We do have a series, a weekly series, that’s been going out explaining this – through the website. But, I look at thyroid conditions as either functional or autoimmune.
When someone is functional, that means they are not truly hypothyroid and they don’t have anything wrong with the thyroid gland. It’s just that the thyroid hormone function is being damaged or interfered with – meaning there might be inflammation or some other kind of factor like insulin resistance (or) adrenal fatigue that is not allowing their thyroid hormone to work properly. Those people don’t really need thyroid hormone; they need to figure out what is interfering with the thyroid hormone they are already producing from being able to work.
Now on the other side, there would be autoimmune. Autoimmune like Hashimoto’s is the most common cause of hypothyroidism in Westernized countries. These patients who are autoimmune and become truly hypothyroid – and I should clarify that not everyone who is autoimmune will become hypothyroid. So, it is important to clarify that you can act on this early to prevent yourself from becoming hypothyroid.
But, when someone becomes truly hypothyroid, they will have high TSH – high outside of the conventional reference range – and low T4 repeatedly. When someone becomes truly hypothyroid, they will need medication. When people go on medication, some people will feel better – boom, everything’s good; they went on the medication and they feel great. Other people may feel only slightly better and really struggle to get to optimum. It’s usually these people that how both hypothyroid, but also have some kind of interfering factor presenting at the same time. So, these people need to go see for a Functional Medicine doctor and figure, ‘OK, is there adrenal fatigue, is there insulin resistance, is there a gut infection, is there inflammation that is thwarting them from responding to the thyroid hormone that they are taking?
Does that make sense, Susan?
SM: Yes, it does. And I think, yeah, a lot of the times the lifestyle…if you’re in that former category where you are in the functional thyroid area where you don’t…you’re not in the lab range, then that’s when we can look at are you sleeping 7-9 hours of good sleep every night? Are you getting outside and walking? What is your food look like? Are you getting enough? Are you eating too much (or) eating too little, because you can see it on both ends.
SM: Those things are where we can really start and make some significant improvement.
DR: Sure, absolutely. So, I want to get into more details and pick apart more of her specifics. So, one or two other points more specifically to her question, and then I want to give people what I call my fast facts. It’s a new format that we are going to be using that we are going to try to lead with the summary on this issue. So, if you are someone who is looking to listen to the first five minutes of the podcast, (they will) get the take-away message and then do other stuff they want to do. That’s the format that we are going to use. The summary will be at the front and then we will follow with an elaboration on how we arrived at the conclusion.
DR: People can have antibodies against some of the thyroid receptor sites as indicated. It’s also possible for people to have antibodies against their T3 (1). These are people that may actually feel worse when they go on something like a desiccated form of thyroid hormone, like Armour or Naturethroid. And there is a lab marker available through Quest; it may also be available through LabCorp, where you can test to figure that out.
However, in her case, I would not expect this to be present, because if you do have an allergy or a reaction to thyroid hormone, then you would feel worse overall when going on the thyroid hormone, most likely. You wouldn’t see just this weight gain – she’d probably feel tired, in addition to the weight gain; (she) may feel depressed in addition to the weight gain; may have insomnia, in addition to the weight gain. Does that make sense, Susan?
SM: Right. It would seem that to have antibodies against either the thyroid hormone itself or the receptor sites, that would be pretty rare, right?
DR: I have to say, it’s really been very rare in terms of do I notice when a patient makes a switch from levothyroxine to Armour do they notice they feel worse. I haven’t even seen that happen in my entire time in clinical practice. The one thing I have seen is people just feel too sped up – meaning they become hyperthyroid. And I think it’s important to mention this because, sometimes we get so caught up in the minutia, that is kind of like trying to navigate from Massachusetts to California looking through a microscope.
DR: And, these things are all very interesting, but the clinical relevance of them, or the clinical practicality sometimes is really sparse. Whether you have autoimmunity to T3 or not, I don’t even know if that’s really the more important factor. I think the more important factor is to just try either a T4 – that’s synthetic, levothyroxine – or try a desiccated like Armour or Naturethroid, and see which one you feel better on. That’s going to help you determine where you fall under this whole issue.
So, also to her question – and this is the part of the thing I think is most likely, might it be something else entirely that is causing her fluctuations in weight? Like adrenal fatigue? Absolutely. Usually, when someone isn’t responding to a thyroid medication, the first thing that I do is look for other organic issues – is there too much stress; is there not enough sleep; is there a gut infection; is there some other sort of chronic infection or inflammatory issue? That is the first spot that I go. So, in this gal’s case, that’s exactly what I would do. Next would be to figure out is there anything else present that may be thwarting her ability to lose weight?
Thyroid hormone impact on weight
DR: But let’s let’s talk about thyroid hormone’s impact on weight (2a) (2b) (2c) (2d) (2e) (2f) (2g) (2h)(2i). I’m assuming that she is taking thyroid hormone and she’s trying different doses, and that’s how she’s noticed she gains weight at a higher Free T3 level than at a lower Free T3 level. Now, something else that is salient for me to mention: if she is just tracking her thyroid hormone numbers over time, and she’s not taking thyroid hormone – so she’s just going through her day-to-day, and she is monitoring how her thyroid levels change, and how that correlates to her weight, well what may have happened is she may have changed her diet. And her diet may have caused a shift in her thyroid hormone levels, specifically her T3 and Free T3 3 levels. This may have correlated with her weight gain. Interestingly, it has been shown to – and we will come back to this in more detail in a minute, and I think I am doing a terrible job with trying to lead with the summary here…
SM: It’s a learning curve, it’s a learning process. We will get there.
DR: Patience, guys. It’s going to take me a little while to get there, yeah. It has been shown that lower carb and lower-calorie diets, but more powerful is the low-carb diet, will cause a decrease in T3 and Free T3. Now, if you look at that, again, in the microscope and in isolation, you may think this is a bad thing. But, when you look at, some of the most successful weight loss trials – not all – some of the most successful weight loss trials are either low-calorie, or, I think more impressively, low-carb. So, you may go on a low-carb diet and notice that your Free T3 goes down but you lose weight. What that tells us is that the change in the thyroid hormone isn’t a bad thing, or isn’t causal – it’s likely more of a metabolic reaction to the change in your diet. So again,it’s important to always try to look at these things globally. Because, if you were just looking at your Free T3 levels, you may say, ‘Oh my God, I went on a low-carb diet and my Free T3 went down. This is terrible. I’m doing damage to my body. Yada, yada, yada.’ But that’s not really the case, because when we see this transient dip in T3 levels from a low-carb diet, that’s in no way damaging your thyroid. It’s merely a metabolic adaptation to this shift you are having in your diet. That maybe what’s happening in your case. If you’re using thyroid hormone, I would call that a more paradoxical reaction, but let me now, finally work my way over to the fast facts here as we are almost half-way into the episode.
Fast Facts – thyroid medication and weight loss
DR: So, thyroid hormone and weight – here are your fast facts or bottom line: if you are hypothyroid, you have a 50/50 chance of losing anywhere from 3-8 pounds from the thyroid hormone.
SM: Over what length of time? Do you know?
DR: The studies in this vary. I would guestimate that we are looking at anywhere over a course of a month to probably 4-6 months – so, average about three months.
DR: So, you have a 50-50 – that means half the people will and the other half won’t – to lose anywhere from about 3-8 pounds from thyroid hormone. Your highest likelihood of this happening is on a T4, T3 combination drug like Armour or Naturethroid, or a straight T3 drug like Cytomel. If you don’t lose weight…so, the previous comment was based upon an exhaustive literature review. This next comment is more my clinical experience and my personal opinion. But if you don’t lose weight from a thyroid hormone, if you are hypothyroid, then you should work with a Functional Medicine doctor to determine what the underlying cause of your weight loss resistance might be.
OK, that’s the really short summary. Here are a few other points that we can potentially elaborate on or not, depending on how much time we have.
People who are overweight are sometimes stereotyped to have a thyroid problem. But this is not always the case. In fact, in many cases (and) many of the studies, overweight and obese subjects have higher levels of T4 and T3 and Free T3 than there healthy counterparts. What may be happening here is we may be seeing these changes in thyroid hormone due to the obesity state itself. These people may be eating more, and that may be causing their metabolism to rev up to try to burn the higher amount of calories that they are eating. Or, it may be due to problems with leptin signaling. But, to say that people that are obese are going to be hypothyroid as a general rule is not always true. More data shows that people who are overweight and obese may actually have slightly higher levels of T4 and T3.
That being said, some observational studies have shown that there may be as much as a 12-pound difference between those with the highest TSH and those with the lowest TSH. So, there is a little bit of evidence showing that there may be a significant swing, depending on if your THS is very high to very low.
Now, how about thyroid hormones as a treatment for weight loss? I think (this is what) most people really care about, right? We just talked about looking at the association between weight and thyroid, but I think for most people the practical question is: ‘Can using thyroid hormone help me lose weight?’
SM: I think people do. They go to their doctor and they find out maybe they are hypothyroid, and they get these pills, and they think it is going to be like the magic pill – they are just going to take that and it’s going to fix everything.
DR: Right, right. So, this is what I think is the most practical piece. But I want to cite the observational studies so people realize that observational studies show one thing, and the interventional studies may show something different. It’s really important for people to keep the mind, because one of the things that can lead people down dead ends or erroneous avenues, if you will, is making decisions about treatment based on observational studies.
For example, you may do an observational study on elite athletes and notice that elite athletes have high C-reactive protein, because of all their training. Then you say, ‘Well, everyone needs to have high C-reactive protein; it’s healthy for you,’ and that may be a really erroneous conclusion to make, because if you are a diabetic, and your high insulin levels are just causing systemic inflammation, you have high C-reactive protein, that’s not going to be a healthy version of high C-reactive protein compared to the athlete that is training a lot and has some muscle soreness.
DR: So, thyroid hormone as a treatment for weight loss: systemic reviews – and, again, systemic reviews are papers that look at multiple other studies and try to find the average finding from them – have found that thyroid hormone is not a suitable treatment for weight loss for those with normal thyroid function mainly because the risk of inducing hyperthyroidism. Hyperthyroidism meaning you can’t sleep, you feel hot, your heart rate is elevated…
SM: It’s very risky.
DR: It can damage cardiac tissue, it can damage your heart. That side-effect is not worth any treatment result…
DR: …which has been questionable. What about in those who are hypothyroid? Well, a T4 medication like levothyroxine appears to generally have little effect on weight loss. One population study – and I had to do a lot of conversion to arrive at this number, and this number is just a rough estimate, but one population study estimated roughly 2.8 pounds of weight loss. That seems to be the general trend – around maybe 2-3 pounds. So, that’s what most people can expect. However, another smaller study – a very small study, so this doesn’t carry as much weight – showed that 50 percent of patients on levothyroxine may lose up to eight-and-half pounds. So, there is a glimmer of hope there that some people may…you know, you have a 50-percent chance of losing what I would consider a significant amount of weight – 8.5 pounds.
SM: I would think that the people that lose more weight wouldn’t have any underlying conditions, and the people that either don’t lose weight or only a little bit probably have the underlying conditions – a gut issue, etc.
DR: Absolutely. And that’s why one of my previous points was if you go on thyroid hormone and you don’t notice an effect, you should look to a Function Medicine doctor to figure out why you are not responding. Absolutely.
Additionally, in those with hypothyroidism, using a T4/T3 combination, like Armour or Naturethroid, or using a straight, pure T3 formulation like Cytomel, the average results here seem to yield about 4-4.5 pounds of weight loss, compared to using only a T4 medication like levothyroxine. And we have better data here – there are a few randomized clinical trials have looked at this, so what they have done in these studies is they have shifted people from levothyroxine, let’s say, to Armour. They’ve noticed that the average finding here is about 4-4.5 pounds of weight loss. So we see what I would consider a marginal amount of weight lost there.
I should also point out that about 50 percent of the patients – half – making the switch from something like levothyroxine purity 4 to a T4/T3 combination like Armour or Naturethroid also reported they feel better overall. Again, of you are hypothyroid, you have about a 50-50 chance of losing weight on a T4 medication – and that can be anywhere from three pounds to eight. But better data suggests that, if your hypothyroid, using a combination T4/T3 or purity 3 will allow better overall weight loss – maybe about four pounds, and that you have a chance of feeling better overall symptomatically. That’s what people can expect from medications on the issue. Does that make sense, Susan, or any kind of clarifying comments on that?
SM: No. I just think that it brings back to when you said that when they add the Cytomel or the combo drug, you do feel better. It goes back to her initial thing saying that, you know, when she’s out of the range she feels better than when she’s in the range, and we really need to pay attention to how we feel. I know more than one person that when their T3 is in the lower range, they actually feel better than when it’s in the range. So, really keeping a journal and writing your moods down and your energy levels sometimes can be as important as stepping on that scale everyday.
DR: Exactly. And the other thing I think is important to remember – and totally agree with posit there, Susan – but also to look at these things broadly. You are much better off looking somewhat superficially and a lot of data points, rather than looking super meticulously at one data point. This is the person that’s these tracking their total cholesterol levels over a five-year period trying to predict their heart disease risk, right? Whereas you’d be better off having three samples. So, let’s say someone did a sample per year, and they are meticulously tracking their total cholesterol, or someone else looked at a very full cardiovascular panel, including all the fractions and inflammatory proteins, but they only did three samples over that period. You’d probably have a better ability to catch someone’s heart disease risk by looking at more marketers, less times, rather than looking at one marker in a super-meticulous fashion.
SM: I guess that begs the question, then, when you go and you look at what she’s testing – her Free T3, and a lot of doctors don’t test for – do you think that she’s getting too much into the details in the weeds? Should she back off and look at what her TSH and her T4 is?
DR: Exactly. Yeah, and that kind of comes back to my point that, sometimes I have a colleague or a friend who wants to send their wife or their family member’s thyroid panel – let’s say it is TSH, T4, and T3, or even an in-depth thyroid test – and the expect me to be able to make some kind of recommendation based upon that.
DR: In a lot of cases, you really can’t because someone at the low end of normal – let’s say that all of their markers look to be a little bit sluggish from a thyroid perspective.
DR: But, they may feel great – be pooping beautiful bowel movements two-to-three times a day, sleeping great, have a good body-fat percentage, super happy with their life, then I’m very happy with where that person is at. There may be someone else who looks better – meaning their thyroid hormone levels are at the higher end of all the ranges that would make you think they have very high, and very healthy, very fast thyroid function – but they may be pooping twice a week, they may be sleeping terribly, and they may have bouts of depression. Well, that person, from a quote/unquote thyroid perspective, looks a lot better, but they may have some other things present that are really important to address – like their gut and bowel function. And, just addressing those gut issues, they may really notice a huge shift in obviously their gut symptoms, but also their sleep and their mood. For those patients, I’ll track the thyroid hormone levels, but they are more along for the ride at this point, and they are not going to be the driving findings for our care and what we do.
SM: That makes a lot of sense. I think sometimes we need to take that 30,000-foot view as opposed to looking at all the differences…I have done it for myself in the past where you want to fall down the rabbit hole of lab test, and if you can just get the numbers at the certain range or ratio, then all of a sudden everything is going to be perfect.
DR: Yeah, the labs don’t always correlate. I had a patient in the clinic last week – a college student who came in with some mild G.I. distress. And when we worked him up, we found that he had SIBO. We treated him for SIBO, and all of his symptoms went away and he was feeling fantastic. He actually came back and his SIBO labs look worse than they did before, but all of his symptoms were gone. So, I elected not to treat him again, but to test one more time to see if this was a false high. But the point I am making there is – not the best analogy – we don’t have to treat labs blindly, depending on what the patient context is. We want to always look at the lab findings and how the patient is presenting, and use those together to guide our decision making.
SM: Yeah, it all has context. It’s not just a math problem.
DR: Exactly. So, that I think, ah….
SM: Wraps it up?
DR: I wanted to start with a summary, and I ended with a summary. But, sorry guys. We are working on this new format. Obviously today we did a terrible job, and that is my fault completely. But, bear with us as we try to lead with a summary. I am hoping that with the next part of this question where we pick apart carbohydrates in your thyroid hormone levels, that we will start with the summary on that one and then take it from there.
SM: Great. OK. Any last words that you want to give everybody at home?
DR: Well, I think the take-away point form this one is don’t get overly caught up in one number – make sure to look at the full body of information because that is going to give you the highest likelihood that you’re not going to be misled.
SM: Well said. And like we always talk about, if something is working for you, and it doesn’t fit into somebody else’s diet or somebody else’s number – or even the lab range – just keep on going because it is working for you.
DR: Absolutely. And I agree 100 percent.
SM: OK, everybody. Have a great week.
DR: Thanks, guys.
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