Dr. Ruscio continues his informative series on Thyroid and Iodine with this episode covering thyroid goiters and nodules. He digs into the research on the probable causes, as well as, the testing and treatment of each of these conditions.
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Review of first two podcasts on Thyroid & Iodine…..1:51
Intro to thyroid nodules and goiters…..2:42
Causes of goiter…..3:23
Causes of thyroid nodules…..10:57
Testing and treatment of nodules and goiter…..18.36
- (6:15)Numerous studies published by the Journal of Clinical Endocrinology and Metabolism and others have shown high iodine intake can cause goiter
- (6:34) “The major cause of the endemic coast goiter seems to be excessive and longstanding intake of iodine from seaweed” he continues, “In a few patients restriction of seaweed induced a marked decrease in the size of goiter.” http://www.ncbi.nlm.nih.gov/pubmed/?term=4158495
- (13:35) The American Thyroid Association states, “Hashimoto’s thyroiditis, which is the most common cause of hypothyroidism, is associated with an increased risk of thyroid nodules. Iodine deficiency, which is very uncommon in the United States, is also known to cause thyroid nodules.” http://www.thyroid.org/what-are-thyroid-nodules/
- (14:46) One study following 2,941 people in a population where iodine was added to the food supply found the incidence of nodules decreased. http://www.ncbi.nlm.nih.gov/pubmed/?term=22663551
- (21:49)Some evidence exists that Goiter is reversible if caught early enough (less than 5 years).
- (25:46) Nodules can respond very well to the basics of autoimmune paleo diet – patient conversation here https://www.youtube.com/watch?v=GY8giRc0H4o&index=13&list=PLCb-zbL-27YmwaqgrRf4UiV5W3DGRVh06
- (35:12)8 mg 2x per month to 30mg 1x per month have been shown to be effective doses in decreasing thyroid gland size in children.
- (35:32) Adding iodine to the food supply
- (36:33) A fairly large study, 1024 subjects, was published in the Journal of Clinical Endocrinology and Metabolism, which examined various treatments effectiveness on reducing nodules and goiter. http://www.ncbi.nlm.nih.gov/pubmed/?term=21715542
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Thyroid Nodules, Goiter and Iodine – Episode 8
Welcome to Dr. Ruscio Radio, discussing the cutting edge of health, nutrition, and functional medicine. To make sure you’re up today on this and other important topics, visit DrRuscio.com and sign up to receive weekly updates. That’s D-R-R-U-S-C-I-O.com.
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!
Susan McCauley: Hey, everyone. Welcome to Dr. Ruscio radio. This is Susan McCauley, from EvolveNutrition.com and EvolvedRecovery.com. And I’m here with the doc. Hey, Dr. Ruscio.
Dr. Michael Ruscio: Hey, Susan. How’s it going?
SM: It’s going good. How about yourself?
DR: It’s beautiful and sunny here in California, so I’m doing great. And I’m excited to, hopefully, wrap up this iodine series, which is just kind of dragging on and on and on and on…
SM: Kind of like the sun shining California dragging on and on and on and on…
DR: Yeah, I know. Poor us, right?
SM: I know. Ok… so what… so you said thyroid and iodide. So, what hot topic, in regards to that, do we have today?
DR: Well, we’ve been talking about pretty in-depth iodine and autoimmunity, up until now. And I think that lays a lot of the important groundwork regarding the issue, but there’s also iodine in the application of nodules and goiters. So that’s what I wanted to kind of round out—the last piece of iodine and thyroid as it pertains to nodules and goiters, today.
SM: Do you want to remind everybody… the first two podcasts so they… if they haven’t listened to them yet, they can go back and check them out?
DR: Yeah, definitely. A great idea. So, we’ve got a two-part series on thyroid and iodine. And, gosh, we’ve gone through pretty much everything, I think. We’ve gone through dietary sources… we’ve gone through ‘Is it good or bad for you’… we’ve gone through some of the halogens, and other things like bromine and fluorine… We’ve gone through… through testing and kind of, hopefully, really giving people a very evidenced-base scientific narrative to help them sort out: “Ok should I do this test? Should I not do this test? Should I take iodine shot? Not take iodine?” So, that… that’s kind of where we’ve gone up until now and today it will be nodules and goiters.
SM: Cool… cool… So let’s dig in.
DR: All right. Well, certainly not as common as thyroid autoimmunity will be on nodules and goiters. So, simply stated, a goiter is just an enlargment of the thyroid gland. And sometimes when we think about goiter we might think about something from, like, a medical textbook. Where someone from a third world country who’s severely iodine deficient has got this huge lump in their neck from severe iodine deficiency—goiter. That is not very common. But some people will have a mild enlargement of the thyroid gland and that’s called a goiter. So there are a few causes of goiter. So, the first, like we just discussed, is low iodine. And maybe the way that one can think about this is… when there’s not enough iodine, the gland becomes very inefficient because the gland needs iodine to make thyroid hormone. So if the gland doesn’t have enough iodine to make thyroid hormone, the gland kind of enlarges, and it gets bigger. You can say, to put it simply, it attempts to try to have an increase ability to make more of thyroid hormone. You can kind of think like… like technology in reverse. If we took a cell phone and made a cell phone less efficient… less efficient… less efficient… less efficient… like they were maybe 10 years ago…
SM: The brick phones?
DR: Yeah, they would be huge, right?
SM: Bigger and bigger, they would be bigger! Now phones are getting bigger, but still.
DR: Right. Bigger in a different way. So you can watch TV on it, essentially. So, yeah. If we look at technology in reverse, when things become less efficient, they often times have to be bigger, right?
DR: And old computer was really big. Now, I have a little laptop that can do the same, or more, in… like… a quarter of the size. So in true iodine deficiency, the gland kind of becomes enlarged because it’s less efficient. So it’s gaining size in the hopes to recover some of its efficiency.
SM: And in the United States this was more common before they started iodizing salt, like in the 1920s. And before, in certain pockets of the country, correct? And is that why are they…
DR: Exactly. The United States, and also in some third world countries, and like we talked about in some of the last episodes: the literature is pretty clear that the United States is not iodine insufficient. So we have “okay” iodine status in the United States.
DR: But that was why, of course, one of the main reasons why, in addition to developmental defects that can occur with low iodine, that we started adding this back to the food supply. Because… we had some pockets that were restricted in their access to iodine in the soil… started to have these problems. So low iodine is one. Another one is high iodine. And ironically, and this is something I’m hoping people kind of got from our last episode, is that, ironically, high iodine can cause the same exact problem in a lot of cases, that low iodine can cause. And like we talked about in the last episode: excessive intake of iodine can cause hypothyroidism. And that’s because too much iodine almost functions the same way as too little iodine does in the body. So, again, if we have too little iodine, that can cause goiter. But also if we have too much iodine, that can also cause goiter. And in case that sounds a little bit funny to you, I’ll link to four papers that have shown that high iodine intake can cause goiter. And there’s also a paper by Suzuki… cause this kind of caught me off guard a little bit when I was researching, as I wasn’t fully aware of the… what’s called goitrogenic effects of excessive iodine. But they quote, or to quote them, I should say, “The major cause of endemic coast goiter seems to be excessive and long-standing intake of iodine from seaweed. In a few patients, restriction of seaweed induced a market decrease in the size of goiter.”
SM: Ok… So, kind of like a lot of different nutrients, there’s a bell curve. There’s like Vitamin D. We talked about: too low is bad, but then, you know, you have your healthy range, but then too high can also be bad.
DR: Exactly, exactly. And that’s, I think, really… really important. And besides, because… sometimes we learn that little is more… and then, so, even more must be…
DR: Oh, I’m sorry, a little is good, and then more must be better. And that’s often times not the case, exactly.
SM: I think most of the time it’s not the case.
DR: Yup. I agree 100 percent.
DR: So we’ve gone through low and high iodine. So we want to be in the iodine sweet spot. And in the last episode we gave some very definitive guidelines for figuring out what your ideal iodine intake might be. So we’re not gonna go into that now, but if you missed that you might want to go back to it… was the second episode in the iodine…
SM: Thyroid series.
DR: …And autoimmunity… and thyroid series, yeah. OK, so then the third… is actually… the third cause of goiter is actually autoimmunity. And what can happen here in autoimmunity, actually, two primary mechanisms are playing. Or can be at play. One can be, essentially, scarring—or what’s called lymphocytic infiltration. And in thyroid autoimmunity, of course, your immune cells start to attack your thyroid gland’s immune cells. Another name for them is lymphocytes. And when you start to attack your own tissue you can start to have damage and scarring, right? And that scarring can actually cause enlargement of the gland. We have a nice little anatomy diagram in our office and it shows a normal thyroid gland and Hashimoto’s thyroid gland next to it. And the Hashimoto’s gland, even though it can produce less thyroid hormone, is actually larger in size.
SM: Ah, that makes sense.
DR: Yeah, but it’s larger in size because there’s some scarring and there’s some damage there that’s happening as your immune cells are coming in and attacking. Just think, like, if you ever had a really bad, you know, cut.
DR: Or injury, there’s scar tissue.
SM: I was just thinking that.
DR: Yeah, exactly.
SM: With the scar the skin is a little bit inflamed around it, and remained so for years. Like, I have a scar on my elbow that I got college that’s still there, and the skin is larger than the skin around it.
DR: Exactly. Right. So, scarring can be one and that, again, the scarring is secondary to the immune attack. And the other can be swelling. And I meant, technically, we would call this hyperplasia, but swelling is a little bit more of a… accessible term. And what can happen here is when your thyroid gland becomes damaged and is not able to produce enough thyroid hormone, then your TSH starts going high, right? Because, remember that the brain signals to the thyroid gland via hormone called TSH. So that’s the brain yelling down: “Hey, thyroid, make some more hormone.”
SM: And that’s thyroid-stimulating hormone for those of you…
DR: Right, exactly.
SM: …new to this. Yes.
DR: So, very common lab marker. And one of the ways that you diagnose hypothyroidism is when TSH starts to go high, well, when TSH starts to go high that signal actually… it does stimulate the thyroid gland. And that excessive and prolonged high TSH can actually start to cause enlargement of the gland through excessive stimulation.
SM: Ahhh, that makes sense. That really makes sense.
DR: It’s kind of like doing a lot of like… biceps curls.
DR: Right, eventually you know that stimulation would cause growth. Same thing can happen in the thyroid gland.
SM: Yeah, your brain is saying make more hormone, make more hormone, make more hormone… and the thyroid’s going: “Okay okay…” but nothings happening.
DR: Exactly. Precisely. So that’s the autoimmune piece and that can… autoimmunity can cause goiter through scarring or through swelling. Or the technical term for scarring would be lymphocytic infiltration, but then that term for swelling would be hyperplasia.
DR: Or maybe hypertrophy, but… ok… so then there’s another cause of goiter. The first, and final, which is nodular goiter. And this is where someone has nodules, and the nodules are causing enlargement of the thyroid gland, which is goiter. So, nodules are just groups of abnormally growing cells that form a lump in the thyroid gland. And something regarding nodules that I should clarify is: most nodules are noncancerous. But a small portion may be cancerous. So, this is definitely an area where it’s important to go see your conventional provider to have the screen for this. And I should give some specifics. According to the American Thyroid Association, by age 60 roughly half of the population will have a thyroid nodules, but over 90% of those will be noncancerous.
DR: So, the odds are in your favor. So don’t freak out. But you definitely want to have that screening in case you do fall into that 10% and you could have a prompt follow through on that.
SM: So the diagnosis… like so if you feel… like… would your neck be sore? Would you see a little bit of swelling? How would you know to go to the doctor?
DR: Well, thyroid palpation is the first line method of diagnosing a nodule.
DR: You may have… and it all depends in the size, right? The smaller the nodule is the less noticeable, of course it’s going to be. But as nodules or goiter become larger they can start to exclude the airway. They can start to impede on the vocal cords, they can start causing difficulty with swallowing… So as it becomes progressively larger they can become much more noticeable. And in some end-stage cases, that are not responsive to other therapies, you have to remove the, you know, the thyroid gland. Or at least part of the thyroid gland. Because if people can’t swallow or have a hard time breathing, that can become very dangerous.
SM: Okay… okay… So go for your annual checkups, cause I know that when I go to my regular doctor they always feel around in my neck… my glands… looking for things. So, make sure you get that palpitation.
DR: Exactly… exactly… So let’s talk about nodules, just for a second, cause we’ve talked about what causes goiter, but we haven’t really discussed causes nodules. This is where there… what exactly what causes nodules is not incredibly well defined, at this point. There’s a couple theories, but there’s someone, in what we call the idiopathic category, where we don’t definitively know, and it may be because it’s multifactorial. But Hashimoto’s thyroiditis, of course, so thyroid autoimmunity is associated with an increased risk of nodules and that’s according to The American Thyroid Association. And we’ll link to that reference. But also, iodine deficiency is associated with thyroid nodules. And those two points kind of contradict each other.
DR: But, I don’t think we have this all completely sorted out. And this may be. as we discussed with iodine… iodine is not incredibly straightforward. Picture, like we talked about, if you have a little bit of iodine that can be OK, but if you have too much that can be problematic. So, it may be someone who’s not in the sweet spot for iodine and then also things, like the sodium iodine symporter, can also affect your ability to regulate iodine absorption. So yeah, I mean we… the two primary theories of what causes nodules are direct contradictions of one another, which tells you that we don’t fully have this sorted out just yet. So, there’s a few studies that I thought were kind of important. And I wanted to note one study, and it’s a population observational study, noticed that when looking at 2,941 people, where iodine was added to the food supply, the incidences of nodules decreased.
DR: Right. So you certainly… there’s some evidence showing. And many of the population-wide studies, that have added iodine to the food supply, have shown that nodules and goiter seem to decrease. So, in my opinion, I think there’s more evidence showing that nodules are not autoimmune in nature but again, you know…we… I don’t think we fully know or fully understand. So, there’s another theory, and this has to do with nodules resulting from damage to DNA. And, of course, if there’s damage to DNA, DNA is responsible for cell replication, excuse me, and growth. And so if nodules are just atypical growth, then DNA damage certainly could set the stage for that. And this is why things, like smoking and some antioxidants, have… smoking has been shown to make, or be a risk factor, for nodules. And certain antioxidants, or nutrient deficiencies, may leave one at risk for nodules. So there’s a few players on the board with nodules: iodine autoimmunity and then, I guess oxidative stress. So something to be aware of. And then, also, remember that there are other causes of nodules like cancers and certain neoplasms or pituitary issues. And this is why I do think it is a good idea, a very good idea, to have nodule screen by a conventional physician, cause this is where a conventional physician should really shine. And this is kind of stepping out of the realm of a functional medicine provider, in many cases—depending on their training—and more into the realm of conventional medicine.
SM: Right, more of a acute care rather than trying to figure out a complex problem in getting to the root of it. This is just a routine screening that everybody should have.
DR: Exactly. Yup.
SM: Because if you do have the oxidative stress, say you just live a standard American life, oxidative stress… you may even smoke, you know, the program cell death they—all cells are, you know, programed to die after a certain amount of time. That stops happening and then you just have this random, you know, then you get the nodules.
DR: Exactly, exactly. And I’m a big fan of just having a good healthcare team. And I remember one of—when I was a student, this is maybe seven or eight years ago, one of my mentors was commenting on, you know, if you’re gonna refer someone for conventional medicine, it was his opinion that you’re better off to refer to a conventional medical provider who’s practicing conventional medicine, not a conventional medical provider who’s, you know, trying to get out of that and into functional medicine.
DR: ‘Cause you want someone who’s going to be sharp in the conventional diagnosis screening and just… catching things… right? So that’s why I’m such a fan of having a good team and, you know, not having one person who’s trying to be the jack of all trades. ‘Cause this stuff can be very very complex and I don’t think anyone, even Dr. House, is really smart enough to be able to do you know all these things at an expert level.
SM: Yeah, I totally agree. I mean, I have a primary doctor and I go… that’s a person… I know exactly who to go to for certain things, you know. But, if it’s it like it gut issue or chronic thing, I go to my functional doc. I don’t go to my primary.
DR: Right, exactly. So this is just a good kind of illustration of that. So to bring things back to testing and treatment, or I guess before I jump into this, are there any clarification questions or any things you want to add?
SM: No, no. I think that… that every thing seems pretty straightforward so far. And, you know, I don’t think there’s anything to clarify at this time, you know, but I reserve the right to ask more questions!
DR: Okay, good. Yeah, you have the… you have a carte blanche to ground me.
DR: Ok, so. For the majority of people I think that treating a goiter and/or nodule will fall into two factors… or there are two factors that we’ll need to address. And that will be: one, your iodine status. And two, autoimmunity. Now, I also just want to repeat this disclaimer one more time: that you should also have a check in with your conventional provider to screen for if you do have cancerous or precancerous cells, right? ‘Cause, depending on the training of the functional medicine provider that you work with they might… they may not be looking for these things. They may be looking for more root cause issues.
DR: So, don’t gloss over that. So regarding iodine: if Iodine is excessive or deficient you have to correct that. And we spent 30 minutes kind of talk—more, we spent 60 minutes really talking about the whole issue of iodine. How much is too much, how much is enough, how much is not enough, testing… yeah. So I’ll refer back to the other episodes for that, but if you’re… if you’re… if you have a goiter or nodule and you’re consuming too much, or too little iodine, you’re gonna wanna address that. And then, also, you’re gonna want to address autoimmunity because that can cause goiter and nodule… more so, close, I think, to goiter than nodule. The autoimmunity, as it pertains, and nodule piece…is not incredibly clear. But certainly goiter can definitely be caused by all autoimmunity, like we talked about, that scarring or that swelling. And so again how to address the autoimmunity is really a whole episode in of itself, which, if it’s not in the podcast cue right now, we’ll definitely have one in there soon. But you want to address the autoimmunity, and the autoimmune paleo diet is a great place to start, we also talked about during the two-part series on iodine… how iodine restriction might be helpful for autoimmunity. And then also looking at the gut health and gut infections can be very important, in my opinion.
SM: So, when you’re talking about autoimmunity in regards to goiters and nodules, are you talking just about thyroid autoimmunity, or autoimmunity in general?
DR: I’m sorry, yes. So I’m referring to thyroid autoimmunity like we discussed…
SM: Hashimoto’s or graves…
DR: …A few minutes ago. Yeah, how Hashimoto’s or graves can cause cause that scarring, and that swelling. And that scarring or swelling can cause an enlargement of the gland, that we also call goiter.
SM: Ok, cool. I just wanted to clarify.
DR: Right. Yeah, no, thank you. So, there is some evidence that shows that goiter is reversible if it’s caught early enough. So I’ll link to a few papers here that have looked at the reversibility of goiter, and if you move to address the goiter within five years of its initial presentation then that seems like the intervention window that will give you the best likelihood of being able to reverse it.
SM: Ok, so, the first step…the one…for people that are thinking “Oh maybe I have this”, is first of all you rule out cancer with your… with a conventional medical doctor. And then you look at iodine: whether it’s excessive or deficient. And then autoimmunity… and then gut and so on.
DR: Right, and you don’t necessarily have to you know rule out the conventional before you start with the functional they can be done at the same time.
SM: Ok, that’s… that’s a good point.
DR: Yeah. They can be done at the same time but you do, you know, you do wanna have the follow up studies to… to determine, you know, do you have a neoplastic growth. A cancerous growth… might there be some kind of a putridity issue… so, yeah. You wanna have the conventional study in conjunction with the functional medicine intervention, so that you can figure out what to do it in. And in some cases, and in my experience, more often than not, people come in already knowing that they have a nodule, you know. I had a patient come in a few months ago that said, and she really kind of gave me a… a tough case. She said ,you know, “I have thirty days until my surgeon is,” you know, “demanding I get this out.” And so I said “Well… you’re not giving me a ton of time here, but we’ll do the best that we can.” Often times they will know if they have goiter or nodule ahead of time. And so in that case I think it’s just important to emphasize, if you are working with a functional medicine provider, or if you are a functional medicine provider, make sure that the patient continues to have the routine follow-up… cause you don’t want one… someone to replace one for the other.
SM: So do you find that often that the… in the conventional world that they’re just wanting to yank that thyroid out?
DR: No… I haven’t seen that so much so for…
DR: …for nodules and for goiter because it… they… standard medical practice seems to be in agreement that you know… I mean… depending on the severity initially the wait-and-see approach is oftentimes advocated before taking out. But for Graves disease that’s where they seem to be a little bit more gung ho about either you know Io–radioactive iodine ablation or just removal so that’s where I think that treatment might be a little more overzealous but in this case I haven’t… at least from my personal clinical experience haven’t found it to be incredibly overzealous.
SM: Ok, cool.
DR: So some testing that can… and I want to come back to this more specific recommendations in a minute, but remember first you want to address iodine and autoimmunity and you know you’ll have to refer other episodes to get the specifics on that some tests we talked about the 24 hour urinary iodine test with creatinine ratio so that something can be helpful to see where your iodine statuses and then also in our last episode we went through, kind of the anywhere from 150 µg a day to maybe 11-12 hundred µg a day of iodine maybe a sweet spot around 400 µg in terms of just dietary intakes for Hashimoto’s, for assessing Hashimoto’s autoimmunity you have the TPO antibodies and the TG or the thyroglobulin antibodies and then for assessing Graves you have your thyroid receptor antibody and your thyroid simulating immunoglobulin so TR and TSI and then there’s another mark that can be run to track the size of the thyroid gland called thyroid globulin so those are a few markers that may be helpful and then in terms of treatment we already talked about that to some extent I wanted to mention a case of nausea that came in maybe six months ago and she responded very very well to the autoimmune paleo diet and I will link to a conversation her and I had we just sat down and kind of discussed her case but she had a nodule to the point where you could see it easily just from external viewpoint it was very well palpable and her conventional doctors you know wanted to potentially remove and so she came in wanted to see if there was another option and within 30 days there was a drastic reduction in her nodule.
DR: Just by going on the autoimmune paleo diet, and I think we also put her on some female hormone balancing herbs. So, this… these things can respond very strongly to do some basic dietary interventions.
SM: So when you said that that the doctor wanted remove it: remove the nodules or remove her thyroid?
DR: Well, often times what will be done, depending on the distribution of the nodules… not that I’m a surgeon, I’m certainly not an expert in the surgical intervention piece… but if the nodule is on one side then they may do a hemithyroidectomy, just removing one of the lobes.
SM: Ah, ok.
DR: And if it’s… I mean if nodules are distributed throughout both sides they may have to remove the whole thing.
SM: Yeah. Ok.
DR: So… but I don’t know the particulars there may be some surgeons out there that can really only remove the nodules in and of itself.
SM: Laser… with lasers or something.
DR: Yeah. So, that’s where I would really follow up with your surgeon and I would a few different opinions.
SM: I was gonna say get at least a second opinion.
DR: Yeah. Definitely, I would–
SM: Especially if they’re gonna remove an organ. People get a second opinion.
DR: Yeah. And so this gal did great, the other gal, who had the thirty day window… we weren’t able to get there in time and we weren’t able to turn things around at the time. And actually, in her case, we tried iodine therapy, without going into, you know, the rational completely, I said “Well this is autoimmune in nature.” I said, “Then there’s probably not a whole lot we’ll be able to do. But we can try a responsible dose of iodine and see if that has an effect.” Because I was looking for something that might be able to produce an effect quickly with her.
DR: The really interesting thing about her case was when we retested her iodine levels they were through the roof. And, I think that probably had to do with the fact that her sodium iodine symporter…
SM: Was off?
DR: … really probably didn’t work well at all.
DR: So, even though she was taking iodine it just wasn’t getting into the gland, and that may have been one of the reasons why she had the nodules because even though she had iodine intake dose adequate on the glandular level her thyroid tissue I’m guesses was probably fairly deprived of iodine.
SM: So, one of those cases… that thirty days just wasn’t long enough to get the inflammation and the oxidative stress down…
SM: Being able to use the iodine and…these things some times take time.
DR: Yeah if we had had more time we may have been able to make it happen, but… you know she’s still, actually, even in spite of that, she’s much healthier than when she first came in because she followed through on treatment and we found a few other imbalances and she’s feeling much better than she was before. And one of the dialogues that we had was, you know she said, you know, “Is this gonna be a big deal? Am I going to be hypothyroid for the rest of my life?” And getting very nervous, and I wouldn’t blame someone for being nervous. And, I just gave her kind of my thoughts on this which are even if you’ve… even if you, let’s say, are frankly hypothyroid. Right? You had really bad diet and lifestyle for lots of years you beat up your body your hypothyroid now because of all this thyroid damage of you’ve had part of your thyroid gland removed, I found that irrespective of what someone’s pas is if they go through the fundamental processes in functional medicine that will help de-inflame their body and just get them healthier in general. Then, they respond much more favorably to the thyroid hormone.
SM: Yeah… I have seen that time and time again.
DR: Yeah, and so, there… sometimes people get freaked out because they hear horror stories about how people go on thyroid hormone, and never feel well again. And I think the majority of those cases are because these people are not healthy to begin with.
DR: And then they just try throwing thyroid hormone and they think that’s gonna fix the problem.
SM: Right, like it’s a magic pill.
DR: Exactly… in fact I have been really kind of taken aback by how the thyroid hormone is really of secondary importance because people come in and they wanna do, you know, the full thyroid panel with the… and I don’t wanna get too tangential here, but people wanna do the TSH, the total and free T4, the total and free T3 the reverse T3 all the antibodies and sometimes I think people think that the answer to whether or not feeling is… resides in those lab tests and it really doesn’t cause we don’t… we don’t have… like a treatment specific for you know we’re gonna bring our T3 down a little bit we’re gonna bring you know free T… free up a little bit… there are general principles we can do, which are: get you less inflamed and then get you in the reasonable range of thyroid hormones supplementation and then from there if your body’s healthy those things should work better and then more inflamed you are the more challenging it’s going to be to find a dose that’s gonna work well for you. And this… this gets really deep. It’s not just an issue of T4 and T3 conversion, like people… people often times think it is. There are other things, for example: we’ve talked about the Vitamin D metabolite called Calcitriol.
DR: That can actually… and so that goes high when someone’s inflamed or has infections that will go high that can actually bind to and blunt the thyroid hormone nuclear receptor and so there are other things that affect the way thyroid hormone works in the body so I mean the answer is not Oh I need Armour or Westhroid or I need more T3 because my conversion is off really as long as you have in the ballpark thyroid hormone levels whether they be through your own thyroid producing them or through taking medication as long as you’re in the ballpark everything from there depends on how healthy your body is and the healthier your body is the better the thyroid hormone will work in your body and the better you’ll feel.
SM: Yeah, and I’ve seen that. I have some… a couple friends that have Hashimoto’s and they’re really super super healthy and their levels are a little lower than what functional people would consider in the range but they feel great and so it like, cause their, you know, their whole bodies working super efficiently and they don’t need to supplement as much.
DR: Exactly, and I’ve seen that same point you’re making in reverse.
SM: Exactly, I’ve seen that too.
DR: Which is… I’ve seen people who have been taking way too much; (their) thyroid hormone levels are high and they still feel bad.
SM: Right, and they’re not willing to look at… they’re not willing to look at the big picture or they’re… you know… who knows what they’re, you know, willing to do but they just think oh I just need a higher dose I just need a higher dose and it’s going to make me feel better instead of addressing the whole– you know the gut, eating the right foods, getting accurate, you know, adequate amount of sunshine all those lifestyle things that we always talk about.
DR: Precisely. And that is something I definitely wanna do a whole episode about, that cause, it’s something that I am really excited… and happy… that the functional medicine community has gotten deeper into thyroid analysis, but I also think to some extent… and I’ve made this criticism before… sometimes in functional medicine it’s complexity for the sake of complexity. And you know, these things are… everyone wants to have the newest bell and whistle, and new information, because we haven’t… we have a group of people here that are seeking out answers, but just because something is new novel or different doesn’t mean it’s useful.
DR: And that I think… I think to some in some instance that’s what hap– that’s what’s happened with this really kind of robust thyroid analysis cause I’ve been doing it for a few years and I’ve just gotten to a point where I’m like… ‘Eh.’ I’m not really overly concerned with your T3 to reverse T3 ratio, because I was obsessed with that for a while and it didn’t really have much of an effect but these more foundational principles where the things that have more of an effect… so…
SM: But the antibody testing, you think, is important, though.
SM: To rule out autoimmunity.
DR: Yes, definitely addressing the autoimmunity. And I would classify that under a more of a foundational piece but… yeah, let’s definitely… I love this conversation, and we’re both passionate about it…
SM: Yeah, I think we have another podcast!
DR: Yeah, but let’s do a whole episode on it, because I do really want to try to help people from maybe spending money on tests that they don’t need to, where I found that some of these things are not needed as an initial line therapy, anyway.
SM: Right. So, let’s… can you… let’s wrap up today’s conversation.
DR: Ok, so. A few…
SM: To bring it to a close.
DR: …Yeah, so… A few things—and sorry everyone for that tangent there but—like I just mentioned the autoimmune paleo diet: I’ve seen work very well for nodules in some cases now in a few studies they’ve used iodine, I’ll link to two papers in the show notes, iodine at 8 mg twice per month.
SM: Oh, that’s a lot—… Oh! Twice per month. Ok.
DR: Twice per month, yeah. Or, 30 mg once per month have been shown effective in decreasing thyroid gland size in children. Just in children. Also there’s been a few studies showing that when iodine has been added to the food supply that the instance of nodules has decreased and I’ll link to three studies that have shown that. But also remember just because some of these studies show that but adding iodine to the food supply we see a decrease in nodules that doesn’t mean even more is going to be better. Because, remember excessive iodine intake can cause goiter also, so there’s a sweet spot there.
SM: Remember that bell– the bell curve.
DR: The bell curve. Absolutely. And, if someone has gone through all of the, what I would term foundational functional medicine interventions which would be: diet, gut health, infections, lifestyle, exercise, sleep, sunshine, those very important fundamentals. Yeah, I think one of the best strategies for nodule or goiter would involve iodine along with thyroid hormone and… linking to a link to a study where 1024 subjects were either given iodine 150 µg of potassium iodine specifically or levothyroxine, I’m sorry iodine with levothyroxine… 75 micrograms… or levothyroxine alone or iodine alone or placebo and there’s actually a great graph from the study that looks at the nodule volume and the total thyroid volume and the greatest decrease was in the group that received both the thyroid hormone with the iodine.
SM: Just for everybody at home levothyroxine is synthetic T4 so… it’s…
SM: It’s a thyroid hormone… it’s the T4 that needs to be converted to the T3. So that’s what they were using.
DR: And that’s most likely going to be the most important type of thyroid hormone…
DR: …T4 and T3. What has the feedback looped to TSH to the brain, and to the gland is the T4… so that’s probably going to be the most important type of thyroid hormone in this application. Now, the best results were seen with the hormone and the iodine, second to that was the hormone alone, third to that was the iodine alone, and fourth to that was a placebo alone. So I think in that application or this application is going to be good for people that are not responding to anything else. So you’ve done the paleo diet, you’ve gotten your gut healthier, you’re sleeping ,you’re exercising… all those other things, and your nodule or goiter is still not responding. That’s when giving a trial to levothyroxine along with iodine supplementation might be a good… a good bet because you want to try to avoid what would be depending or looming recommendation of either radioactive iodine or surgery which are highly effective in reducing the size of the gland, but the side effects make them you know not people’s first choice of course, so…
DR: I guess, in kind of quick recap, the first things that you’d want to do are really the basics: your diet, your lifestyle, exercise, looking into autoimmunity, and that goes deeper into gut health, and gut infections, then maybe looking into your iodine levels, and then finally considering iodine along with levothyroxine… and then at the end of the road, if you’re suffering from some kind of obstruction, or occlusion, then the end of the road is really radioactive iodine or surgery.
SM: Ok, well, that… that wraps it up pretty well with the steps that people should take if they have anything like this or their neck’s tender trouble, swallowing all the… all the different symptoms you talked about earlier.
DR: Exactly, and in a lot of cases there’s not a whole ton of symptoms that are associated with this initially. People may present with, like you said neck pain, hard time swallowing, maybe a hard time breathing… the feeling of things getting stuck in your throat… and then these nodules and/or goiter can manifest along with hyper or hypothyroid or they can even, sometimes, caused hyper or hypothyroidism… so hopefully we’ve given you an outline of some of the causes and some of the treatments and hopefully that will help people navigate this issue and hopefully not have to resort to radioactive iodine or surgery.
SM: Yeah, my grandmother had her thyroid radiated and, so yeah, that’s not something… not a road that you want to go down, if you don’t have to
DR: Absolutely so…
DR: So, hopefully that helps. Thank you everyone. Thank you Susan.
SM: And, uh, see you guys next week!
DR: All right! Bye-bye.
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