The Dr. Hedberg Show

Fiber is an important part of a healthy diet but like anything we consume, too much or too little may be problematic.  Fiber has been touted as an extremely important nutrient but is it really as beneficial as it is purported to be? When used at the right time in the right individual, fiber can be a game changer for healing the gut and improving overall health.  Let’s discuss the health benefits of fiber and the best fiber supplements if supplementation is necessary.

What is Fiber?

Fiber is a compound found in food categorized as soluble and insoluble as well as fermentability.  Fermentability is how well your gut bacteria can eat the fiber. Soluble fiber dissolves well in water and insoluble fiber does not.  This means insoluble fiber is much harder for your gut bacteria to eat and to ferment than soluble fiber so we usually start with soluble fiber supplements.  

Soluble fiber has higher fermentability than insoluble fiber so it feeds your gut bugs much better but this can lead to more gas and bloating.  Insoluble fiber has a greater chance of irritating your intestines so we usually don’t start with this type of fiber. However, insoluble fiber has low fermentability so it usually causes less bloating and gas than soluble fiber.  Most studies show that soluble fiber works better than insoluble fiber for most conditions.

What Conditions can Fiber Help Treat or Prevent?

Fiber research is difficult to properly perform because there are many variables in each person’s life that can affect their disease risk.  And since everyone has a different gut microbiota we have to take some findings with a grain of salt. Many factors have to be taken into account when studying fiber and disease such as:

Exercise

Stress levels

Sleep

Other dietary factors such as sugar intake, alcohol, processed foods etc.

Fruit and vegetable intake

Medications

Smoker?

Genetics

Antibiotic history

 

Here are some quick facts based on the latest research on fiber and various conditions:

Fiber reduces the risk of type 2 diabetes with fiber from fruits and vegetables being more protective than cereal fibers.  Cereal fibers work well just not as well as fruits and vegetables. Fiber supplements lower fasting glucose and hemoglobin A1c.

Paleo diets and low-carb diets work better than low-fat/high fiber diets for heart health and weight loss.  Interestingly, Paleo and low-carb diets are low in fiber indicating that balancing blood sugar and reducing inflammation are more important than eating a lot of fiber.

Fiber supplements decrease blood pressure and cholesterol but it doesn’t mean this reduces the risk of cardiovascular disease.

Fiber supplements help with weight loss.

Some research shows fiber protects against colorectal cancer and some research shows fiber has no protective effect from colorectal cancer.

Fiber reduces the risk of Inflammatory Bowel Diseases (IBD) like Chron’s disease and Ulcerative colitis but once you have IBD it is best to eat a low fiber diet until you are in remission and then slowly increase to a tolerable amount.

Fiber may make Irritable Bowel Syndrome (IBS) worse or it may help.  If you have diarrhea dominant IBS then avoiding fiber is probably a good idea as it can make some people worse.  However, if you have constipation dominant IBS, fiber may help. Like with IBD, it’s best to start with low fiber intake and slowly increase to a tolerable dose.  If your IBS is due to Small Intestinal Bacterial Overgrowth (SIBO), it is best to avoid fiber supplements until the SIBO is under control.  Fiber supplements do not appear to help much with bloating and pain in IBS but they do help with quality of life, stool consistency, and frequency.  Soluble fiber appears to work better than insoluble fiber.

When should you use a fiber supplement?

If you currently have a digestive issue such as SIBO, IBS, IBD, GERD or any of the common symptoms of gut dysfunction such as gas, bloating, cramping, indigestion, diarrhea, or constipation then you should avoid fiber supplements.  

Fiber supplements should be used when your gut is in relatively good health or after you have followed a gut healing program and you’re ready to improve your gut microbiota.  Gut healing programs include dietary changes, probiotics, digestive enzymes, gut healing nutrients, and herbal antibiotics to get the gut back in balance.  

Once your gut symptoms are gone or minimal and you have reintroduced foods that are higher in fiber such as foods that contain FODMAPs without any issues, then it may be time to try a fiber supplement.

What are the best fiber supplements?

Flaxseed Fiber

Moss Nutrition Flaxseed Fiber is made from certified organic, cold-milled whole flaxseeds, a natural source of dietary fiber and other nutrients.  This product is intended for use primarily as a fiber supplement but Flaxseed Fiber also contains dietary protein, dietary lignans and the important omega-3 essential fatty acid alpha-linolenic acid (ALA).  ALA has been researched to help support healthy cardiovascular function, healthy cell membrane structure and a healthy inflammation response.

Flaxseed and the flax plant in general are ancient botanical allies of human beings, cultivated for thousands of years for use in human dietary, livestock and industrial applications.  Flax has provided food, medicine, clothing, paper and more, leading to its Latin name Linum usitatissimum (“highly useful”). Flaxseeds, also known as linseeds, have been recognized for helping to promote healthy bowel elimination since at least 500 BC, at which time Hippocrates made note of their laxative properties. Modern research suggests that flaxseed and the oil it contains also may help to support healthy cardiovascular function and immune system health.

Flaxeed contains three primary functional food compounds: mono- and polyunsaturated fatty acids, soluble and insoluble dietary fiber, and lignans.  Lignans both provide antioxidant activity and exhibit phytoestrogenic effects. Flaxseed is the richest known source of dietary plant lignans, offering 800 times the lignan content of any other plant food.  Flaxseeds also contains vitamin E (mainly in the gamma tocopherol form), B-vitamins such as niacin and folate, and numerous minerals including significant amounts of phosphorus, potassium, magnesium and calcium.

The soluble fiber in flaxseed is rich in mucilaginous compounds that have been shown in both human and animal research to help relieve constipation.  A 2007 study found that daily consumption of ground flaxseeds with yogurt and prunes helped decrease the severity of constipation in seniors with mild constipation.  Soluble flaxseed fiber also has been associated with helping to support healthy serum cholesterol and blood lipid levels within the normal range.  

A 2012 double-blind, randomized study found subjects who consumed a drink containing flaxseed fiber for seven days exhibited decreased fasting LDL and total cholesterol and increased fat and energy excretion.  

Flaxseed fiber drinks also have been shown to help suppress appetite, increase satiety and reduce caloric consumption.  In addition to fiber, a number of bioactive compounds in flaxseeds (e.g. peptides, glycosides, ALA and lignans) have been researched to offer benefits to cardiovascular health in different ways including free radical protection and inflammation support.

The oily, nutritious and fiber-rich core of every tiny flaxseed is surrounded by a shiny, hard husk that is difficult to fully break down by chewing alone.  Pre-soaking, grinding or milling of whole flaxseeds is widely practiced to release their full nutritional and therapeutic potential. Studies suggest that milled flaxseed, such as Moss Nutrition Flaxseed Fiber provides, is remarkably resistant to oxidative degradation.  To further promote and preserve freshness, Moss Nutrition Flax Fiber is cold-milled at low temperatures, and some of the oil in the meal is removed after milling to help optimize product stability. Refrigeration after opening also is recommended to help support and extend shelf life.

How should you take Flaxseed Fiber?

Flaxseed Fiber may be combined with any liquid—from plain water or apple juice to smoothies and protein shakes.  Alternatively, the product may be consumed in a variety of creative ways, both for convenience and to increase the nutritional value of many foods.  Some examples include:

Sprinkle Flaxseed Fiber on top of yogurt, breakfast cereal, grain dishes or salads.

Mix Flaxseed Fiber into condiments such as mayonnaise and mustard.

Add Flaxseed Fiber to batters and baked dishes such as breads, muffins, pancakes and casseroles.

Moss Nutrition premium Flaxseed Fiber is made with organically grown, non-GMO cold-milled flaxseed.  This superior quality raw material is certified kosher by the Kosher Certification Service and certified organic by Quality Assurance International to meet USDA National Organic Program standards.  Upon packaging, the finished product is verified gluten-free by independent laboratory testing.

Start with 1 scoop a day for three days and then increase to 2 scoops a day for three days.  Then 3 scoops a day for three days and then max out at 4 scoops a day. This can be done in two doses or by taking all the scoops at one time.  Flax fiber can be taken with or without food.

If you notice gas, bloating, cramping, increased constipation, or any other gut symptoms getting worse,  reduce the dose to the maximum tolerable dose. If you don’t do well with just 1 scoop a day then it is time to try a different fiber supplement such as Acacia Fiber.

Can’t I just take ground flax seeds?

Although you will get some health benefits from grinding your own seeds, I don’t recommend doing this if you are specifically trying to heal your gut.

Inflammation is at the core of most chronic illnesses including hypothyroidism and Hashimoto’s disease. But how exactly does inflammation cause hypothyroidism? Nonthyroidal illness syndrome (NTIS) is the state in which inflammation causes negative changes to thyroid hormone including low T3 and increased reverse T3 (rT3). T3 is the most active form of thyroid hormone and rT3 actually blocks T3 receptors so inflammation can really knock out thyroid function. TSH levels however stay relatively “normal” in NTIS thus leaving many patients with the symptoms of hypothyroidism but no diagnosis since no one is checking their T3 or rT3 levels.

In this article I’ll be referencing a paper entitled, “IL-6 promotes nonthyroidal illness syndrome by blocking thyroxine activation while promoting thyroid hormone inactivation in human cells.”

T4 is normally converted into the more active T3 under normal conditions but when you’re chronically inflammed, the enzymes that perform this conversion may not be functioning properly. The “4” in T4 indicates that it has 4 iodine molecules and the “3” in T3 indicates that it has 3 iodine molecules. There are three enzymes called deiodinases involved in this process:

D1 converts T4 into T3 by removal of one iodine from T4 to make T3.

D2 does the same thing as D1.

D3 inactivates both T4 and T3 but also increases rT3.

80% of the T3 in your body comes from D1 and D2 converting T4 into T3. Inhibition of D1 and D2 due to inflammation is the most common cause of low T3 but D3 is also a contributing factor to low T3 and increased rT3.

What is inflammation?

Inflammation is basically an overactive immune response that is acute or chronic. This overactive immune response can result in tissue damage if it is localized to a specific area in the body or it can be present throughout the entire body resulting in various symptoms such as fatigue, brain fog, joint pain, digestive problems and much more. There really aren’t any symptoms I could list that aren’t related to inflammation.

If you have elevated C-reactive protein levels on your blood tests then this can indicate inflammation. I test all of my patients for this marker to see their level of inflammation. Cytokines are chemical messengers in your body that communicate with your immune system in response to any kind of stress. Interleukin 6, or IL-6, is a well-studied cytokine that is elevated when there is inflammation and it has been specifically studied in relation to thyroid hormone. Increased levels of IL-6 have been shown to lower T3 levels and increase reverse T3 levels.

What causes inflammation?

Many things can cause inflammation and some of these tend to be overlooked. Here is a list to think about if you have hypothyroidism or Hashimoto’s disease:

Stress-both physical and emotional

Infections of all types ie. viruses, bacteria, parasites, yeast

Food sensitivities ie. gluten, dairy etc.

Loneliness

Social isolation

Lack of meaningful purpose in life

Lack of sleep

Lack of exercise or excessive exercise

Relationship conflicts

Gut dysbiosis

Dental infections

Autoimmunity

Lack of physical affection

Environmental toxins

Some of the above may surprise you but all of these need to be seriously confronted if they are present.

What did the above study find on inflammation and hypothyroidism?

When the authors subjected cells to the inflammatory cytokine IL-6, both D1 and D2 activity decreased thus resulting in low T3 and increased rT3 levels. Additionally, D3 activity increased thus lowering T3 levels even more and increasing rT3. It was clear that inflammation significantly disrupts thyroid hormone in the peripheral tissues of the body. This means that your thyroid may be producing healthy levels of thyroid hormone but once it leaves the thyroid and is supposed to be activated in other organs such as the gut, liver, kidneys etc., it may not do so optimally.

There was a very interesting finding which showed that N-acetyl cysteine actually blocked the negative effects of IL-6 thus preventing decreases in T3 and increases in rT3. N-acetyl cysteine, or NAC, increases glutathione levels and glutathione levels are decreased in inflammation. Glutathione is also required for proper D1, D2, and D3 function so increasing levels of glutathione can ensure proper conversion of T4 to T3 and a reduction in rT3.

I use NAC quite a bit in my patients with hypothyroidism and Hashimoto’s disease because it not only does the above, but it also protects the thyroid gland from damage due to inflammation. Additionally, NAC helps to balance the immune system in autoimmunity and it’s also great for chronic infections such as the Epstein-Barr Virus and Helicobacter pylori.

I like the 700mg NAC product from Moss Nutrition taken 1 capsule once or twice a day with food in patients with hypothyroidism and Hashimoto’s disease. Some people will have a bad reaction to NAC because of its sulfur content or because their gut microbiota is out of balance. Additionally, NAC is going to enhance detoxification which is not the right thing for some people. NAC definitely isn’t for everyone so be sure to take it under doctor supervision or you may have side effects if used at the wrong time.

How else can you increase glutathione levels?

1. Eat plenty of suflur-rich foods such as meat, fish, eggs, onions, garlic, and cruciferous vegetables like broccoli, Brussels sprouts, cauliflower, kale, and mustard greens.

2. Avoid drinking alcohol which depletes your body of glutathione.

3. Optimize your sleep to get 7-9 hours of uninterrrupted rest.

4. Exercise improves glutathione but don’t overdo it or you’ll actually deplete your glutathione levels.

5. Increase your vitamin C intake by eating plenty of fruits and vegetables or supplement with 500-1,000mg a day.

6. Eat selenium-rich foods such as beef, chicken, fish, organ meats, cottage cheese, brown rice and Brazil nuts. Brazil nuts can be highly variable in their selenium content so I don’t recommend them more than once a week.

7. Consume a high quality whey protein supplement like Select Whey from Moss Nutrition available in unflavored or vanilla flavor. Whey protein is rich in the amino acid cysteine which is required for glutathione production.

8. Use turmeric in your cooking and take a curcumin supplement like CurcuSelect by Moss Nutrition which has the patented Meriva curcumin for best absorption.

9. Try a Milk Thistle supplement which has been shown to boost glutathione levels.

You’ll most likely be able to maintain healthy glutathione levels from the food that you eat but you can always add in some of the above recommendations if you’re very ill and need more support. Healthy glutathione levels will ensure your T4 is properly converted into T3 while minimizing reverse T3 levels.

Putting it all together

It is clear that inflammation disrupts healthy thyroid hormone levels so the real key is finding the source of your inflammation and addressing it. Review the above list and be sure you’re working with a functional medicine practitioner who will adequately investigate each potential source.

If you have a chronic infection like Epstein-Barr Virus then you need the right healing plan to get it under control. Or if your gut is out of balance then you need a good plan for optimal gut health. You can immediately begin some of the strategies listed above for ensuring healthy glutathione levels which may help improve your T3 and rT3 levels. Your thyroid issues may simply be due to undiagnosed sources of inflammation so have these thoroughly investigated and you may be on your way to optimal thyroid health.

There is no single optimal TSH level for everyone with Hashimoto’s disease. A TSH result is most useful when interpreted alongside free T4, thyroid history, symptoms, age, pregnancy status, and whether you take thyroid hormone. A result around 2.5–3.0 mIU/L may warrant a closer look in some situations, but it does not, by itself, diagnose hypothyroidism or mean that thyroid medication is needed.

TSH is the current gold standard for diagnosis of hypothyroidism but are the current TSH levels optimal and how do they relate to Hashimoto’s disease? An excellent paper out of China entitled, “Using Hashimoto thyroiditis as gold standard to determine the upper limit value of thyroid stimulating hormone in a Chinese cohort” has shed some light on this important question which looked at the upper limit of TSH levels in relation to Hashimoto’s disease and hypothyroidism.

The authors begin by stating that subclinical hypothyroidism is characterized by “normal” T4, T3, Free T4, and Free T3 with an elevated TSH. And these patients have an increased risk of cholesterol abnormalities, heart disease, mental illness, and pregnancy complications even though their symptoms are relatively mild.

Higher TSH levels may warrant closer evaluation for Hashimoto’s disease in the appropriate clinical context.

The current upper limit for “normal” TSH is 4.0-5.0 mU/L but some authors have stated that it should be 2.5-3.0 mU/L. The National Academy of Clinical Biochemists (NACB) guidelines have stated that 95% of normal individuals have a TSH below 2.5 mU/L which tends to be the upper limit value used by functional medicine practitioners.

How was the study done?

A hefty study group of 2,856 individuals aged 20-60 were examined and tested for the study.

Blood tests included:

Free T3

Free T4

TSH

Thyroid peroxidase antibodies

Thyroglobulin antibody

Total cholesterol

Triglycerides

LDL cholesterol

Fasting glucose

Uric acid

ALT (liver enzyme)

Creatinine

Carbon dioxide combining power

Participants were diagnosed with Hashimoto’s disease based on the presence of thyroid antibodies and abnormalities on a thyroid ultrasound.

They excluded individuals who were taking thyroid medication, pregnant, had a history of thyroid operations, had free T3 or free T4 outside the normal range, or a history of autoimmune disease. The average age was 36 with 75% being women and 25% men.

What were the study results?

7% of the subjects were diagnosed with Hashimoto’s disease with 14 men and 173 females which syncs with previous data that Hashimoto’s disease is more prevalent in women.

Those diagnosed with Hashimoto’s disease did not show any differences in age, body mass index, waist to hip ratio, blood pressure, liver tests, blood glucose, or cholesterol. Creatinine and uric acid levels were lower in the Hashimoto’s disease group but this is due to the higher prevalence of women in this group who tend to have lower levels of these markers compared to men.

The proportion of participants with Hashimoto’s disease was 4% when the TSH was below 2.6 compared to 14% when the TSH was above 2.6. They grouped the participants into three categories of 2.6, 2.9 and 4.5 TSH cutoff values and found some interesting results.

At the 2.6 mU/L cutoff, participants above the cutoff had significantly higher rates of elevated total cholesterol, LDL cholesterol, and triglycerides. At the 2.9 cutoff, the differences were significant for total cholesterol and triglycerides, but not LDL cholesterol. The authors found that 4.2 mU/L was the upper limit using their percentile-based analysis.

However, the authors used a “prevalence of Hashimoto’s thyroiditis” factor to determine the upper limit of TSH and found a range of 2.6-2.9 to be more appropriate. They state that this correlates with the National Academy of Clinical Biochemists findings of a 2.5 upper limit for TSH levels.

The authors reference multiple studies linking TSH levels in the upper limit to high blood pressure, high cholesterol, and a higher Framingham score which is a marker for cardiovascular disease risk. These include:

Age- and Race-Based Serum Thyrotropin Reference Limits

Associations of TSH levels within the reference range with future blood pressure and lipid concentrations: 11-year follow-up of the HUNT study

Serum TSH related to measures of body mass: longitudinal data from the HUNT Study, Norway

Thyroid-Stimulating Hormone Levels within the Reference Range Are Associated with Serum Lipid Profiles Independent of Thyroid Hormones

What this study can-and cannot-tell us

This study found that Hashimoto’s was more common among participants with higher TSH levels and proposed a cutoff around 2.6–2.9 mIU/L for this population. It does not establish that everyone above that range has Hashimoto’s or should receive treatment. The participants were Chinese medical staff aged 20–60, and the researchers noted that their findings might not apply to older adults. TSH is one part of a thyroid evaluation, not a stand-alone verdict.

Author conclusions

“This study shows a high prevalence of Hashimoto’s thyroiditis occurred among individuals with a TSH of 2.6-2.9 mU/L. These values are possible to be the “true” values of normal upper limit of TSH for Chinese population.”

Importantly, the authors noted that this lower cutoff should not automatically be used as a treatment threshold. The study examined Chinese medical staff aged 20–60 and did not test whether lowering TSH improved symptoms or health outcomes. Its findings support closer evaluation in appropriate patients rather than a universal TSH target.

Dr. Hedberg’s Comments

TSH is a useful first-line test for thyroid function, but a normal result does not rule out Hashimoto’s disease. Persistent symptoms deserve thoughtful evaluation, including consideration of thyroid autoimmunity and other possible causes.

This study suggests that a TSH in the upper part of the reference range may warrant closer evaluation for Hashimoto’s disease in the right clinical context. Thyroid history, symptoms, free T4, T3, thyroid antibodies, and cardiovascular risk factors can help guide that evaluation.

However, there are two sides to the coin. Functional medicine practitioners can be just as negligent in their analyses by over-analyzing TSH levels and trying to force the patient’s TSH levels to a lower number despite how the patient is feeling. We treat patients not lab tests.

Additionally, there can be a lack of emphasis on other body systems that are connected to the thyroid such as gut health, stress, blood sugar, hormones, adrenals etc. Additionally not knowing about the intimate connections between thyroid health and ferritin, zinc, diet, sleep, chronic infections etc.

Is it worse to put a patient on thyroid medication who doesn’t need it or to not put a patient on thyroid medication who does need it? They both have their detrimental effects so both conventional and functional medicine needs a thyroid makeover when it comes to thyroid management. And this goes for the use of T4/T3 combination therapy or the use of T3 alone which is rarely necessary but that is for another article.

The most important thing to understand is that we can’t rely solely on TSH values but we can use it as a guide for further investigation into Hashimoto’s disease and cardiovascular risk factors. Some patients can feel well again without thyroid hormone by focusing on their overall health and balancing all the systems in their body.

Would you like to learn how to boost your immune system and stay healthy this cold and flu season? Read on to find out what simple diet and supplement strategies you can follow to beat these viruses in their tracks.

Your immune system is constantly protecting you from invading organisms at a level of complexity most of us cannot comprehend. Modern medicine focuses mainly on the invading organisms as the source of disease without an appreciation for the beauty of your immune system’s ability to protect you from harm. Two people can be exposed to the same organism but only one person may actually manifest symptoms. Why would one person get sick but not the other?

Why do people get sick?

Many factors can answer this question such as the current state of the individual's unique biochemistry, genetics, environment, toxic load, stress levels, nutritional status, state of mind etc. Every day your body accumulates a specific amount of wear and tear. It is up to your immune system to repair the daily wear and tear you experience. It is only when your immune system can no longer keep up that your body begins to break down and cannot fight off an infection. If your body is functioning at a level that puts you in the best possible position to defeat an organism then you will most likely not get sick. There are exceptions to this such as the HIV virus, but in most cases, you can win the battle.

There are many dietary strategies, supplements, and herbs that will help support your immune system. The first thing to look at is your dietary protein intake. The immune system requires high energy levels and amino acids from protein sources to mount an immune assault on an invading organism. A condition known as "PEM" or protein-energy malnutrition can lead to immune system suppression and make you more susceptible to infection. In addition to high-quality lean protein sources, a good quality whey, pea, or hemp protein powder or free-form amino acid powder can provide your body with an extra boost of amino acids.

Processed carbohydrates and sugar can lead to immune system suppression. A study published in the American Journal of Clinical Nutrition found that white blood cell activity was reduced by 50% for 5 hours after ingestion of 100 grams of sugar. Stay away from sugar!

What are the best supplements for immune health?

Essential fatty acids from fish oil such as EPA and DHA help to balance the immune system as well as act as precursors for vital immune system chemicals. Dietary fiber directly supports the immune system by stimulating the lymphoid tissue in the gut where 70% of the immune system resides. Fiber also helps to eliminate toxins and increases the number of healthy gut bacteria. Increase fiber intake from fruits, vegetables, beans, and lentils.

Vitamin D is not actually a vitamin but a prohormone that is intricately involved in a healthy immune system. You must attain 20-30 minutes of sunshine every day on your entire body in order to produce enough vitamin D, so supplementation is usually required. Vitamin D supplementation has been shown to reduce the rate of upper respiratory infections. Vitamin D can be taken at a dose of 800-2,,000IU/day safely and effectively depending on your age and current health. Higher doses are used in our patients with autoimmune diseases and for genetic reasons.

Vitamin A deficiency is the most common vitamin deficiency in the world. Vitamin A is vital for healthy mucosal barriers such as the intestine, lung, and sinuses which account for your first line of defense against invading microbes. Vitamin A is required for white blood cell division, natural killer cell activity, lactoferrin secretion and improved immune system communication and antibody responses.

We can’t talk about immune system function without discussing the mighty vitamin C. Not actually a vitamin, ascorbic acid is highly concentrated in your immune cells and it is not well known that by the time you have a fever most of your body’s vitamin C stores are exhausted. Vitamin C deficiencies are known to cause immune system suppression and an increased risk of infections including upper respiratory infections.

High doses of vitamin C will improve immune cell activity and will reduce free radical production before they can damage your cell’s DNA and cause cell destruction. Vitamin C also boosts natural killer cells, improves immune system communication and boosts T-cell activity. A study published in Military Medicine found that vitamin C supplementation among military personnel consistently reduced the incidence and severity of respiratory infections.

Zinc is a trace mineral found in over 100 different enzymatic reactions in the human body. Zinc deficiencies are linked to increased risk of infections and immune system susceptibilities. Zinc improves immune cell function and enzyme activity. Zinc deficiency suppresses the thymus gland where immune cells mature and are released into the circulation.

Vitamin E is a fat-soluble vitamin and one of your most important antioxidants for immune function. A study published in the Annals of the New York Academy of Science found that just 200 IU/day of vitamin E significantly reduced the incidence of common colds in an elderly population over a year. Vitamin E should be taken as “mixed tocopherols” (delta, gamma etc.) instead of just alpha-tocopherol. Vitamin E works synergistically with the mineral selenium which has been shown to improve immune cell function and activity. Just 200mcg of selenium/day for 9 months was found to reduce the HIV viral load in HIV positive patients.

Other antioxidants such as lipoic acid and N-acetyl cysteine as well as nutrients that protect the powerhouses of your cells including carnitine and coenzyme Q-10 have all been shown to improve immune cell function and reduce the risk of infection. Protecting your mitochondria which are the energy-producing powerhouses of your cells is a significant underlying mechanism to strengthen your immune system and fight off infections. This was actually shown in AIDS patients who were given a cocktail of these nutrients over a 12-week period which resulted in a 24% increase in immune cell count.

Glutathione is another antioxidant found in every cell of the body and can be manufactured from amino acids and increased through oral supplementation of N-acetyl cysteine, whey protein, and milk thistle. Vitamin C recycles glutathione in the cell once it has done its job mopping up free radicals.

Studies on multivitamins have shown mixed results due to the fact that each multivitamin had varying doses of each nutrient. One study found that a multivitamin preparation that included probiotics reduced upper-respiratory infections in healthy unvaccinated adults.

What about exercise and the immune system?

Exercise can be a double-edged sword in regards to immune system function. Prolonged training seems to stress the immune system and increases upper respiratory infections in athletes. However, moderate exercise seems to support and strengthen many immune system functions. Strenuous exercise weakens the immune system by exhausting antioxidant stores, stressing the adrenal gland leading to increased cortisol output and lowering muscle glutamine levels. Vitamin C intake of 1000mg/day was shown to decrease exercise-induced immune suppression.

The rule of thumb for healthy exercise is that you should feel energized at the end of your workout and you would easily be able to do the entire workout over again.

Fish oil supplementation inhibits the exercise-induced inflammatory response in some athletes. Quercetin has been shown to positively balance post-exercise immune system functions and reduce upper respiratory tract infections. Most of the immune system suppression among athletes is due to stress on the mucosal barriers in the body and the herb Echinacea purpurea was shown to reduce the mucosal immune suppression post-exercise.

Does Echinacea Work?

The use of herbs and botanical extracts for immune system enhancement has ancient roots in nearly every culture across the globe. The most widely used herb for immune enhancement in the US is Echinacea. Echinacea has been shown to stimulate white blood cell activation as well as natural killer cell activity. These activities have been shown to be antiviral, antifungal and antibacterial. Echinacea has been shown to reduce the frequency, severity, and duration of upper respiratory tract infections.

One trial showed that children aged 1 to 5 given a liquid herbal blend of Echinacea, propolis, and vitamin C had 50% fewer upper respiratory tract infections, 68% fewer incidents of otitis media (ear infections), and 66% fewer incidence of pneumonia compared to children given a placebo syrup over a 12-week winter season. Even when the children taking the herbal preparation did get sick they had a 45% shorter duration compared to those taking a placebo.

Andrographis paniculata has been used for centuries in traditional Eastern medicine for the treatment of upper respiratory tract infections and sinusitis. The constituents within Andrographis have been shown to possess anti-inflammatory, immune-stimulating, antipyretic, anti-cancer, and antiviral activities.

Arabinogalactan is a fiber derived from the Eastern and Western Larch tree which has immune stimulating properties, up-regulates natural killer cells and enhances healthy bacterial growth in the intestine indirectly aiding the immune system.

Mushroom extracts such as Cordyceps, Shiitake, Reishi, Maitake, and Agaricus are the most commonly used mushrooms to enhance immune function. Each extract has different immune enhancing properties such as activation of natural killer cells, white blood cells and immune chemical messengers known as cytokines.

Astragalus membranaceus root has a deep history in traditional Chinese medicine. Astragalus has immune-balancing,

I’m excited to announce the new release of a protein supplement that I’ve been waiting for for a long time. When I first started practicing functional medicine 15 years ago, most patients could easily tolerate whey protein which was the best quality protein powder at that time. As the years went by more and more patients were reporting sensitivity to whey so I had to try and use alternate solutions like rice, hemp, and pea protein.

But after a few years of using these alternate protein sources I started to get more and more reports of sensitivities to these forms of protein just as I had with whey. All of my colleagues practicing functional medicine were confirming the same issues with protein powders leaving us with little to nothing to choose from.

This brings us to today and the excitement around the new AminoMeal Select by Moss Nutrition which isn’t based on any foods for it’s protein content but rather being a purely amino acid based formula. I’ll get into the specifics of this product shortly but first let’s answer a few questions about why a product like this is necessary.

Why are so many people sensitive to whey, pea, rice, hemp protein etc.?

Our immune systems haven’t changed in just 15 years but what has changed is our environment, microbiota, and our stress levels. Stress drives immune intolerance to foods and we couldn’t be more stressed in today’s modern world. I’ll lay out a few of the main causes of this shift in how our body’s are responding to foods.

1. Blue light exposure

Blue light from cell phones, tablets, and computers is zapping our melatonin levels thus diminishing the quality of our sleep. The loss of quality sleep is the quickest way to stress the body and drive immune system intolerance. I have a “no screens after 6pm” policy so I never look at a device after six. If I’m watching TV then I wear blue light filtering glasses to minimize exposure. I’ve also changed all the light bulbs in my house to blue light filtering bulbs.

2. Social Media

Social media has been shown to cause anxiety, depression, and depressed mood after using it. Additionally, many of the conversations are heated debates about various political and religious issues that create stress. Social media also has lead to more social isolation since everyone already knows what their friends are up to. What is there to talk about or catch up on when you put your entire life on the internet?

3. Social Isolation

This ties into the issue with social media as social isolation is a major stress to the body. Feeling isolated or lonely increases inflammation and stress hormones in the body. This is a recipe for gut problems and immune intolerance. Our society is becoming more isolated with a diminishing sense of community.

4. Gut Microbiota

Our gut bacteria are changing as the use of antibiotics, cleaning products, sanitizers, medications, pesticides, herbicides, and stress all negatively affect our microbiota. When your microbiota is out of balance you become more sensitive to foods.

5. Low HCL

Stress really knocks out stomach acid production which means that the food you eat doesn’t enter the small intestine properly digested. This puts more strain on the pancreas, gall bladder, and the upper GI leading to abnormal immune responses to food. Low HCL also leads to dysbiosis and SIBO which can increase immune intolerance as well.

People are eating way to fast and stressed while they eat due to watching the news, texting, checking social media etc. This keeps you in a sympathetic dominant state of mind which lowers stomach acid production. I always try to get patients to eat in a quiet and comfortable place so they can enjoy their food, chew slowly and thoroughly, and without distractions.

6. Alternative Medicine

This one may surprise you since I am an “alternative medicine” practitioner but many practitioners are doing more harm than good by recommending long-term restrictive diets to patients. Small exposures to a variety of foods over time keeps the immune system healthy and non-reactive. This is the new strategy for many children who have peanut and other allergies for example.

Kids are now instructed to have very small amounts of foods they’re allergic to in moderation until eventually the immune system no longer overreacts to each one. Forcing patients on restrictive diets for many months and even years can do more harm than good in some cases.

Additionally, we know from the psychoneuroimmunology research that what we believe affects how our body reacts to foods and other substances. Once someone develops a belief that they are sensitive to a certain food, there is an increased chance that their immune system will negatively react to it. It’s quite an amazing phenomenon but overlooked by many. Cognitive behavioral therapy can help people overcome developed phobias and beliefs about foods that are “bad” for them.

The above are just a few examples of what is stressing our immune system and our gut microbiota which are important regulators of how we react to foods.

Why are protein powders so important?

As we age, our protein requirement actually increases and we can absorb more protein per meal the older we get. The “Fountain of Youth” is not a mystery at this point as science has shown us that muscle mass is the single best indicator of health and longevity.

There’s nothing sexy or exciting about this concept which is why it isn’t more popular. Maintaining healthy lean muscle mass as we age is the single best way to reduce your chance of disease and live to your maximum lifespan.

If you can’t seem to get enough protein from food due to a gut or psychological issue, then protein powders can really come in handy. Additionally, if you’re an athlete or avid exerciser, protein powders can enhance your recovery from exercise and increase lean muscle mass.

I have many patients with low stomach acid levels, compromised digestion, low pancreatic enzyme output, and sluggish or removed gall bladders all of which can inhibit protein digestion and absorption. Additionally, I have many patients with dysbiosis, malabsorption due to celiac disease, small intestinal bacterial overgrowth (SIBO), autoimmune disease, hypothyroidism, chronic stress, and a host of other issues that contribute to poor protein digestion and absorption.

How much protein do you need?

Most people need about 1.5 grams of protein per kilogram of body weight. So divide your body weight in pounds by 2.2 to get your body weight in kilograms. Then multiply that number by 1.5 to get the total required grams of protein for each day.

If you’re over the age of 50 then shoot for 25-35 grams of protein with each meal which is about one palm-sized portion of meat such as a chicken breast.

What’s so special about AminoMeal Select?

As noted above, AminoMeal Select is pure amino acids so it isn’t a food-based protein powder. You’re just strictly getting all of the necessary free form amino acids to build muscle and for proper body function. The amino acid profile is actually a proprietary blend called “Reginator” which has some excellent research behind it for building lean muscle mass. There are currently 24 studies on Reginator and I won’t get into the details of all these studies since there is so much information.  Reginator was actually developed for NASA's astronauts on deep space missions to preserve muscle mass.

The important thing to know about Reginator is that studies have shown it can increase muscle mass, improve recovery from exercise, and it can even build muscle without exercise. Additionally, if someone is sedentary and can’t exercise due to a recent surgery, it can help prevent the loss of muscle.

There are a total of 20 amino acids used by humans including 11 non-essential amino acids and 9 essential amino acids. You can make all of the 11 non-essential amino acids but we can’t make the 9 essential amino acids so we have to get those from food. Reginator contains all 9 essential amino acids in the right proportion plus some arginine which is a highly anabolic amino acid for muscle growth and strength.

Here are some key points about this product:

Hypoallergenic

Methylated B-vitamins

Chelated minerals

Balances blood sugar

Enhances fat-burning

Vegan

One scoop of AminoMeal Select has an MPS (Muscle Protein Synthesis) factor equivalent to 15-20 grams of whey or pea protein.

Additional special ingredients:

MCT’s (medium chain triglycerides) from coconut oil

Omega-3 fatty acids from flax

Prebiotic fiber from inulin to fuel healthy bacteria

Flax fiber for healthy elimination

Guar gum to lower blood sugar

Green tea extract to burn fat

High gamma vitamin E

Chromium and vanadium to balance blood sugar

White kidney bean extract to lower blood sugar and promote weight loss

What if you have SIBO?

Some of you will take note of the prebiotics in this product and wonder if it wouldn’t be a good idea if one has small intestinal bacterial overgrowth (SIBO). There is no definitive answer to this question as it will work just fine for some with SIBO and not so well with others. SIBO is so individualized that no one can predict how someone will respond. I won’t be hesitating to use it in my SIBO patients if there are issues with gut absorption and protein deficiency signs and symptoms.

Can it help heal your gut?

When your body is under stress or if you aren’t getting enough protein, your body will actually strip your gut lining of amino acids to use them for repair in other parts of the body. This breaks down the gut barrier leading to leaky gut and impaired immune function.

I have worked with many patients who were struggling to heal their gut and we figured out that they were not getting enough protein to recover from the exercise they were doing. Once we got their protein levels up with an additional protein shake on workout days,

IgY Max is a new compound designed to improve gut function with some decent research behind it which I’ll cover in this article. Thousands of studies are coming out every month on the gut microbiome and millions of people worldwide are suffering with gut issues like irritable bowel syndrome (IBS), inflammatory bowel syndrome (IBD), and small intestinal bacterial overgrowth (SIBO). We need all the tools we can get when it comes to gut health so I was excited to see the research on IgY Max and the introduction of GI Globulin Select by Moss Nutrition which contains IgY Max.

Many people have gut problems because they have dysbiosis which basically means that the bacteria in the gut are out of balance. This means that there are too many harmful bacteria and not enough beneficial bacteria. IgY Max actually targets 26 of these bad bugs and helps your body suppress their growth.

What is IgY Max?

It is a compound made from specifically immunized chicken eggs. IgY is in the immunoglobulin family which basically means a protein that is important for immune function. Our bodies have the immunoglobulins IgG, IgA, IgE, IgM, and IgD all of which have important immune properties and functions.

IgG makes up the bulk of the human immunoglobulin system which is used in products like colostrum or specific IgG products all designed for gut healing and immune health. IgY however has some advantages over IgG:

IgY is 3 to 5 times stronger than IgG due to increased efficiency of the immune response

IgY does not stimulate inflammation

IgY has a more rapid and specific local response such as targeting specific bacteria

Eggs have 20 times more immunoglobulins than IgG so it is more economical

IgY Max does the following:

Heals the gut lining making it ideal for leaky gut

Ensures the right bugs stick to the gut lining and the wrong ones don’t stick

Reduces harmful bacteria

Supports overall immune system health

Helps the body fight infections

Reduces inflammation

The gut barrier protection that this compound provides supports any probiotics or prebiotics that you may be taking. The “bad” bacteria are inhibited from multiplying and sticking to your gut lining so the good bacteria can remain intact.

What does the research show on IgY Max?

The first is a pilot study done by the company itself which can be a bad thing but not necessarily if the study is well done. Six subjects with mild to moderate gut complaints were given two 500mg capsules twice a day of IgY Max for 8 weeks and had gut assessments of zonulin, histamine, Diamine oxidase (DAO) for gut integrity at the beginning and the end of the study.

Zonulin is a decent test for gut barrier integrity, histamine is a good marker for inflammation and gut barrier integrity, and DAO is the enzyme that breaks down histamine so low levels are connected with chronic inflammation and autoimmune diseases.

Three of the six subjects did a comprehensive digestive stool analysis to assess their gut bacteria as well as testing yeast.

What were the results?

None of the subjects had any adverse reactions to the supplement. The subjects did report improvements such less gas and bloating as well as feeling more energy at 8 weeks. Zonulin improved, DAO improved, and histamine improved in all six subjects. There was also an improvement in beneficial flora in all 3 subjects as noted on the repeat stool analysis. Lactobacillus was the specific strain in the gut that improved.

Another clinical trial to mention is an unpublished study by Rehnini Ambekar, MD entitled, “Effect of a nutritious drink fortified with immune egg in improving the weight and enhancing the well-being of subjects.” In this study 14 patients with AIDS were given a drink that contained IgY egg powder for 8 weeks. Most of the patients reported significant improvements in all aspects of quality of life including energy levels, mood, and physical health.

Dr. Ambekar reported that symptoms related to IBS and IBD improved such as significant decreases in diarrhea.

And a third clinical trial published in 2004 by Morningstar in JCM entitled, “Hyperimmune egg powder for the treatment of irritable bowel syndrome: A case series” showed some promising results on two patients with IBS.

The first patient had IBS with alternating constipation and diarrhea for four years and was put on a hyperimmune egg powder with IgY for 31 days at a dose of 4.5 grams/day. The patient was instructed not to make any dietary changes to remove that as a variable. She was instructed to keep a detailed journal of her bowel habits during the 31 days.

At the end of the trial she reported complete elimination of her diarrhea and constipation within just 2 days of taking the hyperimmune egg powder. By the eighth day her gut pain and discomfort had completely resolved. Her stool became more solid and much larger in volume. She was able to eat all of the foods that normally caused her gut symptoms such as high FODMAP foods like garlic and onions without any issues during the trial.

The second patient also had IBS for four years but characterized by diarrhea. This patient did notice some improvement in her bowel movements while taking the hyperimmune egg powder.

Dr. Hedberg’s Comments

The small sample size of only six patients in the first study and only three of them receiving a stool analysis isn’t much to go on but these results are promising. When you develop dysbiosis you become more inflamed and your gut barrier breaks down leading to more histamine. This can result in symptoms like fatigue, brain fog, weight gain, pain, diarrhea, constipation, autoimmune diseases and mood disorders like depression and anxiety. This product appears to directly address the integrity of the gut barrier as well as lowering histamine and improving zonulin and DAO.

If in fact these results can be obtained in a study with more subjects in a randomized, placebo controlled trial then we could have a lot more confidence in this compound. On the other hand, those of us in the trenches need all the help we can get with our complex patients presenting with major gut issues, autoimmune disease, mood disorders and many more conditions that are related to gut integrity.

Hyperimmune egg powder has been around for quite some time actually going back to the year 2000 covered in the paper, “Hyperimmune eggs capture natural immune support” published in the journal Alternative and Complementary Therapies.

It was also studied in treating osteoarthritis pain in the paper, “Administration to arthritis patients of a dietary supplement containing immune eggs: An open-lable pilot study” in the Journal of Medicinal Food in 1998.

This product was also analyzed for cholesterol modulating effects in the paper, “Pilot study on the effect of hyperimmune egg protein on elevated cholesterol levels and cardiovascular risk factors” in the Journal of Medicinal Food in 1999 as well as in the paper, “Effect of immune egg on serum cholesterol in rabbits on atherogenic diets.”

Additional studies on gut health were done including the papers, “Inhibition of diarrhea by immune egg: A castor oil mouse model” and “Chicken egg antibodies for prophylaxis and therapy of infectious intestinal diseases, Immunization and antibody determination.”

Additional studies on this technology include:

Kovacs-Nolan J and Mine Y. Egg Yolk Antibodies for Passive Immunity. Annu Rev Food Sci Technol. 2012; 3:163-187.3.

Sandra Müller, et al. IgY antibodies in human nutrition for disease prevention. Nutr J. 2015; 14: 109.4. Sarker SA, et al. Randomized, placebo-controlled, clinical trial of hyperimmunized chicken egg yolk immunoglobulin in children with rotavirus diarrhea. J Pediatr Gastroenterol Nutr. 2001 Jan;32(1):19-25.5.

Miles, Laura. Effects of Hyperimmune Eggs on HSCRP Levels: Results of a private clinical trial. (Unpublished study.)

A proper clinical trial could be years away so we have to try it and see if it helps with the most complex patients. None of the subjects in the above trials had any side effects. And I was involved in the trial batch of GI Globulin Select by Moss Nutrition with a handful of patients and none of them had any side effects from the product.

All of the patients I tried the trial batch on had major improvements in just 4 weeks of taking it. In fact, one gentleman who had severe constipation his entire life reported the constipation was completely resolved while taking the GI Globulin Select.

With no reported side effects and only positive results in this small trial and during the trial batch of the product, I’ve decided to begin using it with patients who are suffering from gut disorders.

What if you’re allergic to eggs?

The answer to this question is unknown at this time. If you have a true egg allergy such as an IgE-mediated allergic response then I would stay away from this product. However, if you simply have a “sensitivity” or “intolerance” to eggs then you may be ok. The benefits of taking the product may actually reduce issues with eggs due it’s positive influence on the gut barrier, microbiota, and immune system. And if you’re struggling with a gut problem then a product like this may provide significant relief.

Where can you get IgY Max?

GI Globulin Select by Moss Nutrition contains 4.5 grams of IgY Max per scoop which is more than double the 2 grams used in the above study on six subjects. One scoop a day should be effective for most individuals but I may use 2 scoops on my difficult cases. This product should be blended in cold water or with ice or sprinkled on cold food. Hot food or hot liquids will diminish it’s effectiveness.

Your gut microbiota has an intimate connection with your thyroid including connections with hypothyroidism, Hashimoto’s disease and Graves’ disease. In this research review I’d like to cover a recent paper entitled, “Microbiota and Thyroid Interaction in Health and Disease” published in the journal Trends in Endocrinology and Metabolism by Eleonare Frohlich and Richard Wahl.

The authors begin by stating that the gut microbiota can act on thyroid function due to the region of where someones lives, their diet including iodine intake, obesity, age, sex hormones, and how autoimmunity can impact the microbiota. I was impressed to see them state that the gut microbiota is linked to autoimmune disease, estrogen, iodine, and obesity. Estrogen can be a key factor in Hashimoto’s disease and a healthy gut is required for optimal estrogen metabolism and excretion through the feces.

They also mention the connection between the gut and the liver in relation to thyroid hormone metabolism in both these organ systems. Your gut is key to properly absorbing and utilizing the thyroid medication that you’re taking and they mention this as well.

Your Gut Microbiota and Hashimoto’s Disease

Thyroid hormone is a vital part of a healthy gut barrier and a healthy gut barrier is vital for Hashimoto’s disease. When the gut microbiota become out of balance, the chances of developing Hashimoto’s disease increases.

The author’s make a very important point that the severity of Hashimoto’s disease is not correlated with the levels of thyroid antibodies such thyroid peroxidase and anti-thyroglobulin. I’ve written about this before that it is unwise to chase antibody levels and get them as low as possible because there is no evidence that lower levels improve Hashimoto’s disease.

The microbiota of patients with Hashimoto’s disease tends to be more diverse and the authors state that this is probably due to slower transit time due to hypothyroidism. I have written about this previously in my Hashimoto’s and SIBO connection article. It’s important to understand that increased diversity of the gut microbiota may be are harmful or beneficial depending on the individual so it isn’t always a good thing to increase diversity.

Interestingly, the authors also state that supplementation with Lactobacillus reuterii improved thyroid function in mice by increasing T4 levels. And when chickens were given lactic acid producing bacteria they had higher T3 levels. We are uncertain if this would also happen in humans however.

As women enter perimenopause, their progesterone levels drop more than estrogen leading to estrogen dominance. Estrogen dominance will have a negative effect on the microbiota but an imbalance microbiota will negatively affect estrogen metabolism and clearance. One of the reasons why some women go through menopause much more smoothly than others is due to the fact that they enter this process with a healthier gut. Increasing estrogen levels can drive autoimmunity so one of the main key factors in Hashimoto’s disease is to focus on a healthy gut so estrogen is in proper balance.

Thyroid medications like levothyroxine may not be absorbed well if there is dysbiosis or small intestinal bacterial overgrowth. Hypothyroidism leads to lower stomach acid levels which can decrease absorption of the medication as well as begin to cause overgrowth and dysbiosis in the the small bowel. Helicobacter pylori infection in the stomach can lower hydrochloric acid levels thus impairing absorption of medication as well. And we know that there is a connection between H. pylori and Hashimoto’s disease.

What about iodine?

Iodine is absorbed in the stomach and upper small bowel but it can be inhibited by inflammation in these areas due to H. pylori, food sensitivities like gluten, and dysbiosis. Fluoride will interfere with absorption of iodine in these areas so be sure you’re filtering your water if it contains fluoride.

Selenium, Iron, Zinc and the Thyroid

The authors point out that these three minerals are vital for proper thyroid function. The thyroid contains more selenium per mg than any other tissue in the body. Selenium is also important for the conversion of T4 to T3. Interestingly, your gut microbiota competes with you for utilization of selenium. You’ll only absorb what gets past your gut bacteria and what they don’t use themselves.

Zinc deficiency has been shown to cause a 30% decrease in T4 and T3 levels. Hypothyroidism causes zinc deficiency and zinc deficiency causes hypothyroidism. Zinc is required for the conversion of T4 to T3 as well. Zinc supplementation inhibits diarrhea and it also promotes the growth of Lactobacillus which can be beneficial.

Iron is required for the production of thyroid hormone in the thyroid gland. Iron is also required for the utilization of T3 in the cell. Iron does decrease microbial diversity which can be a good or bad thing depending in the individual as mentioned above. You must have healthy stomach acid levels to absorb iron which happens primarily in the small intestine.

Another fascinating statement in this paper is that gut bacteria can act as a reservoir for T3 levels thus decreasing the need for T4 medications and also this can prevent fluctuations in thyroid hormone levels. In fact, a study was done on the commercial probiotic product VSL #3 which resulted in fewer thyroid medication dose adjustments compared to those who didn’t take this probiotic.

Your gut microbiota even regulates your neurotransmitters including dopamine which inhibits TSH production. They even interact with your hypothalamic-pituitary-adrenal axis (HPA axis) which is intimately connected to your thyroid through the production of cortisol and adrenaline.

The Link Between Your Gut and Thyroid Disorders

The authors state that the gut-thyroid connection was actually discussed in the 1950’s using the term “thyrogastric syndrome.” Your gut and your thyroid actually come from the same embryonic tissue, in fact the thyroid actually develops from primitive gut cells!

Author Conclusions

There is a connection between altered gut microbiota and Hashimoto’s disease as well as Graves’ disease and hypothyroidism. Key points:

The microbiota influences the uptake of iodine in the intestine as well as utilization in the liver.

The microbiota influences selenium, iron, and zinc which are vital for thyroid health.

The microbiota influences absorption and utilization of thyroid medications.

Probiotics may be a useful therapy for thyroid disease.

We don’t know for certain at this point if there is a single direct connection between microbiota imbalances and autoimmune thyroid diseases.

Dr. Hedberg’s Comments

This paper is a real gem with some many excellent key statements. It does a great job tying together the connection between the gut microbiota and the thyroid. I was impressed to see them discuss minerals like zinc, iron, and selenium as well as key points about absorption of thyroid medication, iodine, the HPA-axis, estrogen, and they even mentioned leaky gut.

If anything, this review should be a strong reminder of how important it is to focus on gut health if you have hypothyroidism, Hashimoto’s disease, or Graves’ disease. Be sure you work with a functional medicine practitioner who truly understands the gut-thyroid connection like Dr. Hedberg so you can get well and stay well.

Ashwagandha is one of my favorite supplements for Hashimoto’s disease and hypothyroidism and we have some excellent studies to support using it for these conditions.

The main study I’ll cover in this research review is entitled, “Efficacy and Safety of Ashwagandha Root Extract in Subclinical Hypothyroid Patients: A Double-Blind, Randomized Placebo-Controlled Trial” published in The Journal of Alternative and Complementary Medicine. We’re already off to a good start just by reading the title which indicates that it is a double-blind, randomized placebo-controlled study so we know it is of the highest standard.

The authors begin by discussing subclinical hypothyroidism which is usually caused by Hashimoto’s thyroiditis. Subclinical hypothyroidism is characterized by a TSH of 4.5-10 with or without the symptoms of hypothyroidism as well as positive thyroid peroxidase (TPO) and antithyroglobulin antibodies. Subclinical hypothyroidism is connected to type 2 diabetes, abnormal cholesterol, atherosclerosis, aortic calcification, impaired vascular function, as well as abnormal heart, muscle, and nerve function.

Interestingly, a full review was done which found that treating patients with prescription thyroid hormone who have a TSH between 4.5 and 10 did not yield any improvements in any of the above risks.

What is Ashwagandha?

Ashwagandha or Withania somnifera is an adaptogen which stabilizes biochemical processes in the body. Scientific studies have found Ashwagandha beneficial for adrenal stress, fatigue, depression, anxiety, inflammation, and it helps to regulate the immune system, improve low blood pressure, and it works as an antioxidant. It has been shown in previous studies to improve T4 and T3 levels in animals. And in a human study on those with bipolar disorder, Ashwagandha improved TSH, T4, and T3 levels. Ashwagandha was even able to reverse hypothyroidism caused by the drug Metformin.

How was this study done on Ashwagandha and Subclinical Hypothyroidism?

This was an 8-week study including 25 subjects taking Ashwagandha at 300mg twice a day and 25 taking the placebo pill. They all had an elevated TSH between 4.5 and 10 but T4 and T3 levels were within the normal range. TSH, T4, and T3 levels were tested at the beginning of the study, at 4 weeks, and at 8 weeks.

What were the study results?

2 subjects from each group dropped out of the study so we finished with 23 people in each group.

T3 levels increased by 18.6% at 4 weeks and 41.5% at 8 weeks.

T4 levels increased by 9.3% at 4 weeks and 19.6% at 8 weeks.

TSH levels decreased (which means they improved) by -12.5% at 4 weeks and -17.4% at 8 weeks.

Only 1 person in the Ashwagandha group experienced side-effects including fever, cough, headache, and weakness but these were reported as mild and temporary.

Author conclusions:

The author’s do state that Ashwagandha normalized thyroid function in subclinical hypothyroid subjects to a significant degree and treatment was safe and tolerable. They do point out the limitations of this study including small sample size and the low duration of the study of only 8 weeks. A better study would include hundreds of subjects monitored for a much longer period of time.

Dr. Hedberg’s Comments

I was impressed to see a discussion in the paper on how stress inhibits thyroid function. When the hypothalamic-pituitary-adrenal axis, or HPA axis, is upregulated, it suppresses the hypothalamic-pituitary-thyroid axis, or HPT axis which inhibits thyroid function. We also know that cortisol inhibits T4 and T3 production so Ashwagandha can help lower excess cortisol levels which will allow thyroid hormone levels to improve. Inflammation will also upregulate the HPA axis and Ashwagandha is an excellent anti-inflammatory agent.

Since this was a double-blind, randomized placebo controlled trial, I don’t have much criticism for the study other than what the author’s already pointed out including the small sample size and short duration.

I would have liked to see the thyroid antibody levels of the participants so we could see if they improved or stayed the same.

I have used Ashwagandha in my practice for the past 15 years with excellent results for Hashimoto’s disease and hypothyroidism as well as many other health issues. I like the Ashwagandha Select product by Moss Nutrition at 1 capsule once or twice a day. Do not take Ashwagnadha without doctor supervision as you may be one of the people who has side effects. Any herbal medicine can cause side effects depending on the individual and their unique genetics and biochemistry.

Should you worry about Ashwagandha and Th1 and Th2 issues in Hashimoto’s disease?

Inevitably, there will be someone who will contact me after reading this that Ashwagandha should not be used in Hashimoto’s disease because it is in the nightshade family and nightshades aren’t on the Autoimmune Paleo Diet. Nightshades eaten in meal-size quantities can certainly cause problems in some individuals with Hashimoto’s disease but the amount of Ashwagandha in a capsule or tincture is so minute that it usually won’t cause issues.

Ashwagandha is actually one of the most preferred herbal medicines in Hashimoto’s disease used by traditional herbalists and Ayruvedic practitioners for centuries. Without going into detailed immunology, Ashwagandha inhibits NF-kappaB which is involved in inflammation and autoimmune disease. You want decreased activation of NF-kappaB if you have an autoimmune disease like Hashimoto’s disease so Ashwagandha is an excellent choice to reduce inflammation and autoimmunity.

However, things are never that simple when it comes to immunology. Ashwagandha is also a prebiotic which can stimulate certain bacteria in certain individuals which will have an effect on the immune system. Also, Ashwagandha acts differently depending on whether it is consumed with fat or without fat.  If Ashwagandha is taken with fat, it stimulates a Th1 immune response.  If taken without fat, it has no effect on Th1.   So it depends on the dose, the state of the individuals microbiome, their diet, and if it is taken with or without fat. This is why you shouldn’t take Ashwagandha if you have Hashimoto’s without doctor supervision.

Ashwagandha is a fantastic herb for many health concerns including subclinical hypothyroidism and Hashimoto’s disease with a few caveats as noted above.

We finally have a study specifically looking at the efficacy of the Autoimmune Protocol Diet, also known as the Autoimmune Paleo Diet or AIP, and Hashimoto’s disease. The exact title of the paper is, “Efficacy of the Autoimmune Protocol Diet as Part of a Multi-disciplinary, Supported Lifestyle Intervention for Hashimoto’s Thyroiditis” by Abbott et al. Published in April of 2019 in the journal Cureus.  I break down the study details below so you can better understand if this diet actually works for Hashimoto's disease.

I have written before about the Autoimmune Paleo Diet but this was on a paper looking at inflammatory bowel disease which did show some promising results.

The authors begin the study by stating some of the potential causes of Hashimoto’s thyroiditis including genetic and environmental factors, pregnancy, drugs, nutritional intake, vitamin D receptor defects and infections. They also state something very important which is the fact that individuals with Hashimoto’s disease who are treated with thyroid medication tend to continue to have a reduced quality of life and chronic symptoms like fatigue, nervousness, dry skin, hair loss, and irritability even though their thyroid numbers look fine.

I also liked the fact that they stated there isn’t enough evidence that goitrogens consumed in moderation negatively impact thyroid function.

How was this study done?

17 subjects between the ages of 20-45 with Hashimoto’s disease began the study but only 16 finished due to one of them getting pregnant. They couldn’t have been following the AIP diet within 30 days of starting the trial and it was ok for them to be taking thyroid medication. Subjects did a 2-week washout period and filled out symptom and food questionnaires.

The following blood tests were done:

TSH

Total and Free T4

Total and Free T3

Reverse T3

Thyroid peroxidase antibodies (TPO)

Anti-thyroglobulin antibodies (TGA)

Complete blood count (CBC)

Complete metabolic profile (CMP)

Vitamin D

Highly-sensitive C-reactive protein (hs-CRP)

And surprisingly they did an organic acids test and a stool analysis. A stool analysis is vital for those with Hashimoto’s disease to identify infections like H. pylori, Blastocystis hominis, and Yersinia enterocolitica. Organic acids gives a detailed view of overall metabolism so we know how well someone is making energy from fat, protein, and carbohydrates as well as detoxification, gut health markers, neurotransmitters, and certain amino acids, vitamins and minerals.

After the two week washout period, the subjects started a 10-week process including:

-Six weeks of food elimination which included gluten, all grains including gluten-free grains, dairy, nuts, legumes, nightshades, eggs, coffee, alcohol, seeds, refined sugars, oils, and food additives.

-More nutrient-dense foods including bone broth, fermented foods, seafood, organ meats, and more mono and polyunsaturated fats.

-Lifestyle modifications including sleep hygiene, support systems, stress management, movement, and more time outdoors.

-A four-week maintenance phase with no food reintroductions.

All participants had the support of health coaches and NTP’s who helped them with menu planning, grocery shopping, recipes, cooking, and lifestyle modification suggestions. Unfortunately, the participants engaged in a private Facebook group despite the fact the Facebook has been shown to cause anxiety and depression.

Once the 10 week intervention was over the subjects repeated all of their lab tests and questionnaires to see how they responded.

Did the Autoimmune Paleo Diet yield good results for Hashimoto’s thyroiditis?

All of the symptoms measured in the questionnaires improved and the symptom burden decreased significantly. None of the thyroid blood tests changed with any significance including TSH, total and free T4, total and free T3, and the thyroid antibodies did not change either. Inflammation did however decrease significantly as measured by the highly-sensitive C-reactive protein test. There was also a shift in the white blood cell count for the better indicating improved immune system function.

The author’s conclude that this dietary and lifestyle intervention is successful in reducing inflammation, improving immune system function, and reducing the symptoms associated with Hashimoto’s thyroiditis.

One interesting thing to note is that 6 of the study participants were able to reduce their thyroid medication. And 3 of these women were able to decrease their dose even further after the full 10-week program.

Author discussion

The authors make a very important point about the community support that each participant received through the online group and coaching support. Following a restrictive diet can be stressful and adherence is low in many people. The participants were set up for success from the beginning due to all of the support they received.

The weaknesses of the study are clear including a lack of a control group, small sample size, lack of blinding, selection bias of the participants, and a response bias of reported weight. The symptom questionnaire they used is not a validated form of symptom tracking. And there was a lack of data on how well the participants were sleeping, physical activity, social support, stress levels, and there was no reintroduction of foods that were eliminated.

Dr. Hedberg’s Comments

This is a great start to studying the potential benefits of diet on Hashimoto’s disease. There are many obvious weaknesses as noted above but the authors had to start somewhere.

We still don’t know if all of the foods in the Autoimmune Paleo Diet need to be eliminated or if the results would be the same just eliminating gluten, dairy, and sugar for example. Some people may do fine with some nuts or some rice or some lentils etc. etc. It will be extremely difficult to ever study this however as large numbers of study participants would have to avoid specific foods for long periods of time and compare them to other groups avoiding different foods.

The study participants knew that they were following the Autoimmune Paleo Diet so they knew they were following a diet that is designed to treat the condition they have. This creates a major problem in the results because we know from the psychoneuroimmunology research that what we believe directly changes our biochemistry.

If you have allergies and you take a sugar pill but are told that the pill is a drug designed to treat allergies, approximately 60-70% of those who take it will see improvement in their allergies. In fact, some patient’s allergies will completely go away when they take it. If you’re told that you’re following a diet to treat this or that condition, you’ll have a similar positive response in most cases. This is why blinding is so important in research so we can remove this bias.

One would expect inflammation to decrease as found in this study by removing gluten and dairy from the diet. Again, we don’t know if all the additional food restrictions are necessary to reduce inflammation and see improvements.

None of the thyroid numbers changed, not even a drop in thyroid antibodies. But after looking in detail at the data, most of the participants had antibody levels <500 so they were clinically insignificant to begin with. Perhaps following the diet for longer periods would show improvement in thyroid numbers.

The biggest variable is the community support and the support of the health coaches, nutrition professionals, and the doctors. We know that people begin to make better food choices when they have community support. Additionally, community and practitioner support can reduce inflammation, improve mood, and improve important neurotransmitters and hormones like oxytocin and serotonin. So we don’t know what would have happened without all of this support or if the study participants did have the support but just followed a healthier diet.

There are so many unknowns but this is a promising start. I applaud the researchers for taking the first step in studying diet and Hashimoto’s disease.

Is there a connection among Hashimoto’s disease, hypothyroidism, and small intestinal bacterial overgrowth also known as SIBO? Does Hashimoto’s disease cause SIBO or does SIBO cause Hashimoto’s? I’ll answer these questions in my latest research review below.

There isn’t a lot of research, only two papers actually, on the specific connection between Hashimoto’s disease and SIBO which I’ll cover in this article. There are more papers on the connection between hypothyroidism and SIBO without mention of Hashimoto’s and the basic conclusion of those papers is that hypothyroidism is connected to SIBO because gastric motility is decreased in hypothyroidism. Decreased gastric motility basically means the food you eat is moving through the bowels to slowly so bacteria can build-up in the small intestine.

The first paper is entitled, “Association between Hypothyroidism and Small Intestinal Bacterial Overgrowth” published in the Journal of Clinical Endocrinology and Metabolism.

The authors begin by giving an overview of SIBO which is basically an overgrowth of bacteria in the small intestine which damages the gut wall leading to malabsorption of nutrients. The main signs and symptoms of SIBO are bloating, abdominal pain, cramping, gas, weight loss, and diarrhea or constipation or actually a mix of the two.

The main causes of SIBO are hypothyroidism, proton pump inhibitors and antacids, Helicobacter pylori, autoimmune disease, malnutrition, and immune dysfunction. Anything that can decrease gut motility may lead to SIBO such as gut surgeries, inflammation, metabolic issues, endocrine diseases, and muscle and nerve illnesses.

We know that thyroid hormones, especially T3, are involved with proper movement of food through the intestines known as peristalsis. Those with hyperthyroidism tend to have diarrhea and those with hypothyroidism tend to be constipated due to too much or too little thyroid hormone.

The authors wanted to answer three questions:

1. Is hypothyroidism associated with the development of SIBO?

2. How does treatment of SIBO affect those with hypothyroidism?

3. Does SIBO affect thyroid hormone levels?

How was this study on Hashimoto's Disease and SIBO done?

50 patients with hypothyroidism due to Hashimoto’s disease were enrolled. TSH, Free T4, Free T3, thyroid peroxidase (TPO), and antithyroglobulin antibody were tested. Hypothyroidism was considered a TSH above 2.8 and low Free T4 and Free T3 which was quite promising because most studies use a higher cut-off point for TSH. Thyroid antibody levels were elevated and thyroid ultrasounds were done showing tissue changes in the thyroid gland which is a normal sign in Hashimoto’s disease.

These patients were supplemented with synthetic T4 which normalized their thyroid function in 2-6 months before beginning the study. The good news is that we did have a control group of 40 healthy volunteers which strengthens the validity of the study.

A glucose breath test was done on everyone to measure hydrogen levels which is a gas produced by bacteria in the gut. Every patient who tested positive for SIBO was then treated with the antibiotic Rifaximin for 7 days. A glucose breath test was then repeated one month after the antibiotic treatment to see if the SIBO was eradicated.

Thyroid hormone levels were tested prior to beginning the study and one month after antibiotic treatment and then one month after the initial evaluation in those who didn’t have SIBO.

Patients were asked to fill out a symptom questionnaire before and after treatment including abdominal pain, bloating, gas, constipation, or diarrhea.

What were the study results?

27 patients or 54% of the study group tested positive for SIBO compared to only two in the control group which was statistically significant.

No significant association was found between the presence of SIBO and age of hypothyroidism diagnosis, time from diagnosis, or average T4 daily dose.

Abdominal discomfort, gas, and bloating were the most common symptoms in those with SIBO. There was no significance however related to constipation or diarrhea.

19 of the 27 patients (70.4%) who were treated with antibiotics for SIBO tested negative for SIBO. These 19 patients reported significant improvement in their abdominal discomfort, bloating, and gas. There were no changes in constipation and diarrhea however. None of the symptoms improved in the 8 patients who were unsuccessfully treated for SIBO with antibiotics.

The daily dose of T4 was similar among all patients regardless of how they responded to antibiotic therapy for SIBO. Thyroid hormone levels were similar to those who tested negative for SIBO.

Author discussion

The authors do conclude that hypothyroidism due to Hashimoto’s disease is a risk factor for SIBO development. Their hypothesis is that insufficient thyroid hormone levels leads to decreased gut motility thus leading to insufficient clearance of bacteria from the small intestine.

The patients with SIBO did not require extra thyroid hormone indicating that any malabsorption caused by SIBO did not affect T4 dosing. Those who were treated successfully did not show changes in any of their thyroid hormones.

We weren’t given thyroid peroxidase and antithyroglobulin antibody levels before and after SIBO treatment which would have been interesting to see.

Studies on hypothyroidism and SIBO

As noted above, I’m not going to go into detailed reviews of the papers on hypothyroidism and small intestinal bacterial overgrowth because they don’t discuss Hashimoto’s disease and the conclusions are all the same that there is a connection between the two due to decreased gastric motility. Thyroid hormone drives the movement of food through the gut so low levels lead to constipation and SIBO.

Here are the studies in case you want more detailed information:

Link between hypothyroidism and small intestinal bacterial overgrowth

The Interdigestive Motor Complex of Normal Subjects and Patients with Bacterial Overgrowth of the Small Intestine (This study showed that decreased gut motility leads to bacterial overgrowth).

This study found that more than half of patients with hypothyroidism have SIBO.

And this study also found a direct connection with hypothyroidism and SIBO but also interestingly found that the thyroid medication levothyroxine was also connected to SIBO. This tells us that taking thyroid medication for hypothyroidism does not appear to correct SIBO but also those who take levothyroxine have higher rates of SIBO.

The second paper I’d like to cover was only published in Polish so I was unable to read the entire paper. However, the abstract was available in English so I just had to go on what was available. If you know anyone who can translate Polish to English please let me know. Here is the abstract breakdown which I have edited to make it easier to read:

Article title: [Thyroid dysfunction in patients with small intestinal bacterial overgrowth]

Authors: Konrad P1, Chojnacki J1, Kaczka A1, Pawłowicz M2, Rudnicki C2, Chojnacki C.1

Article summary:

“Small intestinal bacterial overgrowth (SIBO), similarly as thyroid diseases, is characterized by chronic diarrhea or constipation, but it is not known whether there is a causal relationship between these disorders. The aim of the study was to assess thyroid function indices in different clinical forms of SIBO.

Material and methods:

The study was performed in 34 patients with diarrhea predominant SIBO (group I), 30 with constipation predominant SIBO (group II) and 30 clinically healthy subjects. Small intestinal bacterial overgrowth was assessed with lactulose hydrogen breath test (LHBT). Serum thyrotropin (TSH), free triiodothyronine (FT3) and free thyroxine (FT4) levels were determined and anti-thyroid peroxidase (ATPO) antibody level.

Results:

I’ve put the results into a table for easier access:

Group 1 SIBO-Diarrhea

Group 2 SIBO-Constipation

Control Group

TSH

2.5 +/- 0.7

3.8 +/- 1.8

2.5 +/- 0.7

Free T4

1.10 +/- 0.19

0.73

1.10 +/- 0.19

Free T3

3.3 +/- 0.8

2.4 +/- 0.65

3.3 +/- 0.8

TPO Antibody

39.9 +/- 23.4

94.1 +/- 56.3

6.3 +/- 3.1

Author Conclusions:

Thyroid function may be impaired in patients with small intestinal bacterial overgrowth which should be taken into account in the diagnostic and therapeutic management of the diseases of these organs.”

Dr. Hedberg’s Comments:

So as you can see, and the author’s do point out, that the TPO antibody levels are statistically significant compared to the healthy control group. Those levels aren’t exactly clinically significant however since they are well below the 500 mark.

I’m not surprised to see the constipation dominant SIBO group to have higher TPO antibody levels since constipation dominant SIBO is much more difficult to treat than diarrhea dominant SIBO. You’ll also notice that the constipation dominant SIBO group appears to be more hypothyroid than the diarrhea dominant SIBO group as seen by a higher TSH and lower Free T4 and Free T3 levels.

So as you can see, we have some decent studies up to this point that connect Hashimoto’s disease and hypothyroidism to SIBO. You can get SIBO first and then develop Hashimoto’s disease or hypothyroidism and you can get Hashimoto’s disease and hypothyroidism first and then develop SIBO. One can definitely cause the other in both possibilities.

If you have either SIBO or Hashimoto’s disease or both then it’s important to work with a functional medicine practitioner who has a deep understanding of both of these conditions. If you have both then they both must be treated at the same time to have success healing both conditions.

If you’ve been struggling to heal your Hashimoto’s disease or SIBO then perhaps you need a thorough evaluation of both possibilities which may be the missing link to getting well.