The Functional Medicine Approach To Hypothyroidism And Hashimoto’s Disease - Transcript

Dr. George Papanicolaou: There's a strong connection between Hashimoto's and gluten, that a large number of patients that have Hashi's also have genes that make them more predisposed to gluten sensitivity and celiac disease. Dr. Mark Hyman: Welcome to The Doctor's Farmacy. I'm Dr. Mark Hyman, and that's farmacy with an F, F-A R-M-A-C-Y, a place for conversations that matter. If you've struggled with low thyroid, which, by the way, affects one in five women and one in 10 men, this conversation is going to matter to you. And we're lucky to have my colleague, my friend, Dr. George Papanicolaou, from the UltraWellness Center here in Lenox, Massachusetts, to talk about this very common and often very poorly treated condition. Welcome. Dr. George Papanicolaou: Well, Mark, thanks for having me. It's always a pleasure. Dr. Mark Hyman: Okay. So let's get into it. We're going to talk today about a very specific kind of thyroid dysfunction, which is probably the most common type of thyroid dysfunction, called Hashimoto's thyroiditis. Now, that is an autoimmune disease that gets treated in a way that really isn't that great for most of the people, because they don't feel that great, even if they're treated by the traditional endocrinologist. Dr. George Papanicolaou: No. Dr. Mark Hyman: First, what is Hashimoto's? It sounds like some kind of Japanese dish. And what is the consequences of that for people who have it, and how do we approach it? Dr. George Papanicolaou: Yeah. So as you said, it affects a vast number of people in our country. 27 million Americans have thyroid dysfunction, and 12% more are likely to get it every year. Hashimoto's is the most common cause of that dysfunction, particularly hypothyroidism. And Hashimoto's is an autoimmune process. What is autoimmunity? It's when your body's immune system starts making antibodies against your own tissue, and in this particular case, it's the thyroid. Dr. Mark Hyman: This is the most common autoimmune disease in America, right? Dr. George Papanicolaou: It is. It is. It is the most common. Dr. Mark Hyman: And we don't really treat it as an autoimmune disease. Dr. George Papanicolaou: No, we treat it as hypothyroidism. Dr. Mark Hyman: Right. Dr. George Papanicolaou: And there are probably many women... And we speak mostly about women because they make up a large number of the patients we see with Hashimoto's, and a large number of these women do not feel better when they're treated. They get diagnosed with hypothyroidism without ever being tested for Hashimoto's, and the reason being is, I think, the big disconnect in conventional medicine, and that is that it's seen as a thyroid condition, and it's really an autoimmune condition that affects the thyroid. Dr. Mark Hyman: Yeah. Dr. George Papanicolaou: In that setting, with that mindset and that paradigm, the thought is, well, it doesn't really matter where the hypothyroidism comes from because the belief is is that there's nothing to impact that immune response against the thyroid. In conventional medicine, you just sort of let that immune response continue flaming until the thyroid is burned out. And then the person is on whatever dose of thyroid medication will get their thyroid number, their TSH, into the normal range. And that's considered good medicine. One problem, one problem- Dr. Mark Hyman: What is that? Dr. George Papanicolaou: There's a lot of women running around with a normal TSH that still feel like crap. Dr. Mark Hyman: That's right. That's right. So a lot of people who- Dr. George Papanicolaou: So there's something going on. Dr. Mark Hyman: ... are diagnosed... And by the way, half of people with low thyroid are not diagnosed. Dr. George Papanicolaou: Oh, yeah. Dr. Mark Hyman: Okay. So that's a problem in and of itself. And if you're talking about 20% of women, it's a lot of people. Dr. George Papanicolaou: Oh, yeah. Dr. Mark Hyman: And 10% of men, it's a lot of people. That's one problem. The second problem is, like you said, we treat it by just giving people thyroid replacement without actually dealing with the root cause of why their thyroid isn't working in the first place. And it's like the same way we treat all other autoimmune disease, which is we say, "Oh, there's inflammation. Let's give you an anti-inflammatory drug," right, whether it's Advil or steroids or chemotherapy drugs or immune suppressants that are super powerful. They can cause cancer and overwhelming infection and death in many people. We don't go, "What's the cause of the inflammation?" So George, with Hashimoto's, which is again so common, what causes the autoimmune disease in hypothyroidism, in this particular kind of autoimmune disease? Dr. George Papanicolaou: There's no clear understanding of the exact mechanisms that cause the immune system to go awry. There are some theories, and there are some associated conditions. One of the strong thoughts is that again... I should go back. I want to get this in a more clear model. Autoimmune diseases tend to cluster. If you have one, you're much more likely to have another. The reason why Hashi's is most prevalent is that there's a strong connection between Hashimoto's and gluten, that a large number of patients that have Hashi's also have genes that make them more predisposed to gluten sensitivity and celiac disease. Gluten, therefore, is seen as a pretty strong trigger to Hashimoto's. Now, I would say, if you're thinking about what's the one thing that you can do if you think you have Hashi's, go gluten free. Dr. Mark Hyman: Or check your antibodies. Dr. George Papanicolaou: Right. Or check your antibodies. Dr. Mark Hyman: Now, I've checked antibodies for years on these patients because I think this is a pretty well-established phenomenon in the literature. It's not like- Dr. George Papanicolaou: No. Dr. Mark Hyman: You can go on PubMed, which is the national library of medicine, and look it up, Hashimoto's, gluten, and you'll come up with plenty of articles. And yet, your traditional endocrinologists don't even look at it. And I check antibodies on every patient with hypothyroidism, with Hashimoto's, and about 30% of the people have some level of antibodies. They might not have celiac, but they have some level. So tell us why is gluten so connected to autoimmune disease? Dr. George Papanicolaou: Gluten is very similar... So what gluten can do is it can trigger something called leaky gut. But in most cases, I would say that a person who develops a thyroid disorder, particularly Hashimoto's, probably already has a disordered gut, probably already is experiencing some amount of dysbiosis or imbalance in their gut microbiome. They're, therefore, experiencing some level of inflammation in their gut. And if you have that inflammation, then you're already going to be disturbing the permeable membrane that's responsible... It's the gatekeeping system for nutrients to go in and for toxins and for the bad guys to be kept out. That's probably already disrupted. Dr. George Papanicolaou: Gluten, which is very prevalent in our processed foods, does one more thing. It triggers something called zonulin, which is the gatekeeper. Zonulin is the compound that's responsible for opening and closing the gates that allow good nutrients and compounds to enter in and then closes to make sure we keep out bacteria, viruses, and toxins. Dr. Mark Hyman: That's right. And I think when you start to create a leaky gut with the gluten, it creates inflammation throughout the body, and it can attack different organs. Some people can get rheumatoid arthritis. Some of them get psoriasis. Some people get Hashimoto's thyroiditis. Dr. George Papanicolaou: Because when gluten enters in, there's the leaky gut. Now the immune system sees it as a foreigner, and it begins making antibodies against it. Unfortunately, those antibodies are also made against the thyroid because the gluten structure is very similar to the thyroid. So you get this sort of molecular mimicry that causes the immune system to become confused, and now it's making antibodies against your thyroid. Dr. Mark Hyman: And studies have shown that people with Hashimoto's, when they cut out gluten, their thyroid antibodies come down. Their autoimmunity gets less. Dr. George Papanicolaou: Absolutely. And I would also... In regards to the testing and looking particularly at something called thyroid peroxidase antibody, because that's the antibody that's made. It's made against this enzyme that the thyroid makes that's responsible for making thyroid hormone. It can also make an antibody against thyroglobulin, which is another compound that the thyroid makes that is also responsible for making thyroid hormone. When you test them, if it's positive, that's great. But it's also possible that you'll get false negatives and that commonly... If I really think a person has Hashi's, they're displaying all the signs and symptoms, then I will retest them, and I might even do it after a gluten challenge. If the patient has been gluten free, I will do that just to make sure we confirm the diagnosis. Dr. Mark Hyman: Yeah. So it's really important to think about all the factors that cause autoimmunity, because it could be gluten. That's the most common. But in functional medicine, we don't just look at one thing. We look at all the triggers, and there's a lot. There's a lot of things that cause inflammation and autoimmunity. So can you take us down the road of what are some of the other big ones? Dr. George Papanicolaou: Well, I would say this. This is a more complicated one to bring up, but pregnancy. So a lot of the patients that come to me with thyroid dysfunction come after pregnancy, or they come years after pregnancy, and they say, "It was after I delivered my first child. It was eight months later that I developed Hashimoto's thyroiditis." Now, there are different thyroiditides that you can develop, but Hashi's can occur after pregnancy. And it is. The mechanisms that are there are largely immune dysfunction. They're related to immune dysfunction. Dr. George Papanicolaou: There's large spikes and drops in estrogen. That's been linked to the triggering of the immune dysfunction that leads to Hashi's. There's also this idea that when a woman has a child in utero, you have to suppress your immune system. And after the baby is born, you get immune rebound, and this results in a dysfunction or imbalance in an appropriate immune response, and you develop antibodies against the thyroid. Dr. Mark Hyman: Now, I'm going to say, there's also other things that we're learning about, and the thyroid is sort of like the canary in the coal mine. Dr. George Papanicolaou: Right. Dr. Mark Hyman: It's one of the most sensitive organs. It's a gland that regulates our metabolism and our mood and our sexual function and our weight and our muscle mass and skin health and hair health. I mean, there's so much... We'll go over some of the symptoms that people can have, but- Dr. George Papanicolaou: Triggered by mercury and toxins, heavy metals, so we can't ignore those. Dr. Mark Hyman: Exactly. So what's happening is that there's this incredible flood of environmental chemicals that we've been exposed to, that our toxic load is so high. And mercury and heavy metals and many others interfere with thyroid function, and they're known as autogens, like antigens, but they're autogens. They cause autoimmune disease, and these environmental toxins have really been well-documented to do this. And yet most doctors who are endocrinologists will not check for your level of toxic load or a level of mercury, and they don't treat that. And that's what we do in functional medicine. We look for some of these underlying causes. Dr. George Papanicolaou: Absolutely. Dr. Mark Hyman: So it can be gluten. It can be leaky gut. It can be the environmental toxins. It can be heavy metals. It can be other- Dr. George Papanicolaou: It can be viruses. Dr. Mark Hyman: Viruses, blatant infection. Dr. George Papanicolaou: It can be reactivated viruses. It can be stress related. Stress has a huge impact on all of the endothelial linings, particularly the gut and the brain, and can cause leaking of the gut and brain, which will then trigger an autoimmune condition. Dr. Mark Hyman: Exactly. And so the question is, from a functional medicine perspective, we don't just say, "Oh, you have low thyroid. Take thyroid." We go, "What is happening in terms of the causes? And then how do we address those directly, whether it's gluten or heavy metals or whatever? And then how do we help the thyroid work better?" And in traditional medicine, once you have thyroid issues, we don't bother trying to think about reversing it or stopping it. And particularly if you get it early, you can actually reverse and get the antibodies down. Dr. George Papanicolaou: Yeah. And I think it's really important... And what I said earlier is that hypothyroidism, particularly Hashimoto's thyroiditis, is a thyroid... It's a body problem. It's a systemic problem that affects the thyroid. And that's how I approach it when somebody comes to me, because even if I get their antibodies down, that will have an impact. That will actually allow their thyroid to function better, because now it's not under this assault, under this attack. But there are other organ systems that impact the thyroid. So when you have a woman that comes in and she's got three kids and she has lots of stress when she's having hormonal imbalances, you're now talking about the adrenal gland being involved and the cortisol being involved. You're talking about estrogen and progesterone balance. You're talking about high levels of testosterone if that woman tends to have PCOS. Dr. Mark Hyman: That's polycystic ovarian syndrome, right? Dr. George Papanicolaou: Right. And if we don't address those along with the thyroid, they're never going to feel better. Dr. Mark Hyman: It's sort of a comprehensive approach. Dr. George Papanicolaou: Absolutely. Dr. Mark Hyman: It's a comprehensive approach. And we don't look at all the factors. We don't look at other hormones, like sex hormones, adrenal hormones. I mean, if your adrenals are shot from chronic stress, your thyroid is not going to work properly. And if you take too much thyroid or the right amount of thyroid, your body might feel like you had too much because your adrenals can't keep up and aren't working. So you have to deal with all of it. You have to deal with the gut. You have to deal with a leaky gut. You have to deal with nutrition. I mean, there are some key nutritional deficiencies that are linked to low thyroid function. Can you go through what those are? Dr. George Papanicolaou: Well, one of the... It's interesting. The first thing that people will think of is iodine, but iodine isn't necessarily the problem. I just wanted to bring that one up right away because iodine can be somewhat controversial. There actually have been studies in China that showed that people with lower iodine or deficient iodine levels actually have less thyroid disease and Hashimoto's than those that have higher iodine levels. But other ones that would be involved would be vitamin D. Vitamin D plays an important role in thyroid function. Selenium plays a very important role in thyroid function, as does zinc and magnesium. Dr. Mark Hyman: Absolutely. And selenium is, for example, necessary to convert T4 to T3, which is the active hormone. And we need, for example, vitamin D to help bind the thyroid hormone at the nucleus to have the effect on gene transcription. So these are all critical steps. So iodine, zinc, selenium, omega-3 fats, vitamin D. Dr. George Papanicolaou: And when I test patients, I will routinely test them for selenium levels and vitamin D levels. And I can tell you that eight out of 10 women are deficient in vitamin D and low in selenium, and that definitely becomes part of the equation. I would say that, for our listeners, that if you're a woman or a man who is being treated for hypothyroidism and has never felt well under thyroid medication despite getting their TSH level into the normal range... Now, for some doctors, they may still be going by the archaic value of 0.45 to 4.5 and not the functional value of 1.5 to 2.5. So you might not even be looked at in the right range. If you're one of those people, then this is the conversation, because there's so much more to be looked at. There's targeted nutrients that you've just mentioned. Dr. Mark Hyman: I mean, selenium can drop your thyroid antibody levels- Dr. George Papanicolaou: Yes, absolutely. Dr. Mark Hyman: ... just like getting off of gluten and reduce the autoimmunity. Dr. George Papanicolaou: Yeah. Dr. Mark Hyman: So these are all important things. And there are foods that contain these things. So there's thyroid-boosting foods, right? We have selenium, which is in fish and Brazil nuts. You have zinc, which is in pumpkin seeds and oysters. You have omega-3 fats, which are in fatty fish. You have vitamin D. Well, you can have that in herring and porcini mushrooms, although you probably need to get sun or vitamin D to get enough. Iodine can be from eating fish and seaweed. So there's a lot of ways to get these nutrients to help regulate our thyroid. And most of us are insufficient or deficient in these at some level. Dr. George Papanicolaou: Yeah, yeah. Dr. Mark Hyman: Hey, everybody, it's Dr. Hyman. Thanks for tuning into The Doctor's Farmacy. I hope you're loving this podcast. It's one of my favorite things to do and introduce you to all the experts that I know and I love and that I've learned so much from. And I want to tell you about something else I'm doing, which is called Mark's Picks. It's my weekly newsletter. And in it, I share my favorite stuff, from foods to supplements, to gadgets, to tools to enhance your health. It's all the cool stuff that I use and that my team uses to optimize and enhance our health. And I'd love you to sign up for the weekly newsletter. I'll only send it to you once a week on Fridays. Nothing else, I promise. All you have to do is go to to sign up. That's, P-I-C-K-S. Sign up for the newsletter, and I'll share with you my favorite stuff that I use to enhance my health and get healthier and better and live younger longer. Now, back to this week's episode. Dr. George Papanicolaou: So, paying attention to your diet is very important. And again, it tends that when I have patients that are struggling with thyroid, they're also struggling with their nutrition, and they'll tend to have diets that are higher in carbohydrate, higher in processed foods, higher in sugars. They'll have carb cravings, again, because it's related to the host of systemic issues around the adrenal, around gut function, and around carbohydrate metabolism and insulin resistance that can occur. Dr. Mark Hyman: Okay. That all makes tremendous sense. And then the question for people listening is probably, "Well, how do I know if I have low thyroid function? What are the symptoms? And then what are the tests that I should get to diagnose it? And is my doctor going to do the right ones, or do I need to go to a functional medicine doctor to figure it out?" Dr. George Papanicolaou: Yeah. So the common symptoms are going to be you're going to feel fatigued. You can have potentially weight gain. You're going to have harder bowel movements, maybe constipation. Dr. Mark Hyman: Constipation. Dr. George Papanicolaou: You're going to have... Potentially, you're going to be depressed. You may have apathy. You're going to experience potential hair loss. Your eyebrows will get thinner at the ends of the eyebrow. You may notice that your nails get a bit harder. Your skin gets drier. Those are some of the common symptoms. Dr. Mark Hyman: They've got skin dry, cracked nails, fluid retention, muscle cramps- Dr. George Papanicolaou: Oh, headaches. Dr. Mark Hyman: Sex drive, depression, memory loss. Dr. George Papanicolaou: Yeah, headaches in the morning that go away. Dr. Mark Hyman: Fatigue in the morning is a big one. Dr. George Papanicolaou: Brain fog. Yeah. Dr. Mark Hyman: If you can't get going in the morning, that's a big one. Dr. George Papanicolaou: Yeah. Dr. Mark Hyman: So all these weird, vague symptoms, and you think, "Oh, this is just like normal aging, or I'm just working too hard." These are just little things that don't seem like life-threatening problems, but they are because we know that people with untreated, even subclinical hypothyroidism, just mild hypothyroidism, have a far higher risk of heart attacks and other serious consequences. Dr. George Papanicolaou: And in the case of Hashi's, it should also be noted that when you first develop Hashimoto's, your thyroid is under attack. And one of the first things it does, it starts releasing an abundance of thyroid hormone. So your initial symptoms of Hashimoto's- Dr. Mark Hyman: It could be hyper. Dr. George Papanicolaou: ... may be like hyperthyroidism. And then as your disease progresses, even if you're being treated, and probably because you're being treated inappropriately, you're going to experience cycles of hypothyroidism and hyperthyroidism, hypo and hyper, because it will... If you're not paying attention to your diet and you continue eating gluten and other inflammatory foods, that's going to invariably trigger your immune system so that you'll have... You'll trigger your immune system because you've had beer and pizza. And then now you go on a good diet. I had a bad weekend, and I'm going to eat well. And then you find over the next couple of weeks while you're avoiding gluten, you're avoiding other inflammatory foods, that you feel better. So there's cyclical behaviors that happen. And I only bring that up because hyperthyroidism and those symptoms can be part of what you experience in Hashi's at the onset and also throughout the treatment if we don't address these other issues. Dr. Mark Hyman: So you can go to the doctor with these symptoms, and what are the tests they're going to do? What's the first test they're going to do? Dr. George Papanicolaou: If you can get them to test your thyroid, right, they're going to check your TSH, which is your thyroid stimulating hormone. That's released by the pituitary gland to tell the thyroid to make more thyroid hormone. And if you have low thyroid, then you're going to have a very high level of TSH. Dr. Mark Hyman: That's right. So they just check TSH or thyroid stimulating hormone, which is a hormone that comes from your pituitary gland, communicates with your thyroid gland to make hormone. And if your thyroid gland is not working, that's going to create more TSH to try to pump more thyroid out. But we're learning that even what we thought were, quote, "normal" levels are not optimal. Dr. George Papanicolaou: No. Dr. Mark Hyman: That even when we thought... If you look at the reference range and it's 5.0, and if they were 5.0, they might say, "Oh, you maybe have a little bit of thyroid issues." Well, we know from the American College of Endocrinology that the reference range should be maybe 3.0 or 3.5. And I would probably say it should be 1.0, 1.0 or 2.0 at the most. Even over 2.0, I don't like to see. And then they don't check all the other tests that actually are important. And there are so many other ways that you have to look at the thyroid to understand its true function and what you're dealing with. So what are the other tests we would do at the Center for Functional... I mean, at the- Dr. George Papanicolaou: We would check for a free T3, which is your free thyroid, T3, your free- Dr. Mark Hyman: That's the active hormone. Dr. George Papanicolaou: It's active. So when your thyroid makes thyroid hormone, it makes two. It makes T4, and it makes T3. T4 is not the active form. It's T3. T4 goes to your body, and it's converted in the liver, in the muscles, in the intestine, in the heart to T3. T3 is the active form. And that is then going to enter the cells and have its result, its important impact in cellular metabolism. So we check for free T4, free T3, and something called reverse T3. Reverse T3 is an active T3, and it acts as a- Dr. Mark Hyman: Like a brake on the car. Dr. George Papanicolaou: It's a braking system. And basically, when you, for any reason, you have too much T3, T4 will get converted to reverse T3. And reverse T3 is sort of this inert T3 that won't have any impact. And that sort of is a braking system. And reverse T3 is also a marker for inflammation. It can be elevated when people have significant inflammation. Dr. Mark Hyman: Inflammation or chronic illness. Right. And it can block your thyroid, and so you can look like you have normal levels, but actually you're really functionally hypothyroid, even though your other levels may be normal. Dr. George Papanicolaou: Exactly. Dr. Mark Hyman: And that's something very rarely checked. And then there are antibody levels that we check. Dr. George Papanicolaou: Right. So we check the thyroid peroxidase antibody, and that's the main antibody that we check. It's probably the most sensitive for diagnosing Hashimoto's. Dr. Mark Hyman: Yeah. So we check the thyroid antibodies, like thyroid peroxidase, anti-thyroglobulin antibodies. And what I've learned over the years is people can have completely normal TSH, a normal T3, a normal T4, and they can have sky high antibodies. Dr. George Papanicolaou: Absolutely. Dr. Mark Hyman: And most traditional doctors, one, never even bother getting there because unless the TSH is elevated, they don't look. And second is if you have elevated antibodies, it means there's an autoimmune process going on, and you'd better get on it before it gets too far. And often these patients feel much better when they get on thyroid replacement once they start having antibodies. But there's a lot of efforts that people are doing and that we... I mean, there are a lot of efforts that people are doing to try to reverse Hashimoto's, and often very successfully in bringing the antibodies down, using a more functional medicine approach with diet, lifestyle, the right supplementation and detoxification, hormonal balance, and all the things we're talking about. Dr. George Papanicolaou: Right. Dr. Mark Hyman: I mean, it's not always that easy, but it's possible. And I think if you get on it early, it's much easier before your thyroid's burned out. So you also want to look at other things, right? You want to look at other tests that reflect your nutritional status because if your- Dr. George Papanicolaou: Oh, yeah. Dr. Mark Hyman: Right? So what are the kinds of things we'd measure to see if people are getting the right thyroid nutrients? Dr. George Papanicolaou: Yeah. So we measure a lot of... We always look at nutritional deficiencies. But specific to the thyroid, we want to look at iodine levels. Sometimes we'll do a spot iodine. A 24-hour urine iodine is usually the best. Then we'll also look at selenium levels. We'll look at zinc and magnesium levels. Those are the major... And vitamin D. Those are the major nutrients that I will look for when I'm trying to assess whether somebody has the nutrients they need for their thyroid to function. Dr. Mark Hyman: Yeah. It's super important because you want to optimize nutrition, and you want to make sure you're not doing certain foods that might be a problem. One of the things I've found is that everybody's into these green juices. And they'll think they're great, but if you're juicing a lot of raw kale, kale has these goitrogens in them that basically can block thyroid function. So kale is great, but cooking cruciferous vegetables is good. You don't want to have too much of the raw stuff. Dr. George Papanicolaou: Yeah. Dr. Mark Hyman: There was a woman, apparently you heard, that these cruciferous vegetables were good for her, and she decided to eat two pounds of raw bok choy every day, which is a cruciferous vegetable. It's a Chinese vegetable. And she put herself in a hypothyroid coma after eating two pounds of raw bok choy a day. So be careful of a lot of those green juices. Soy can also be a goitrogen. So you want to be careful if you're eating a ton of soy. But it's really not in the normal amounts you'd eat in your normal diet. Dr. George Papanicolaou: Yeah. Dr. Mark Hyman: So it's okay. Don't be freaked out about it, but it's really just don't be juicing kale all day long. So this is really a common issue. It causes a lot of suffering. It's not diagnosed in half the people. If it is diagnosed, it's poorly treated in probably half the people, and even their levels may not be normal because the doctor might not check T3. They might not do all the full profile of testing to see what's going on. And when you see someone with Hashimoto's, rather than just slapping them on Synthroid, which is the typical prescription, what is our approach overall to dealing with this autoimmune condition? And what are the kinds of things we do from a dietary and lifestyle point of view, and how do we then do the right supplementation? And then if we need thyroid medication, what do we do? Dr. George Papanicolaou: So to get all that information, I will do some of the tests that we talked about earlier, looking for some of those nutrients, but I also do additional testing. As we talked about earlier, we look for leaky gut. We look for dysbiosis in the gut. We look for potential sources of that inflammation that we were talking about or potential sources for autoimmunity in the gut that we had talked about earlier. Dr. George Papanicolaou: We'll also do hormone testing because the balance of hormones is very critical for most of the patients that I'm dealing with. So we'll do some advanced hormone testing. We'll also look... And that hormone testing will include adrenal function. And it will include a four-point salivary cortisol test, so we can know what your cortisol is doing all day long. Dr. George Papanicolaou: I commonly find in my patients that are coming to me with difficulties treating their thyroid, with known Hashimoto's or not known Hashimoto's, that it's just never the thyroid. It's always going to involve the gut. It's always involving the adrenals. So we'll do that advanced adrenal testing. And we'll also look to make sure that their hormones are balanced, so we'll do advanced hormonal balance. Dr. Mark Hyman: So you do the testing, but once you want to start on the treatment with a diet and lifestyle, what do you do with them? Dr. George Papanicolaou: So immediately, I definitely will talk to patients about going gluten free if they're not already gluten free. I want them to be dairy free because casein can also trigger an immune response in some patients as well. Those are going to be critical pieces. Dr. George Papanicolaou: Then we really want to work on reducing inflammation, so there's some basic things. Like, omega-3 fatty acids are very important in reducing inflammation, so we want to make sure that we're doing that to reduce inflammation. I want to really support their detoxification because that detoxification is really important for getting rid of any excess thyroid hormone that's being built up, because your detoxification system is impacted by your hypothyroidism. Your thyroid does play a role in helping your liver detoxify, get rid of all the toxins that are building up that you're making and that you're also taking in every day. Dr. George Papanicolaou: So I want to support detoxification, and I will do that with N-acetylcysteine, which is a precursor to glutathione. I'll do it with high doses of vitamin D. I'll also do it with glutathione itself. And when I use glutathione, I'll typically use it liposomally or as a cream, because it's best absorbed that way. So those are some of the things I will do. Dr. Mark Hyman: I think of replacing those minerals, like giving them zinc and selenium, doing it as a multivitamin. Dr. George Papanicolaou: Oh, yeah. Dr. Mark Hyman: Giving them fish oil, giving them vitamin D. Just the basic stuff makes such a difference for people. Dr. George Papanicolaou: Huge. Dr. Mark Hyman: Yeah. And then you can get fancy with some of the other stuff. But I think that getting people on this elimination diet, an anti-inflammatory diet, and some of these [crosstalk 00:30:05]. Dr. George Papanicolaou: One of the things that is... And when you say elimination diet, is definitely removing gluten, dairy, corn, soy, egg, yeast, and sometimes even legumes. When we put the patient on that diet, typically within six to eight weeks, they're already feeling better, particularly if we've added some of those other nutrients we know support the thyroid. Dr. Mark Hyman: That's right. So really we need a more comprehensive approach. Dr. George Papanicolaou: Absolutely. Dr. Mark Hyman: Absolutely. Years ago, I saw so much thyroid issues in my practice, and I saw how poorly it was handled. And I saw how many people were suffering and how many people weren't diagnosed. And they didn't get the right test. They didn't know what to eat. They didn't have the right supplements. So I actually created this thing called the Ultra Thyroid Solution, which is an online eBook that you can order. You can just Google Ultra Thyroid Solution. And it provides really a roadmap for how do you know what right test to do? How do you know what the symptoms are? How do you know which foods to eat, which nutrients to take? If you need thyroid hormone replacement, what should you take? Do you need just Synthroid, or should you be taking a combination? Do you need pig thyroid or free T3 or free T4? What are you doing with the thyroid replacement? There's a bit of a nuance there. Dr. George Papanicolaou: Yeah. There's a lot. There's so much that we can really... a lot of important offshoots to this conversation. Balancing. I think one of the things that I also focus on is balancing that immune system. So, I mentioned the high-dose vitamin D. That is really important for balancing the immune system, along with the glutathione and getting your gut healthy and under control. So I really think going back to getting that immune balance is really important. Dr. George Papanicolaou: And one of the tests that I do is something called a DIO3, which looks at a gene that is responsible for making the enzyme that converts T3 to T4. Some people have a gene that doesn't work. And if you can't convert T3 to T4, then traditional T4 therapy, which is the first line of therapy for hypothyroidism, isn't going to work for you. Dr. Mark Hyman: That's right. Dr. George Papanicolaou: So that's another test that we do, and it's readily available. Dr. Mark Hyman: So it's very nuanced. It's very personalized. It's very specific, and everybody's different. Dr. George Papanicolaou: Absolutely. Dr. Mark Hyman: It's not just one. "Everybody gets Synthroid. That's it. Goodbye. We'll see you later. And if you don't feel better, I don't know why." Dr. George Papanicolaou: And that's exactly the message I get from my patients that come to me with thyroid disorder and Hashimoto's, is that they've been told, "You're fine. Your numbers are normal. Everything's okay." And everything's not okay. Dr. Mark Hyman: That's right. I mean, if you are diagnosed with low thyroid function, if you are taking thyroid replacement and you still don't feel great, you're not crazy. Dr. George Papanicolaou: You're not. No. Dr. Mark Hyman: It's just that your doctor may be missing something. And that's really why we do what we do here at the UltraWellness Center. That's why we practice functional medicine, because it goes deep. It's personalized. It looks at your whole system and not just one thing. And we treat the whole shebang of everything that can go wrong to get you optimized, including your adrenals, including your sex hormones, including your leaky gut, including environmental toxins, including your nutritional deficiencies, all of which impact your thyroid. So it's really a really beautiful, elegant approach that you've outlined. And I think, George, we are so lucky to be able to practice here at the UltraWellness Center. Dr. George Papanicolaou: Absolutely. Dr. Mark Hyman: We're now seeing people virtually. We can see people from all over the world. You can go to, learn more about what we're doing. But you don't have to suffer, and I think that's really why we do this work, because so many people suffer needlessly when there are solutions. Dr. George Papanicolaou: Absolutely. Dr. Mark Hyman: Look, we can't end hunger, end war, and end all viruses, which we'd like to do. But this stuff we know how to fix, and people don't have to suffer. It just breaks my heart when I see so many people struggling unnecessarily. And that's really my mission in life, is to end needless suffering. Dr. George Papanicolaou: And I'll tell you, I picked... Hashi's and thyroid conditions from women are huge, and it's one of the most satisfying conditions I treat because it's the entree into so many other parts of their health, and we're able to work on things that have frustrated them for so many years. The functional medicine model does work. And this is a particular disease process that I love to treat women and see them end their years of frustration and really reach their optimal health, energy levels, libidos, enjoy their life again. Dr. Mark Hyman: There you go. It's all about enjoying life. Well, thank you, George, for being on The Doctor's Farmacy. Dr. George Papanicolaou: It's always a pleasure. Dr. Mark Hyman: If you've struggled with some of these symptoms, with thyroid issues, be sure to take a deep listen to this podcast again. Share with your friends and family on social media. Leave a comment. Tell us how you maybe cured your Hashimoto's. We'd like to learn. And subscribe wherever you get your podcasts. And we'll see you next week on The Doctor's Farmacy.